Place and Health as Complex Systems: A Case Study and Empirical Test

Brian Castellani, Rajeev Rajaram, J Galen Buckwalter, Michael D. Ball, Frederic Hafferty

Over the last decade, scholars have developed a complexities of place (COP) approach to the study of place and health. According to COP, the problem with conventional research is that it lacks effective theories and methods to model the complexities of communities and so forth, given that places exhibit nine essential "complex system" characteristics: they are (1) causally complex, (2) self-organizing and emergent, (3) nodes within a larger network, (4) dynamic and evolving, (5) nonlinear, (6) historical, (7) openended with fuzzy boundaries, (8) critically conflicted and negotiated, and (9) agent-based. While promising, the problem with the COP approach, however, is that its definition remains systematically untested and its recommended complexity methods (e.g., network analysis, agent-based modeling) remain underused. The current article therefore conducts an exhaustive test of all nine characteristics and suggested complexity methods. Method: To conduct our test we made two important advances: First, we developed and applied the Definitional Test of Complex Systems (DTCS) to a case study on sprawl—a "complex systems" problem—to examine, in litmus test fashion, the empirical validity of the COP's 9- characteristic definition. Second, we used the SACS Toolkit, a case-based modeling technique for studying complex system that employs a variety of complexity methods. For our case study we examined a network of 20 communities (located in Summit County, Ohio USA) negatively impacted by sprawl. Our database was partitioned from the Summit 2010: Quality of Life Project. Results: Overall, the DTCS found the COP's 9-characteristic definition to be empirically valid. The employment of the SACS Toolkit supports also the empirical novelty and utility of complexity methods. Nonetheless, minor issues remain, such as a need to define health and health care in complex systems terms. Conclusions: The COP approach seems to hold real empirical promise as a useful way to address many of the challenges that conventional public health research seems unable to solve; in particular, modeling the complex evolution and dynamics of places and addressing the causal interplay between compositional and contextual factors and their impact on community-level health outcomes. ...Click here for complete text.


Epidemiology and Susceptibilities of Methicillin-resistant Staphylococcus aureus in Northeastern Ohio

Thierry Delorme, Stacy Rose, Julie Senita, Cynthia Callahan, Payman Nasr

A retrospective survey was performed on all staphylococcal infections diagnosed by the Ashtabula County Medical Center (ACMC) during 2006/2007. Of the 1612 Staphylococcus aureus isolates evaluated for their antibiotic resistances, 947 were methicillin-resistant Staphylococcus aureus (MRSA). In 2007, MRSA infections reached 589 cases per 100,000 inhabitants, a 77% increase compared to 2006. The increase in MRSA infections was noticeable among youth (6 to 25 years old), middle-aged persons (45-50 years old), and elderly (86-90 years old). MRSA infections increased among inpatients by 58%, among outpatients by 43% and among nursing home patients by 183%. More than 66% of MRSA infections were found among healthy individuals in the community with no apparent risk factors. More than 88.7% of the infections belong to only 9 profiles of antibiotic resistances indiscriminately distributed among inpatients, outpatients and nursing home patients. This report sheds further light on the rapid spread of MRSA across Northeastern Ohio, stressing the need for better education in preventive measures and infection control at the level of community and healthcare settings. ...Click here for complete text.


Methicillin-resistant Staphylococcus aureus among younger population in Northeastern Ohio

Payman Nasr, Thierry Delorme, Stacy Rose, Julie Senita, Cynthia Callahan

The Ashtabula County Medical Center (ACMC), a 241-bed medical center in Ashtabula County, Ohio, has been providing inpatient and outpatient services for a portion of Northeastern Ohio for over a century. In the current report, we have investigated the rate of Methicillin-resistant Staphylococcus aureus (MRSA) occurrence among the younger population (less than 25 years of age) who sought medical attention at ACMC emergency room or one of its outpatient-affiliates (e.g. physician's office or clinics) from January 2006 to December 2007. Here, we report a significant increase in incidence of MRSA among patients six to 25 years of age during this time period. Considering the age population and the origin of specimens, the present findings suggest a rapid increase in incidence of MRSA among the general population in Northeastern Ohio. These findings demonstrate the need for the development of new protocols aimed at identifying preventive measures in order to immobilize the spread of such pathogens among the younger population in the region. ...Click here for complete text.


The SACS Toolkit: E-Social Science from a Systems Perspective

Brian Castellani, Ph.D., Frederic Hafferty, Ph.D., Michael Ball, B.A.

The SACS Toolkit provides researchers a new informatics-based ontology and methodology for managing and analyzing the massive, multi-dimensional databases regularly encountered on the web today. The SACS Toolkit does this by functioning as an intermediary between the web and researcher. Its intermediary function provides researchers several advantages. In terms of ontology, the SACS Toolkit: 1) provides a user-based filing system (social complexity theory) that help researchers organize and link multidimensional databases in a theoretically meaningful manner; 2) the filing system is also designed to form a complex system—to match the complexity of most web-based data. In terms of method, the SACS Toolkit: 1) provides a novel algorithm (assemblage) researchers can use to model complex systems with web data; 2) this algorithm works with any type of data; and 3) can be used with most methodological techniques (e.g., field research, statistics, etc), including the latest advances in agent-based modeling, network analysis, e-science and web science. In the current paper, we demonstrate the utility of the SACS Toolkit by applying it to a web-based community health science database we are currently studying. We begin with a review of e-social science and the SACS Toolkit. Next, we explore the challenges that our web-based database presented us, focusing on how the SACS Toolkit solved them. We end suggesting how others may likewise use the SACS Toolkit. ...Click here for complete text.


Addressing the U.S. Financial/Housing Crisis: Pareto, Schelling and Social Mobility

Brian Castellani, Ph.D., Michael Ball B.A., Kenneth Carvalho, B.A.

Two important principles governing upward social mobility are Pareto's 80/20 rule1-3 and Schelling's segregation threshold.4-5 Pareto shows that wealth follows a power law, where a few have the most. Schelling shows that neighborhood preference (beyond a certain threshold) leads to spatial segregation. The link between these two principles, however, remains undeveloped—particularly in relation to the current U.S. financial crisis. To explore this link, we created an agent-based, Pareto universe of rich, middle and poor agents.17 The rules for this universe follow Schelling, with a slight modification: while rich agents seek their own, middle and poor agents do not; instead (pursuing upward mobility), middle agents seek rich agents and poor agents seek middle agents. Congruent with the current U.S. financial crisis, our model finds that, in a log-normal wealth distribution with a power-tail, moderate upward social mobility produces spatial segregation, instability and, in particular, unhappiness on the part of middle-class and poor agents. We call this insight the upward social mobility rule (MR). Unexpectedly, the MR also provides a corrective: it appears that, at threshold, upward social mobility leads to integrated, stable neighborhoods with very high rates of happiness. The MR therefore suggests that the U.S. financial/housing crisis might be effectively addressed for the greater good of all if upward social mobility is controlled and regulated, even on the part of poor households. ...Click here for complete text.


The Complexities of Medical Professionalism: A Preliminary Investigation

Brian Castellani, Ph.D., Frederic Hafferty, Ph.D.

Efforts within organized medicine over the last twenty years to reestablish an ethic of professionalism have obscured the fact that currently there are several competing clusters or types of medical professionalism, each of which represents a unique approach to medical work. Stated differently, the "professionalism" that has emerged within the academic medical journals, conferences, debates, and discussions over the past twenty years is a highly selective and privileged narrative, developed and delivered by one, possibly two, particular strata within the organizational structure of medicine. We call this strata the ruling class of medicine, and we refer to its medical professionalism as nostalgic. The other clusters of medical professionalism that we empirically "discovered" include entrepreneurial, empirical, lifestyle, unreflective, academic, and activist professionalism. The development of this seven-cluster system of medical professionalism was by no means an accident. Instead, it was the direct result of our involvement in the new science of complexity (e.g., Axelrod, 1997; Bak, 1999; Capra, 1996; Cilliers, 1998; Holland, 1998). Specifically, we are in the process of developing our own theoretical and methodological framework, which we applied to the current study. The purpose of this chapter is to introduce readers to a more "complex" medical professionalism. To do so, we begin with a quick overview of the theory and method we developed, along with the historical archive we used to conduct our empirical analyses. Next, we review the five important ways the theory and method helped us to recognize, discover, analyze and assemble medical professionalism as a complex social system, including a thick description of the seven clusters we discovered. We conclude by putting the complex social system of medical professionalism together, reflecting on the insights our results have for the future teaching and evaluation of professionalism. ...Click here for complete text.


Grounded Neural Networking: Modeling Complex Quantitative Data

Brian Castellani, Ph.D., John Castellani, Ph.D., S. Lee Spray, Ph.D.



The latest advances in artificial intelligence software (neural networking) have finally made it possible for qualitative researchers to apply the grounded theory method to the study of complex quantitative databases in a manner consistent with the postpositivistic, neopragmatic assumptions of most symbolic interactionists. The strength of neural networking for the study of quantitative data is twofold: it blurs the boundaries between qualitative and quantitative analysis, and it allows grounded theorists to embrace the complexity of quantitative data. The specific technique most useful to grounded theory is the Self-Organizing Map (SOM). To demonstrate the utility of the SOM we (1) provide a brief review of grounded theory, focusing on how it was originally intended as a comparative method applicable to both quantitative and qualitative data; (2) examine how the SOM is compatible with the traditional techniques of grounded theory; and (3) demonstrate how the SOM assists grounded theory by applying it to an example based on our research. ...Click here for complete text.


Data Mining: Qualitative Analysis With Health Informatics Data

Brian Castellani, Ph.D., John Castellani, Ph.D.

The new computational algorithms emerging in the data mining literature—in particular, the self-organizing map (SOM) and decision tree analysis (DTA)—offer qualitative researchers a unique set of tools for analyzing health informatics data. The uniqueness of these tools is that although they can be used to find meaningful patterns in large, complex quantitative databases, they are qualitative in orientation. To illustrate the utility of these tools, the authors review the two most popular: theSOMandDTA. They provide a basic definition of health informatics, focusing on how data mining assists this field, and apply the SOMandDTAto a hypothetical example to demonstrate what these tools are and how qualitative researchers can use them. ...Click here for complete text.


Moving Beyond Nostalgia and Motives

Frederic Hafferty, PH.D., Dana Levinson, MPH

Modern-day discourse on medical professionalism has largely been dominated by a "nostalgic" view, emphasizing individual motives and behaviors. Shaped by a defining conflict between commercialism and professionalism, this discourse has unfolded through a series of waves, the first four of which are discovery, definition, assessment, and institutionalization.They have unfolded in a series of highly interactive and overlapping sequences that extend into the present.The fifth wave—linking structure and agency—which is nascent, proposes to shift our focus on professionalism from changing individuals to modifying the underlying structural and environmental forces that shape social actors and actions.The sixth wave—complexity science—is more incubatory in nature and seeks to recast social actors, social structures, and environmental factors as interactive, adaptive, and interdependent.Moving towards such a framing is necessary if medicine is to effectively reestablish professionalism as a core principle. ...Click here for complete text.


The Increasing Complexities of Professionalism

Frederic W. Hafferty, Ph.D., Brian Castellani, Ph.D.

Organized medicine's modern-day professionalism movement has reached the quarter-century mark. In this article, the authors travel to an earlier time to examine the concept of profession within the work of Abraham Flexner. Although Flexner used the concept sparingly, it is clear that much of his writing on reforming medical education is grounded in his views on physicians as professionals and medicine as a profession. In the first half, the authors explore Flexner's views of profession, which were (1) empirically (as opposed to philosophically) grounded, (2) case based and comparatively framed, (3) sociological in orientation, and (4) systems based, with professionalism conceptualized as dynamic, evolving, and multidimensional. In the second half, the authors build on Flexner's systems perspective to introduce a complexity science understanding of professionalism. They define professionalism as a complex system, introduce a seven-part typology of professionalism, and explore how the organization of physician work and various flash points within medicine today reveal not one but several competing forms of professionalism at work. The authors then develop a tripartite model of professionalism with analysis at the micro, meso, and macro levels. They conclude with observations on how best to frame professionalism as a force for change in 21st-century medical education. Flexner's reforms were grounded in his vision of two particular types of professional—the physician clinician and the full-time academic physician– scientist. The authors propose reform grounded in professionalism as a complex system composed of competing types. ...Click here for complete text


The Complexity in Health & Infrastructure Group is located in the Robert S. Morrison Health & Science Building, on the campus of Kent State University at Ashtabula.

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