In much of the modern world, objective truth rules. Objective truth is not swayed by the vagaries of subjective experience, preference, emotion and interpretation. Certainty prevails and we all know where we stand in relation to the world around us. Objective truth is central to the medical model of care. The system requires clinical outcomes over social outcomes, success over failure and clarity over confusion, all driving us inexorably towards a truth that is independent of human experience, networks (or Assemblages, as previously discussed) or bias. Medically we elevate causation over correlation.

Not so in the messy world of online communities. Social outcomes sit alongside, sometimes higher, than clinical ones. Failure can be prized as much as success as in an information rich environment all experience contributes to learning. Confusion reigns, certainly in terms of developing a finite and definitive view in an environment where the data sets we collectively generate are so large and complex that it is impossible to grasp a coherent understanding of an issue. Correlation wins out over causation in efforts to make sense of the world.

Medically we castigate the social: the plural of anecdote is not data; user generated content gets a bad rap; patient reported data is inherently biased. The list could go on.

Socially we rebuke the medical model: the important outcomes are social; innovation happens in relational, expansive systems, not transactional reductive ones; focussing-in means we miss the big picture and the important connections that lead to better care.

The medical and the social, for all intents and purposes, operate in different realms. However, objective truth still calls the shots in terms of resource allocation, decision making and operation of our health services. This is stifling, crippling even, attempts to harness the big data generated in the online communities that run on those exact vagaries of subjective experience, preference, emotion and interpretation that the current system defends against.

Bemoaning the medical model has a long history in medicine but perhaps the iron rule of objectivity is softening as it becomes clearer that all understandings of ‘objective truth’ are much more complex than the 20th century stories we still use in medicine. On the social and political sides, the world of complex adaptive systems explains why policy making has less and less connection with what happens on the ground. The nature of power is itself changing[i] and becoming more relational. Concepts like entanglement, and assemblage theory parlay a more nuanced approach to influencing others, systems and pathologies into the clinical space.

Just as significantly there is a profound shift on the scientific side where the complex interactions of genome, proteome, biome are leading to what has been termed the ‘evo-devo-eco’ revolution[ii]: our individual biology is not so much a machine as a never ending dance in which symbiosis, phenotypic expression, environmental stimuli and disease are part of an immense ever-shifting web of interactions.

These shifts still have a long way to go to reach either patients or the street level bureaucrats whose actions instantiate the day-to-day reality of the NHS. Nevertheless many of the concepts we discuss here – scale as a bug, patients as adults not children, gift economies not market economies – fit easily into these relational frames which in turn gives hope of new, more fluid ways of understanding health and disease opening up as the 21st century progresses.



[i] The End of Power. Why being in charge isn’t as much fun as it used to be. Moises Naim Basic Books 2013

[ii] The best overview of the biology of this revolution is ‘Ecological Developmental Biology. The environmental regulation of development, health and evolution’’. Gilbert S, Epel D. 2nd Edition Sinauer Associates 2015.


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