White , Norman F., "System Models in the Health Sciences", 1983

SYSTEM MODELS IN THE HEALTH SCIENCES

Norman F. White
McMaster University Faculty of Health Sciences

Hamilton, Ontario, L8N 325

ABSTRACT

In the health sciences, concepts are shifting toward
system models which recognize multiple factors interacting to
determine health phenomena. ‘The hybrid biomedical disease
model has proven insufficient for the analysis of modern health
problems. A population perspective and an expansion in the
influence of the behavioral and social sciences have required
conceptual models with greater breadth, and facility in
relations between models. Morbidity is portrayed here as two
domains of phenomena, the disease process and the illness
state, each seen as part of a socio-ecological dynamic.
Applied to major disease problems, the utility of these
propositions can be examined. In the McMaster M.D. Program,
this set of models has been translated into a curricular
structure which has the individual in all her/his healthy or
morbid aspects as the interface between biological and social
systems. Perplexing dilemmas in health care thus become not
only understandable but predictable. Adopting this approach
creates a new generation of problems. Just as our students
have become familiar with the critical appraisal of evidence,
the testing of conceptual models becomes a necessary skill.
The background to this analysis is the socio-ecological niche
of concepts. A model of models is proposed in which concepts
interact with problem environments and modern medicine emerges
as a case study for socio-ecological epistemology.

Concepts in Medicine
A major shift is occurring in the conceptual basis of the

Health Sciences. Its degree, scope and speed suggest the term
‘revolution’, and its effects promise to be as seismic as the
development of the antibiotics. ‘The student of health issues

now needs a repertoire of conceptual models which recognize the
several factors interacting to determine all health phenomena.
Because of the complex relationships involved, the models have
a systems configuration, and the properties of systems have
become an important issue. Feedback and interaction are not
new ideas in medicine, but the self-regulation principles
familiar in homeostasis and endocrifie axes have been elaborated
to include all body systems and social systems. Health care
strategies, medical education and research are being
significantly influenced by both the character and the variety

of these emerging concepts.

In physicianly discourse, ‘concept' is used as a summary
label for theories, deeply believed but often unsubstantiated
‘facts', and widely applied principles. It is generally held
that the theories and propositions which support health care
practices are to a greater or lesser degree ‘true*, and that
good science, which is seen as the progressive accumulation of
fact, brings them ever closer to the truth. Questionning the
assumptions and logical structure of the resulting factual
edifice is regarded as a self indulgence which gives way to
professional maturity, and is dismissed condescendingly as
‘philosophy’. In an informal (uncontrolled, non-random,
biased, but so far uncontested) survey, final phase medical
students were asked to state the ideas out of which clinical
decisions and health policies emerge. A few ventured opinions
about what 'disease' is, A better response would have been to

describe the properties and boundaries of that entity, and to

582

account for its origins and consequences; none was able to do
that. A substantial proportion seemed to interpret the
question as a test of faith, and recited some version of the
W.H.O. definition of 'health', This state of affairs is
fascinating and disturbing, because there is such a conceptual
model. For a new physician to be unaware of it is a little
like a graduating engineer being unable to state the Second Law
of Thermodynamics or the relationship between force, mass, and

acceleration.

The concept most often goes by the label of ‘the medical
model', and the history of modern biomedicine is largely the
story of its evolution. It is half of a dual foundation of the
medical enterprise; but, significantly, it is always implicit.
However, we should not be too hard on the students; few of
their teachers could answer the question and, although the
model is assumed, alluded to, criticized, defended, modified

and expanded, it is never depicted [1,2].

At its centre is the lesion, which is the 'pathology' of
disordered tissue, chemistry or physiology. It is
ontogenetically separate from the organism, and its origin,
morphology, and effects constitute the characteristics of a
disease. Not only does the lesion have an existence discrete
from that of the organism in which it is found, but the
influences bringing it into being (infection, trauma, neoplasm,

degeneration) are seen to be ‘external’ to the healthy function
of the organism. The lesion arises from these agencies, or
causes, or aetiologies, through a process of ‘pathogenesis’

[1l. This is the Biomedical Disease Model (BDM).

CAUSE ————» LESION ————»> SYMPTOMS

eieeia expression
AETIOLOGY > PATHOLOGY > PRESENTATION

COURSE
[oRicIn ——> moRPHOLOGY ——> EFFECTS »

The disease process
Yoked to the BDM, as the other half of the conceptual
foundation of medicine, is a view of ‘health’ which supposes
that there are conditions to be enhanced, promoted, or
preserved, which are unrelated to disease. The most
influential definition of health corresponding to this view
occurs in the Preamble to Constitution of the World Health

Organization;

«sea state of complete physical, mental and social
well-being, and not merely the absence of disease or

infirmity...

Despite its rhetorical appeal, none of the attempts to

operationalize such a Positive Health Model (PHM) has been very

successful. Differences of degree in well-being become
subspecies of morbidity; and, coupled with the BDM, anything

short of complete well-being, by whatever name, is kin to

583

disease, Although the W.H.O. definition is criticized for
being excessively utopian, its principal flaw is that its goals

are practicably unspecifiable.

Together, the PHM and BDM provide the conventional
underpinnings of modern medicine, and they have been enormously
useful. ‘The BDM, also known as the ‘germ theory’, has ordered
a century of data, and was largely responsible for the
explosion of biomedical technology following World War II. The
W.H.O, definition of health has shown remarkable political
durability, and has permitted the implementation of humane
programmes under geo-political circumstances where only the
‘health’ label made them possible. However, this conceptual
partnership has been applied so widely that we are approaching
the limits to its utility. ‘wo developments have taken place:
we have employed these concepts beyond their competence, and
their application has actually altered their human biological
context, ‘There are well-known examples of both developments:
first, medical solutions to several behavioural problems, such
as addiction, obesity, and criminality have expensively and
painfully eluded us; second, the antibiotics have contributed
to increases and change in the age structure of populations, so
that health problems differ from those which preceded the

antimicrobial therapies.

Variations on a Biomedical Theme

Successive modifications to the BDM have been necessary
to account for exceptions to the basic model, and to
accommodate discoveries. ‘The most conspicuous problem with the
BDM is the irregularity of symptoms, including the frequent

occurrence of symptoms without lesions. ‘This gave rise to the

psychosomatic variant.

The psychosomatic variant

Here the 'lesion', and sometimes the ‘cause’, are found
in the psyche. An explanation for symptoms without lesions was
Freud's point of departure and the origin of psychodynamic
psychiatry. Despite broad cultural influence, its clinical
performance has been poor. The evolution of this conceptual
variant has gone from exclusively intrapsychic factors (such as
‘conflicts') to more environmental (such as 'stress') factors.
Its ultimate form is the 'biopsychosocial' view of ill health,

combining terms and relations from other variants [3].

A related variant, the socio-cultural, has had the twin
Purpose of explaining variations in the manifestation of
sickness and in health service utilization. It is sometimes
combined loosely with the psychosomatic variant into a hybrid
‘psychosocial model’. It provides uneasy accommodation for the
"sick role' concept, the ‘illness behaviour' concept, and

ethnomedicine [4,5,6,7].«

584

7
C—L{rs-yr Dr
/ / /
E /

foc foc fae

The socio-cultural variant
Here there are no ‘lesions’ or ‘causes' but, rather, a

series of interactions in parallel to the disease process.
They are not subject to 'treatment' and are distinctly

environmental.

The observation that the same ‘cause’ may result in
different lesions and that the same lesion does not regularly
arise from a supposed cause, has given rise to the

multifactorial or multicausal variant.

Here, ‘causes’ act in varying proportions and
combinations, neither simultaneously nor sequentially, and more

or less additively.

During the 1920's, an ecological variant was proposed by
Jacques May who had observed that Indo-Chinese rice farmers
developed Schistosomiasis at a far greater rate than their
silk-farming co-villagers [8]. The parasite causing this
disease spent part of its life in a snail living in the rice

paddies. Here, disease is seen as originating in an
interaction between the victim host, the infecting agent, and

the conditions of the environment which bring them together.
lid s
Ll—>s

4
‘The ecological variant
Also called the 'tropical medicine’ or ‘public health' model,
it has led to the study of host resistance and of the

environment as a disease determinant.

The behavioural variant, based in learning theory and
social psychology, is addressed primarily to symptom variablity

and to symptoms without lesions.

The behavioural variant

Here, symptoms (subjective states) and performance deficits
(disability) are seen as behaviours which are altered, or

generated, through learning.

In practice, the BDM, modified by the principal features
of each of these variants, is still woven through most health
care thinking. Behavioural, social and environmental
influences are acknowledged, but are seen to exist outside of

the central linear causal sequence which proceeds from cause to

585

lesion to symptom. However, there are important health
problems which cannot be understood employing this view [9].
Contrary to predictions from the rationale underlying health
care systems in the industrialized countries, neither cost nor
morbidity has diminished dramatically in response to the
distribution of biomedical technologies across societies
[10,11,12]. To some extent, this results from the creation of
a survivor population, but it is also due to morbidity and
supply/demand relationships behaving differently from what had
been expected, when measures (models) that practitioners
believe effective for individuals are simply multiplied into
large scale intervention strategies [13,14,15]. A shift of
focus from the individual to populations has been spurred by
the increasing importance of chronic, slowly developing,
multifactorial diseases. These clearly do not have single
causes; several ‘determinants’ interact over many years. To
reach useful conclusions about such multiple, and interacting,
determinants requires the study of large groups over long

periods of time [16].

We have also witnessed a huge expansion in the influence
of the behavioural and social sciences. Populations obviously
cannot be studied without taking into account social and
cultural variables, but there are also problems at the clinical
level. ‘Thirty to eighty per cent of the complaints seen by
physicians are pathologically inexplicable, and eligible for a

collection of such diagnostic ciphers as ‘functional’
586
10

'psychosomatic', or ‘stress-related’, The ‘clinical art', it
is supposed, enables the physician to contend with the
irregularity of symptoms [17]. It is about as consistent as
most intuitive processes, and is not much improved by the
addition of psychiatry. There have been stubborn theoretical
problems in both practice and planning: psychogenesis and
system abuse (‘overutilization') are weak and misleading

constructs.

The Dual Nature of Morbidity
Considering the influence of social and behavioural
factors upon both the origins of sickness and the forms
sickness takes has led us away from a unidimensional view of
sickness, or 'morbidity'. Medical sociology and medical
anthropology have long found it useful to distinguish between
the pathological process of ‘disease’ proper (e.g., the liver
damage and metabolic changes occurring with Hepatitis), and the
‘illness' which consists of the sufferer's perception of the
disease and the role changes which occur because of it. The
factors which influence the development of disease differ from

those which affect illness.

Over the last decade, the distinction has been sharpened
by the demonstration that subjective states (i.e., experiences,
sensations and symptoms) can be manipulated by environmental
and behavioural means [18,19]. ‘This has resulted in a model of

morbidity which portrays the whole realm of unhealth or

sickness as comprised of the disease process (anatomical and

physiological changes which occur with the development of a

lesion) and the illness state (symptoms, illness behaviours,
and role changes which occur with disease or with the belief
that disease is present). Substantial experimental, clinical
and epidemiological evidence indicates that the intervention
strategies required for the two are dissimilar. These are two
domains of phenomena; the distinction is not intended to
separate ‘real sickness' from 'psychogenic' or imagined
sickness, The two most often coexist, but either can (and

frequently does) exist without the other.

UNHEALTH

1
~ illness
Process =| State

anatomical | @ subjective
physiological! behavioural
change | role change

The interaction between person and environment which
results in one is different from that which results in the
other: the disease process comes about through a
biophysiological interaction between the cells, organs, and
systems of the body, and the physical environment; the illness
state comes about through the socio-behavioural interactions
between a feeling, perceiving, thinking and behaving organism
and its social environment. ‘The first process can be

summarized as ‘pathogenesis’; the second as ‘learning’.

Having made the disease process/illness state
12

distinction, we must account for each. For the disease
process, we may consider an ecological-interactional model
(BIM), which portrays multiple factors in a human ecosystem
interacting with each other and with a person, Within this
system, a set of interactions is specifically related to a
disease process outcome. In Chronic Obstructive Lung Disease,
e.g., lung tissue is the interface between the atmosphere and
interrelated body sub-systems (respiratory, circulatory,
immune), ‘he quality of breathed air results from climate,
pollinating flora, work conditions and smoking, The internal
sub-systems have their contacts with the external milieu

through diet, physical demands, and microorganisms.

A view of the illness state as phenomenologically and
ontogenetically separable from the disease process, and with

subjective states, behaviours and role changes derived from the

social environments is the soci ehay

ioural model (SBM).

In both cases, sub-systems in the human organism interact
with systems in the human environment. Advocates for a unified
theory of health and disease point out that it is the same
organism and the same environment, It is also true that there
are physiological elements operating in the genesis of the
illness state, and important behavioural constituents of the
disease process, Moreover, the two aspects of morbidity
influence each other: disease process is one factor

contributing to the illness state (tissue damage, for example,

587

13

is obviously related to pain in many circumstances); and the
illness state affects disease process through maladaptive
health behaviours, impact on immune systems, and

psychophysiology. The combination of the two can be referred

to as a socio-ecological model (SEM).
Socio-Ecological Model

nS
>

liness
= State
P
Socio-Behavioural

Model

“9
f
'
'
1
i
'
4
1
t
1
1

-4.

The overall model is based on the view that an organism's
total "behaviour' (i.e., not simply what it does, but
everything which occurs within it) is a function of its
interaction with its environment (B=£[0B]). An ecological view
of the human organism's interactions with the environment
understands those interactions to be with interrelated social

and physical elements,

Ecosystem interactions
14

Here 'P' (the person) is one of many interdependent elements.
To apprehend the outcomes of this of interaction, we apply
systems principles: the system as a whole has properties which
are not reducible to the properties of any single constituent;
the function of any single element is affected by the operation
of the system as a whole; and change in any point of the system
can be predicted to have remote effects. ‘This changes our view
of causation. A ‘caused' outcome requires a number of

preceding events which are not linear.

Sometimes, when it is convenient to identify a single
"causal' element, We may distinguish between proximal and

distal determinant-causes.

Proximai and distal ‘causes”

In health care, we are traditionally most familiar with
the proximal causes and, not surprisingly, our conventional
disease models are best suited to them. More modern disease
problems, as viewed in a population or behavioural perspective,

require us to contend with intermediate and distal causation.

588

15
Some examples are; are;
PROXIMAL INTERMEDIATE DISTAL
LUNG CANCER CARCINOGENIC TARS SMOKING BEHAVIOR SOCIAL PRESSURES
TB, ‘TUBERCLE BACILLUS NUTRITION/HYGIENE INDUSTRIAL REV'N

BEHAVIOR ‘CONDITIONING SOCIAL SETTING CULTURE

Judgements about which outcomes of a person-ecosystem
interaction are undesirable, and about which of these should be
regarded as ‘unhealth', are determined by socio-cultural
factors. We may use scientific method to study the phenomena
upon which we base such judgements, but the judgements

themselves are dialectical, not technical.

In our culture, the key factor influencing the decision
about ‘what sickness is' appears to be the institution we wish
to have responsibility for it. That is, some of outcomes
w,%,Y,z are identified as "health problems’ because our society

wants medicine to look after them.

Critical Appraisal of Conceptual Models

The origins of this model, as outlined above, were in the

increasing failure of multiply-modified disease models to
589

account for important phenomena, and the inappropriateness of
these models for the planning of modern health care
interventions. Setting this new formulation alongside
conventional conceptual models raises some interesting
questions: Can we tell whether this model is superior to those
it is proposed to supplant? If it is superior, was the old
model always ‘wrong’? What are the consequences we might

expect from the widespread adoption of this model?

Merely proposing an alternative conceptual framework has
some interesting impacts and implications. Suggesting a degree
of choice in how we assemble information collides with the
notion of absolute ‘truth’, To imply that we can design these
ideational structures also implies purposes and specifications
underlying the design, and that its success may be judged [20].
Within the context of the purposes for which it is constructed,
the conceptual model can be appraised with respect to its

clarity, comprehensiveness, correspondence to related models,

and utility. This last is, of course, the ultimate test, and
there are subcategories of utility: heuristic, predictive,

praxeological, and sociological [21]. The importance of

appraising the quality of evidence has become an accepted
principle [22,23], but we must now also test the non-evidential

component of claims and propositions.

The application of the SEM to two major health problems,

Infantile Diarrhoea and Coronary Heart Disease, illustrates how

such appraisal might be directed. The magnitude of the
Coronary Heart Disease problem in the industrialized countries
is well documented. Smoking, diet, lack of exercise, stress,
hypertension, gender and genetics have been identified as its
major determinants (we no longer speak comfortably of
‘causes'), he disease process consists, e.g., of abnormal
blood vessels, damaged heart muscle, enzyme changes, clots, and
conduction abnormalities. ‘The chain of events leading to each
of these abnormalities either is already explicable in
biophysiological terms, or in principle can be. The illness
state in a person having suffered a heart attack consists of
chest pain, weakness, fatigue, and general malaise. It also
includes the fear, loss of confidence, dependence upon
physicians, and interruption of normal activities. Besides
these behaviours, there are special roles assigned to the
coronary patient which entail the gain of some privileges and
the loss of others, Patients with the same degree of coronary
exhibit widely varying disibility, and this variation is
relatively inaccessible to medical treatment. The
affective-cognitive-behavioural sub-systems which, in
interaction with the socio-cultural environment, are
responsible can be influenced through methods based in learning
theory and social psychology. When the socio-behavioural
dynamic of the illness state is approached as if it were
Gisease(-like), the result is often increased morbidity through
unnecessary medication or exaggeration of the sick role. The

hazards of applying a socio-behavioural strategy to the
18

biophysiological dynamic of the disease process are even more
obvious: it is yet to be demonstrated that we can alter

clotting times through persuasion.

While the final events leading to the lesion in CHD are
biophysiological, it is clear that the earliest events are
behavioural and social. Damage done by the combustion of
tobacco begins with the socio-cultural determination of smoking
behaviour. Whatever lipid havoc is wreaked on vessel walls
begins with dietary habits. Exercise, high intensity life
styles, and poor compliance with preventive regimens are all
behavioural. In the ecology of this disease, behavioural
determinants are our main targets in trying to achieve some
degree of control. In the illness state, we cannot ignore
physiology; arrythmias, for example, are well-known to be

triggered by sudden emotional stress.

Infantile Diarrhoea is responsible for about a third of
all deaths in children under five in the developing world.
International agencies have discovered that introducing clean
water is not only expensive but often ineffective. A complex
web of behaviours involved with water use, hygiene and child
care determine how an infection cycle occurs. Dietary, social
and health care customs support these habits and, in. turn, are
founded in cultural beliefs and socio-economic circumstances.
Medical treatment of diagnosed cases is too late, too little

and too expensive. What is needed are low-technology

590

strategies which can be implemented by the people themselves
and which are not culturally disruptive. Socio-ecological
analysis makes it possible to choose a number of accessible,
unobtrusive intervention points which can alter the operation
of the community system to reduce a diarrhoeal outcome in a way

which suits local needs and resources.

In CHD, there are two major problems of which neither, in
the traditional sense, is biomedical: prevention of the
disease, and mitigation of distress and dysfunction in those
who already have it, The disease process itself, once
established, is incurable. In ID, the problem is prevention,
but this also has two parts: interruption of a socioecological
disease cycle, and appropriate response to identified disease.
In both cases, different strategies are needed for the disease
processes and the illness states. Moreover, each depends upon
adequate analysis of interrelated social, physical and

behavioural factors,

Systems Epistemology

A conceptual model, as considered here, is an imagic
representation of some part of a natural phenomenon, devised to
assist us in understanding the operations of the phenomenon,
predicting its course, or manipulating it. We can think of an
expanding series of concentric formulations proceeding from
small or 'sub~' models through larger models and conceptual

frameworks to paradigms and, finally, to a world view or
20

‘Weltanschuung’.

The scope of concepts
For example, we might employ a micro-model of ion transport
across the cell membrane in a renal tubule; a larger model
accounts for the physiological operations of the kidney; the
logical structure within which the 'kidney model' must be
understood is homeostasis; the paradigm in which homeostasis
finds its home is a cybernetic variant of natural science; and,
finally, such paradigms are possible only with certain
assumptions about existence, causation, and time. We are
usually concerned with the first levels of abstraction, but
cannot disregard the impact of paradigm shifts: notions of
homeostasis, systems dynamics, and the ‘selfish gene', have all
had palpable impact on health theorizing. The probablistic
view of causation which arose in both small particle physics
and biology over the last half-century has affected such
matters as how to understand the multifactorial etiology of

heart disease [24,25,26,27].

A conceptual model comes into being in response to a
problem. Its survival depends upon its degree of 'fit' with a

problem environment. Models which breed successful solutions

591

2.

tend to dominate those which do not. However, as occurs in the
relationship between any organism and its environment, the
interaction between the model's progeny and the environment
changes that environment. As problems are solved, the
environment is changed simply by their having been subtracted
from it; for example, the increased incidence of the cancers is
due almost entirely to the elimination of other life-shortening
disease, The health field shows another way in which the
problem environment is affected, through the impact of
unsuccessful solutions. The misapplication of biomedical
strategies to behavioural-existential disorders has, to cite a
widely disussed example, resulted in an epidemic of
psychotropic drug use. There are also indirect effects, such
as the steering of cultural priorities through allocation of

resources to technologies.

The more successful a conceptual model, the more
certainly and rapidly it will be found interacting with a
problem environment different from that for which it was
originally devised, To be continued in use, the model must be
progressively modified (updated); the existence of unsolved
problems and exceptions to the rule must be denied or
attributed to factors outside the jurisdiction of the model;
special solutions for these new problems must be devised, in a
way which is apparently consistent with the model but also
separates these problems from it; or a successor to the model

must be devised. All of these things have occurred in the
592
22

recent history of biomedicine, ‘The more completely and quickly
a conceptual model is applied in the real world, the more
clearly the limits to its utility are discerned. One would
also predict, however, that a conceptual model would not lose
its utility for the solution of at least some of the problems
for which it was originally constructed, This is true also for
physics; Newtonian mechanics is still very useful for building
a house, and played a large part in getting us to the moon.
This model of models portrays a (health) concept as a tool
interacting with a system of problems, beliefs, institutions,
technologies, and roles, Efforts (as in Kuhn's ‘normal
science’) to keep it static have the same distorting effects
one would expect in any system [28]. Changes in any part of
the system will, if equilibrium is to be maintained, be

reflected by adjustments elsewhere.

Thus, the biomedical disease model was/is not 'wrong', although
its utility with respect to the modern problem environment may
be less than in its original environment; its future can only

be grasped within such an epistemological system.

Impacts and Implications

One response to the ‘information explosion' in some
medical school curricula has been to emphasize "how to learn"
over “what to learn". Students learn information management
and the critical appraisal of evidence to survive in a sea of

data. It is clear, and quite consistent with scientific

23

tradition, that conceptual fluency is a crucial skill in this
information management. Changes in the problem environment
brought about by the deployment of biomedical strategies have
created the need for a broader repertoire of conceptual tools.
Each has its appropriate application; which is to say, each has
a unique problem environment, or epistemological system. The
student must be able to discriminate between concepts and to

judge their performance.

A systems approach has changed our views of causality and
of the nature of what we are studying. Simple linear causation
is seldom even an acceptable approximation; in the 1950's, a
student would have been failed for not saying that the tubercle
bacillus is the cause of T.B., and today would be failed for
saying that it is. We now have determinants and risk factors,
rather than causes. Students learn how to formulate the most
useful hypotheses, rather than to have a store of answers.
Probabilities dominate facts. Prevention and the avoidance of
iatrogenic morbidity do not demand new treatments, but call for
attention to the system out of which disease and illness have

arisen.

The shift toward a population perspective is more than
just epidemiology coming of age. All the manifestations of
ill-health - symptoms, emotions, behaviours, roles - are
essentially interactional phenomena [29,30,31,32]. Indeed, the

individual in all her/his healthy or morbid aspects is the
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24

interaction between biophysiological and environmental systems.
This organizational model can be seen in the structure of the

M.D. curriculum at McMaster University.

socienes POPULATION penvecrIvE
communes exrenat
‘omen racrons
evavionat rensrecTWe
ne INTERNAL
resus racrons
caus B1oLoaica penarecrive
mouecues

The content areas are social-environmental systems (‘population
perspective’) and body systems (‘biological perspective'), and
the "behavioural perspective’ which is at the interface between
them. Studying all individual health, disease and illness
phenomena as products of the interaction between body and human
ecological systems significantly alters the student's task. It
also relocates medicine (or, better, ‘health studies") as a
sub-set, simultaneously, of human biology, the social and
behavioural sciences, and the humanities [33]. Many otherwise
perplexing clinical and preventive dilemmas become not only

understandable but predictable,

For the relationships between technology, society and
ideas, the modern history of biomedicine provides an ideal case
study. ‘There probably has never been a combination of
technique and concept applied as widely, rapidly and
confidently as in the large-scale health systems instituted
since WWII. This is where we can learn about both systems as

concepts and concepts as systems.

25

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