Ashish Ranpura, MD, PhD
September 2022



An ecological system is a network of relationships rather than a network of things. This means that the parts of the system have properties based primarily on how they relate to the rest of the system.

For example, I am my mother’s son but my wife’s husband and my son's father. My properties as a member of my family emerge from these roles. However, I'm not 33% son + 33% husband + 33% father, I am completely all of these things and more, all the time. My family is the system formed by this network of relationships, and my existence within that system is defined by my relationship with all the other members of the family.

The relationship between organ systems in the body is similarly ecological. Blood pressure is controlled by a complex system involving stretch receptors in the heart, smooth muscle tone in the arterioles, osmo-receptors in the kidney, hormone responses in the adrenal glands, and enzymatic activity in the lungs. Those same organs form entirely different networks of relationships to carry out tasks like metabolism and thermoregulation. The functional role of an organ depends entirely on how it interacts with all other organs to meet the demands of the moment.

Health and disease are ecological, but our health care systems are mechanical. Changing to an ecological point-of-view will require a simple but radical re-conceptualisation of what we mean by health care.

The modern understanding of disease is the biopsychosocial model. Doctors understand that the body is constantly colonized by pathogens, and that it's not exposure to disease that causes a breakdown in health. Disease is an interaction between biological vulnernabilities, social factors affecting health care access and equity, and psychological factors affecting health behaviours. The biopsychosocial model is therefore explicitly ecological, in that it moves beyond a mechanistic connection between pathology and disease and towards an understanding of the relationships that affect health.

Mechanical systems are most stable when their parameters are fixed, but ecological systems are most stable when their parameters are changing.

This is the difference between a motor boat and a sailboat. The motor boat cruises over the surface of the water with little regard to wind and current, while a sailboat requires continual adjustment and optimization.

The motor boat is effective but resource-intensive. It requires expensive technology but little skill or experience and in fact, high levels of skill do not make it any more efficient. The motor boat attempts to minimize the effects of the wind and waves, typically through increased size and power.

In contrast, the sailboat requires relatively less technology but much more skill and experience. Exceptionally high levels of skill can result in greatly increased efficiency without consuming more resources.

The sailboat attempts to take advantage of the effects of the wind and waves, navigating within this energetic environment rather than despite it.

Ecological systems like sailboats have no single optimal configurations, only a balance which is right in the moment. If we look at the drive behind concepts like ‘personalised medicine’ we can see this is already a goal for modern healthcare: systems which flexibly reconfigure around the needs of the patient, the skills of the staff, and the demands of the moment. This is what I mean by a dynamic balance.

As an aside, capitalism dramatically favours the motor boat model. It's easy to pay for for a bigger and better motor but it's hard to pay for a better sailor. Moreover, the better the sailor is, the more leverage they have over the owner of the boat. Hospital are run by investors, and they typically do not like being at the mercy of their staff.

In hierarchical systems, command and control mechanisms are used to create one-way flows of information. The relationships in these systems are neccessarily fixed, because ambiguity would obstruct the flow of information and impede action.

Ecological systems have no command and control mechanisms. Instead, elements of the system each respond to the other elements and to the overall state of the system. Information in ecological systems doesn't have a single direction of flow, but it flows everywhere all at once. When a tree suffers from drought there is no central executive which decides how to respond. Every element of the tree (leaves, branches, roots) responds simultaneously and in concert with every other element to conserve water.

While it is difficult to conceive of health care systems with such tight integration and coordination, flattening of hierarchies has already been shown to strikingly improve outcomes. When every member of the hospital staff is able to flag potential medical errors, lives are saved. The more health care systems can function and feel like interdependent and equipotent communities, the better they will serve patients.

In a natural environment, sometimes small interventions have very large effects and at other times very large interventions have neglible effects. A single beaver dam can create an upstream flood, changing the local ecosystem from one typical of a river into one typical of a lake. Different plants are favoured in the new lake environment, leading to differential success of herbivores and therefore differential success of predators. The dam also changes the course of the river, resculpting the entire landscape in a relatively short amount of time.

The systems works the other way too. Introduction of a few apex predators like wolves puts pressure on herbivorous species like rabbits and deer, in turn allowing certain plants to thrive which help to shore up the soil along waterways. This in turns forces rivers to deepen rather than widen, again resculpting the landscape relatively quickly.

The nonlinearity of health care interventions has been seen many times already. For example, Dr. Ignatz Semelweiss’s 19th century observation that a simply asking physicians to dip their hands in chlorine prior to examining pregnant patients resulted in a dramatic decline in childbed fever. When we understand that health care is ecological, these sorts of heroic improvements become more likely.

Our concept of collective intelligence is much, much more than team building. We mean a situation where one person's ideas and knowledge shapes the way another person acquires new ideas and knowledge, and those new ideas feedback to the first person, who in turn reshapes their own ideas. Collective intelligence is not a collection of ideas – it is using collective processes as a mechanism for thinking.

In this way, what we mean by collective intelligence is ecological. It is a network of relationships that mutually influences its members, rather than simply transmitting and receiving information from many voices. It is the difference between belting out ‘Happy Birthday’ as loudly as possible in twenty different keys, and singing a hymn in a well-rehearsed choir: only in the latter case, the sum is greater than the parts.

Collective intelligence shifts the focus of an activity from the product to the process, and this is a shift is particularly relevant in health care. We do not see the patient as a customer or a stakeholder, but as a human within a durable network of humans. Time spent between the patient and a health care provider, though sometimes inefficient in the short term, can help to form a relationship which will be very efficient in the long term. A patient’s experience in the hospital emergency room on one particularly frightening night could lead to a lifetime of trust in medical advice or a lifetime of fear and skepticism. The process of medical care matters.

In a health care setting which prioritises collective intelligence, information would be universally shared and opinions universally facilitated and welcomed. However, decision-making, though integrative, would still be centralised and accountable. The patient would still be able to communicate with a single team member who would coordinate all other voices.

Diagnosis achieves a few important things. It enables physicians to place patients in a group with what they believe are other similar patients. That enables them, in theory, to understand the pathophysiology of disease, based on extrapolation from previous research. And finally, it enables them to make predictions about treatment and disease progression, also based on extrapolation and analogy.

However, diagnosis causes many problems. Obviously it elides individual differences. But it also creates a false confidence about how well pathophysiology is understood. If I diagnose a patient with depression and theory predicts that depression results from low serotonin, how confident am I that my patient also has low serotonin? Unless I have measured it directly, I have no reason to be confident at all.

Two people may both have multiple sclerosis but nevertheless have very different physiologies, depending on their individual genetics, their diet and exercise habits, and the health habits of people in their close social circles. Should a physician prescribe the same medication to both patients because of their shared diagnosis?

Today we have no choice but to say yes. Enthusiatic talk about concepts like ‘personalised medicine’ demonstrates the frustration we all have with these broad diagnostic labels. At the moment all of medicine depends on diagnosis. It is the way we make treatment decisions, the way we organise hosptials, the way we train clinicans and the way we fund health interventions.

If the future of medicine is to do away with diagnosis, we must replace it with an ecological approach. Rather than giving someone a diagnosis of diabetes and treating them with insulin, we must consider the balance between their body systems and their environment and plan a re-balancing intervention.

An ecological approach to health care is not particularly holistic or idealistic. It is simply an acknowledgement that we, like all living things, function as part of and within an ecological system, and that what we consider disease occurs when we suffer from intolerable imbalances with this system. I see the ecological approach as a reductionist one. To paraphrase Einstein, we are making the problem as simple as possible, but no simpler.

I am also not arguing that health must be optimised in every possible aspect, or endorsing an unending sense of ‘wellness’. To me, the ecological approach is about balance, not optimization. For a patient with depression, for example, changing the balance may require medication but it may also require a change in lifestyle or indeed a change in their social world. The ecological approach means that we are treating whole systems.

Can we achieve this kind of approach without dismantling our entire health care system? Can we really get rid of hierarchies, of narrowly- focused clinical departments, of algorithmic responses to laboratory results instead of clinical responses to patient stories? I believe that we can, and I actually believe it would be very simple. We must simply realise that we are in a sailboat and not a motor boat, and then steer the ship accordingly.