Chaos and complexity: New practices for an emergent concept of family health in a Brazilian experience

Ivan A. Guerrini
State University of S. Paulo, BRA

Regina Stella Spagnuolo
State University of S. Paulo, BRA


The so-called theories of chaos and complexity developed in the second half of last century look at any natural phenomenon from a radically different point of view. In fact, from this new perspective, any natural phenomenon is seen as an Adaptive and Complex Dynamical System (ACDS), subject to the Butterfly Effect, the extreme sensitivity to initial or external conditions, and generating patterns of all kinds. Together with the basic ideas of complex living systems (Bak, 1996; Kelso, 1999) they are generating a revolution in science (Bohm & Peat, 2000). It has been emphasized recently that ACDS are open, evolving, creative and robust systems (Carlson & Doyle, 2000; Kitano, 2002, 2003; Aldana & Cluzel, 2003). Along with the principles of Quantum Physics and the recent Systems Biology, this new theory calls for an educational trend in teaching and research in terms of what has been called by Morin, (2000) and Nicolescu, (1999) as a transdisciplinary approach. These issues have been debated at the International Transdisciplinary Congresses already held in Europe in recent years and supported by UNESCO. In this short discussion paper we will be presenting some aspects of what might represent this new approach as applied to family health-related problems in a Brazilian context. In order to search for emergent properties and other levels of reality as the transdisciplinary approach states, a new complex and dynamical definition of health is required. According to West and Deering (1995), an old and homeostatic definition of health is a very well defined point of equilibrium to which any living system has to be brought back to if for any reason it starts to move away. That concept is being replaced by a homeo-dynamical one in which health is the condition where an individual has the access to a constellation of complex and interconnected system of points. In the eyes of the new science, the individual in this situation is within a region said to be ‘far-from- equilibrium’ where even matter ‘starts to see’ (Prigogine, 1996). The question that we propose to deal with here is: how do we apply this new concept in family health? In this sense, a small and subtle but decisive experience has been carried out in Brazil. With the background in Chaos and Complexity Theory, Transdisciplinary Education, Quantum Physics, Systems Biology and related topics being constantly studied, reviewed and discussed, we have worked hard in order to put these ideas into practice. In doing so, alternative and systemic treatments have been the focus in an official health unit maintained by the Federal Government Program in Brazil called Programa de Saúde da Familia (Family Healthcare Program). This experience has been carried out in the city of Botucatu, State of Sao Paulo, in one of the seven units called Jardim Iolanda, where the health staff is constituted by thirteen professionals among which, there is one physician and one registered nurse. Natural flowers, homeopathy and other natural and nonconventional methods constitute the mainstream of the prescribed medication in that unit. However, by no means has classical and conventional medicine been disregarded when necessary. Through study and practice, professionals involved in this case are learning how to identify patterns of health in the individuals and in their family, either good or bad, and evaluate those patterns as attractors (fractals) to be wanted or avoided. Cancer patients have received special attention, once the disease has also been analyzed as an ACDS which tends to maintain its robustness and differentiation in order to evolve (Kitano, 2003; Harris, 2004). An understanding of the human being also as an ACDS, where the whole family integration and interconnections are decisive, along with other proper therapies and alternative medications, has been a successful approach in many instances as is evidenced by a number of cases.

An overall evolution of the main philosophical ideas will be presented here as necessary for the ultimate comprehension of this study. According to Huertas, (1996), this review will allow anyone to understand what is the real meaning of these new trends in health science and especially in health family practice. Discussions will cover topics like, why is the scientific community and society being called to acknowledge and embrace a new paradigm which encompasses the new discoveries of the last century in a deeper sense? Bioethical aspects of this new approach, methodologies, use of new medication and other practices will also be discussed following the directions of a very recent debate raised by Guerrini, et al. (2002) and Guerrini and Spagnuolo (2004).


In his “Lesser Writings”, in order to defend a radically different paradigm in medicine, Samuel Hahnemann argues: “How can small doses of such very attenuated medicine as homeopathy employs still possess great power?” (Ruiz, 2002). Should we compare it to what Edward Lorenz said about the Butterfly Effect in 1960s: “How can the flap of a butterfly wings in Amazon forest cause a tornado in Texas?” With his discoveries in weather studies, Lorenz was starting to develop Chaos Theory and bringing to light the so-called Adaptive and Complex Dynamical Systems (ACDS), those systems which are subject to the Butterfly Effect, and develop dynamical patterns of behavior, i.e., natural fractals. Philosophical arguments brought about by these two views in science might be contrasted with other scientific evidence given the surprising increase in the use of alternative medicine. Should it be pointing toward an interpretation of the human being as an ACDS? Would that make the controversy of allopathy versus alternative medicine more understandable? In fact, the subtle and immaterial part of a dynamized homeopathy medicine would then be very efficient for such an open system as a human being treated as an ACDS. Other branches of alternative medicine would look at the human being as an open, whole system as well, generally including the transcendent and non-material dimension, which requires a transdisciplinary approach. The more the system is open, the more the immaterial would emerge and the more efficient the alternative medication would work. Likewise, the more closed the system of a human being, the more the material is reinforced and the urgent necessity to employ allopathy exclusively. For the broader complex view, however, emergency cases would necessarily use allopathy, as in nature an ACDS would need a classical approach in limiting cases where the system can be treated as a simple one. For a human being to be treated as an ACDS, no possible tools of efficient inner knowledge offered by transpersonal psychology, for instance, should be neglected. Another reason why alternative medicine is to be confronted and continuously challenged by classical science is that the latter offers quite a restricted ‘one dimensional’ view of reality as compared to ‘multi-dimensional’ transdisciplinary approaches.

In this short discussion paper, the vision of the human being as an ACDS has allowed to incorporate, in practice, the use of alternative and non-conventional medicine in an official health program in Brazil. This way, the working team itself felt the necessity of creating conditions to be an open system also, an ACDS as well, with qualities and difficulties that will be discussed herein.

Brief ideas on chaos, complexity and transdisciplinarity

It is commonly accepted that so-called modern science was born in 17th Century and is based on the ideas of Bacon, Galileo, Newton and Descartes, among others. It is often referred to as deterministic science and also as reductionism, mainly because of the analytical and specialized method proposed by Descartes to facilitate the study of any system in nature. It assumes that a natural system is a machine and can be broken down into its small parts in order to be studied. Prediction of the behavior of the systems studied is, according to this approach, desirable and assumed to be possible. The discoveries of the last century, however, have caused an enormous disturbance within the scientific and academic media, challenging their philosophical and epistemological grounds. Firstly, Einstein’s Theory of Relativity changed the way we understand general concepts such as mass, length and time. In fact, very few were prepared to deal with a nonlinear time at the beginning of the 20th Century and to accept that the mass of a ball would increase with its speed when approaching the speed of light. Then, by the 1930s, the first quantum effects revealed the necessity of a yet deeper revolution in the fundamental base established in 17th Century science. Three decades later, the emergence of chaos and complexity theories showed that the uncertainties of the micro-level revealed by quantum theory in the 1930s was, in a sense, being expanded to the macro-level. These sources of scientific unpredictability started within meteorology, but were soon extended to any natural system. Complex and dynamical systems are subject to the so-called Butterfly Effect, i.e., they display an extreme sensitivity to the initial or external conditions, as well as forming different patterns in space and time. The term Adaptive and Complex Dynamical System (ACDS) has been coined for such systems. Such patterns were first referred to as fractals by Benoit Mandelbrot, a polish scientist who initiated his studies within mathematics and computational science.

Recent analysis (Guerrini, 2003; Guerrini & Spagnuolo, 2004) of the first years of the millennium suggest that during the last decades, scientists who have been aware of these incredible epistemological advances in all branches of science have felt the necessity to focus on the behavior of the irregular patterns of their studies, and that was the reason why Fractal Geometry gained so much space in the scientific media. In that sense, methods to determine the fractal dimension of any system spread in different types of scientific publication during the last two decades. Of course, as a new branch of science, scientists are continuously searching for different methods of investigation and interpretations for the dynamical patterns formed by ACDSs and many doubts and difficulties have arisen.

Meanwhile, a new fundamental base necessary to comprehend the many transformations in science was emerging among educators and philosophers of this time: the transdisciplinary approach. Built mainly within three different international meetings, the transdisciplinary approach, according to Nicolescu, (1999), recognizes many dimensions of reality, opening spaces for the interpretation of some bizarre quantum effects as well as many consequences of the complex view of the Universe. It also opens the possibility of reintegrating popular (common sense) knowledge along with other branches of human knowledge to be used in promoting healthcare based on an integrative view of the human being. In doing so, the human being might be represented as an ACDS, an open system. In that sense, Guerrini, (2003) reinforces that the study of any complex system today should be concerned with the irregular patterns formed by the system and be followed by the new transdisciplinary approach.

Family healthcare program

In Brazil, the Family Healthcare Program (FHP) was born based on the positive view of the old idea of family doctor. During 1973 and 1979, efforts coming from the World Health Organization (WHO), Brazilian Nursing Association, Oswaldo Cruz Foundation (FioCruz) and the Brazilian National Institute for Social Security (INAMPS) were directed to consider the role of the so-called family doctor. Starting from 1994, with the official institution of HFP, the family doctor program, an assistance-based and medical-centered medicine, was transformed into a family healthcare program, reinforcing some elements of the original proposal, like the humanization of caring and the link between service and the medical program users (Paim, 2001). Today within the FHP, however, the focus on healthcare is not based on the family doctor anymore. The working team, with its dynamical webs, is essential to the treatment of the patient and his/her family, also regarded as forming webs of relationships. So, the program, the working team, the patients and their families are all being assumed to be ACDSs where new and flexible rules come to effect.

In Botucatu, a city with approximately 130 thousand people, located about 150 miles southwest of São Paulo city, the FHP was introduced in May 2003 with seven working teams. Each team was constituted by a medical doctor and a registered nurse, among other professionals. Students and trainees were also accepted in a regular basis. During the first year and a half the Jardim Iolanda team (FHP-JI) has been working with a total of thirteen professionals besides four grad students in nursing and medicine in a very poor area about four to six kilometers from downtown Botucatu. The group of FHP-JI has gained special attention for its outstanding performance among all others in the city and some results, to be presented here, are related to its experience.

Family health as a ACDS: An open system

Traditional medicine is based on classical science and when one studies the new discoveries of the 20th Century it becomes clear why the conventional Allopathic Medicine, which is deterministic and linked to reductionism, is desperately fighting to sustain its position. Since the formation of the FHP teams in Brazil, approaches on healthcare based in the classical science have been challenged, mainly because of its old and linear model of communication (Huertas, 1996; Morin, 2000).

When families as well as health family working teams of the FHP are be seen as ACDS, patterns of behavior are sought instead of linear paths. Uncertainties are allowed to prevail instead of deterministic answers. From this perspective, webs of relationships forming chaotic or strange attractors, i.e., dynamical fractals according to chaos and complexity theories, are no longer issues exclusively for physicists and mathematicians. As long as they depart from simple systems and transform into ACDS, those systems turn out to be open systems, without authoritarianism and plenty of creativity and life. In the view of Bohm and Peat (2000), those open systems are chaotic and auto-organized, avoiding the need for manipulation. Learning the lessons of creative chaos, one should take advantage of the auto-organized systems instead of resisting to accept them. General archetypes, however, still demand long range predictions for the systems as well as the completely controlled behavior of its members. The new science, on the other hand, searches no more for linear and predictive behavior, but for irregular and dynamical patterns of their own, where creativity can emerge unexpectedly.

It is important to note that the FHP was introduced at a time of great scientific transformation. Once the new vision had found room to be adopted at a theoretical basis within healthcare related projects in Brazil, FHP constituted one of the first official health care programs trying to bring to practice the advancements of the new scientific discoveries. This new paradigm in health sciences, as we may name it, might be considered ethical, responsible and quite appropriate in our new age according to West and Deering (1995), Huertas, (1996), Bak (1996), Bohm and Peat (2000) and Mainzer, (2001).

Questions arise, however, concerning the conditions under which one could apply this new paradigm in practical services. What would be the differences in strategies for the new approach to be applied? What kind of particularities should carry the working teams? What kind of courses should the team enroll and what type of consciousness is expected and possible to achieve when the hard reality is taken into account? So far, there have been good tentative experiences to answer those questions, mainly in terms of the real and profound desires to change the healthcare program in a developing country with so many differences and problems like Brazil (Spagnuolo & Guerrini, 2005).

A successful Brazilian experience

During this first year and a half of implantation, the FHP-JI working team has developed actions of health prevention and promotion in order to improve the life quality of its population. These actions have been directed to families in an open and dynamical view of health so that they may be allowed to mobilize their own resources to achieve what is called their health dynamical state (West & Deering, 1995). Although conventional medicine has not been disregarded at all, herbal medicine, homeopathy and other alternative and popular medication have been regularly prescribed to patients with very good results.

Working groups within the community were created to maintain a valuable link between the FHP team with people who live in their covering area of action. Those groups were defined as: walking for all, women’s space, children’s spot, hypertension and diabetes pals. For each one of those participating groups, each containing approximately ten people, there is a weekly meeting to encourage actions that improve life quality with the emphasis on preventative actions.

It was also created a Health Local Council, open for participation for all community to discuss adequate healthcare political actions to their covering area.

Main difficulties could be related to human and financial resources. It is not easy nowadays to find open-minded professionals to work hard in a public healthcare promotion team, willing to learn how to bring into practice the new scientific paradigm. Although it would certainly be necessary to significantly improve the financial budget, the FHP-JI team has been learning to use creative means to overcome such budgetary restraints. The advancement developed within the working groups cited above was only possible because of the tremendous efforts, combined with topics of creativity, that the leadership of FHP-JI helped to construct.

Another point to be highlighted during this initial period of action of FHP-JI is the possible introduction of a new product developed to help in many degenerative diseases, nutritional deficiencies and other damage resulting from cancer. In fact, Tivallec®, a mineral supplement authorized to be sold regularly in pharmacies by the official Brazilian Agency of Sanitary Vigilance (ANVISA), has shown excellent results when administered to treat the different consequences of cancer (Guerrini & Spagnuolo, 2004). Ethical aspects of the use of this product have also been discussed within the academia during recent years through the details of case studies (Guerrini, et al., 2002). Although with extra caution, Tivallec® is being considered to be recommended for patients who agree to it in an already confirmed non-toxic base dosage. This is happening without interference or interruption to (or from) the conventional treatment normally prescribed by the overall medical system.

Herbal medicine and other alternative methods have also been introduced and regularly used during this initial period of functioning of FHP-JI with great success. Tansagen (Plantago major) and chamomile (Matricaria chamomilla) teas, for example, have shown excellent acceptance with very good results in treating dermatitis in children below two years old. Also with good results is the use of those teas to treat other types of dermatitis in adults, although the data has not yet been compiled.

In general, monthly meetings with the working team and the whole community have endorsed the great positive impact in public health carried out in the area of implantation of the program. The poor people who live in the region of FHP-JI are starting to gain confidence in the proposed open healthcare system which is very different from the conventional model. They are being nurtured by it and learning to use the popular and natural medicine more frequently with constant advice from the team of professionals.


After a year and a half since their creation, the FHP-JI working team of Botucatu-SP, Brazil, has been evaluated as a successful Brazilian experience by the mentors of the official Brazilian Program. In fact, by October 2004 a mission of the Health Brazilian Ministry, with emphasis in healthcare integrality goals (LAPPIS), visited the unit in order to collect experimental data and results obtained by the outstanding working team. Integral actions in healthcare promotion envisaged by that group called the attention of the offices of Government Health Ministry in Brasília. They wanted to hear from the registered nurse, the head of the team, about the actions taken in this relatively short period of time that brought FHP-JI to the limelight as a positive example of the healthcare improvement carried out there. As mentioned above, the approval received mainly from the more needy people who really use the FHP-JI services on a daily basis, has been positively indicated a while ago during the monthly meetings. Reasons to keep going in the direction of always implanting new ideas and methodologies, based on what is known as an open system, are definitely not lacking at this stage. As Paim, (2001) pointed out, each particular reality in Brazil would define the FHP working team and its performance differently as the country has a very complex and heterogeneous population. In that sense, FHP-JI, in its particular search and evolution, has found its own path with excellent results so far. In doing so, healthcare is not centered around traditional medical teams anymore, nor a registered nurse, a medical doctor or any other professional specialized in whatever area. Rather, in good agreement with Solow and Szmerekovsky (2004), in an evolving community like that, it is often the case that the individuals tend, over time, to become more specialized in performing the tasks necessary for survival and growth of the community as a whole. In fact, all conventional and nonconventional activities and prescriptions related here emerged as necessities of the population, exactly as proposed by the concept of an ACDS within the context of chaos and complexity theories. In other words, that functional specialization emerges naturally within the group, rather than initially placed as necessary settings. In this sense, in order to achieve the goals of a new and integrative way of promoting heathcare in Brazil, uncertainties and unpredictabilities rule this open system of the FHP-JI team, which is governed by creativity and professionalism.


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Commentary by Richard Knowles
The SOLiance Group, USA

This paper is an outstanding example of how the ideas coming out of the work on chaos, com­plexity, complex adaptive systems and complex responsive processes can be applied to help a team of health care professionals, the patients, the families and the community. Building on these ideas, they created the conditions for a better way of working and effectively self-organized so that health care was more quickly provided and accepted by those who were involved; they believed that their collective actions would improve both health care and promote an improved quality of life in the population at minimal costs.

The way the Family Healthcare Program (FHP) was set up created the conditions where an open flow of all the information could take place; where people were treated with respect and valued thus allowing trust to emerge; and where everyone could see how their role in this way of working improved both the understanding, effectiveness and coherence of the health care delivery for individuals, the families and the community thus leading to an improved quality of life.

Sharing information, building interdependent and trusting relationships and helping everyone to see their identity within the larger picture are the condi­tions for purposeful self-organization to take place. While self-organization is going on all the time, the way the FHP-JI worked set the conditions for the emer­gence of self-organization focused around improving health care.

This is the process of Self-Organizing Leader­ship©. This process was connected to doing the real work that was associated with improving the quality of life and health care delivery. This connection to real work prevented the process from degenerating into just sitting around, feeling good and talking things to death without achieving anything. “Health care is not medical centered anymore” rather it is now embraced by the community.

“This ethical, responsible and quite appropri­ate” way of working together quickly produced quite extraordinary results at a very low cost. This is quite consistent with my own experiences in working this way with organizations of all sorts over the last 20 years.

As people worked together in this way the positive results of their work quickly rose to the atten­tion of the offices of the Government Health Ministry in Brasilia thus providing support for further work for this way of promoting improved health care in Brazil.

Commentary by David Boje
New Mexico State University, USA

The essay by Guerrini and Spagnuolo makes some assumptions about the relationship between open systems and complexity I would like to comment upon. Their assertion is that Adaptive and complex dynamic systems (ACDS) turn out to be open systems, they are auto-organized, and we can take advantage by not resisting them.

I see a problem here that takes me back to my mentor Louis R. Pondy. Pondy’s (1976) “beyond open system theory” model, later revised with Ian Mitroff (Pondy & Mitroff, 1979) raised a classic challenge to the field. Using Kenneth Boulding’s (1956) models of orders of system complexity, they challenged the field to move beyond level four (open system theory) to the higher orders of system complexity. These higher order levels of system complexity involve humans with brains using language and symbols to communicate.

In first cybernetics, the Shannon-Weaver (1949) sender-receiver-feedback loop model was adopted by von Bertallanfy (1956, 1962) as the basic language model of open system theory in the 1950s. The calamity of this line of inquiry is that information processing models presume a monologic language theory.

The second cybernetics movement was sup­posed to take the field of complex systems beyond simplistic information processing models. Maruyama (2003) summarizes the rise of second cybernetics since the 1960s. His own contribution is to argument deviation-counteraction loop (of first cybernetic) with the second loop of deviation-amplification loop. Maruyama, and Pondy and Mitroff’s work moves us away from the sender-receiver-feedback loop, into the possibility of a less monologic view of system theory than what is presented by Guerrini and Spagnuolo.

A heteroglossic language theory (e.g., Bakhtin, 1973, 1981, 1990) argues that there are many languages in complex systems, and that these interact in ways that form deviation-counteraction and deviation-amplifica­tion dynamics. Here is one way to integrate Bakhtin’s language theory with Maruyama’s second cybernetic model. Heteroglossia for Bakhtin (1973, 1981) is defined as the relativity (in an Einstein sense) of centripetal (deviation-counteraction) and centrifugal (deviation- amplification).

In sum, the essay is an open system theory, but one that is at level four of Boulding’s model of system complexity. To get to the higher order levels it is necessary to engage with second cybernetic in ways that do not constrain it with monologic language theory. This, I think, can be done by attending to the relationships between medial language, administrative language, and language of community practice. It is in the ethnographic study of these language interactions, that higher orders of system complexity understanding can be realized.


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Commentary by Ken Baskin
ISCE Research, USA

As I read through this article on an experimental healthcare program in Brazil, I realized that I was having a double reaction. On one hand, it brought me back to a three-day workshop on complex­ity in healthcare systems that ISCE sponsored several years ago; on the other, I found myself hoping that this will be the first of several articles on this experience. In many ways, the dysfunctions in healthcare systems around the globe make them among the most ripe of our social systems for the application of complexity principles, and the literature documenting such ex­periments is beginning to accumulate. The Brazilian experiment is among the most exciting; so much so

that it might be valuable for this journal to ‘adopt’ the experiment as a focus for examining how to apply complexity principles to this deeply troubled sector of our social system.

But I get ahead of myself. In reading this article, I thought first of the ISCE workshop because many of the principles of the Brazilian experiment conform to the conclusions we reached in our three days together. The workshop brought together about 30 people - in­cluding nurses, doctors, healthcare administrators, academics and consultants - from the United States, Canada, Great Britain, the Netherlands, and Sweden to discuss the insights available when we examined our healthcare systems in the light of complexity studies. For the first day and a half, members of the group staked out their positions, provoking extensive dialogue where, for the most part, participants explored each other’s points of view, rather than arguing them. By the end of the second day, we’d reached several conclusions: that, from a complexity viewpoint, health was a more than the absence of dysfunction; that the healthcare system incorporated a great deal more than the community of healthcare professionals, and espe­cially the family and friends of any individual; and that the appropriate social level to address developing and maintaining people’s health was in their communi­ties.

These conclusions, it seems to be, lie at the heart of the Brazilian experiment, and even the one problem cited in the article repeats the experiences of workshop participants. The idea of locally based working teams, for instance, or those teams’ focus on treating “the patient and his/her family” are exactly the sort of approach we had discussed in the workshop. Similarly, the devotion to health “prevention and pro­motion to improve life quality ... directed to families in an open and dynamical view of health so that they may be allowed to mobilize their own resources...” reflect the same habits of mind that a complexity perspective excited at our workshop. Finally, the authors note that it is difficult “to find open-minded professionals to work hard in a public healthcare promotion team...” is exactly the kind of reaction that a complexity perspec­tive suggests in any attempt at radical change. Similarly, in the workshop, one British nursing manager pointed out that the dominant system was so powerful that attempts to change it ended up reinforcing it.

As I noted earlier, I hope this experiment can excite a series of articles. For one thing, it kicks up some important public policy implications. What are the conditions that enabled this experiment? Would such an experiment be possible in more affluent areas? One of the examples in a recent book, Complexity and Healthcare Organization (see my review issue 6.3

of E:CO), suggests that successful community-wide projects are possible in deprived areas of Great Britain. Whether they would also be accepted by the profes­sional healthcare community in wealthy communities in London seems less likely. What can we learn about these more ‘political’ issues from the Brazil experi­ment? Similarly, a more nuts-and-bolts approach to how the teams work in their communities would be highly valuable. How do they use existing social net­works? Have they created new ones? What have they done about those, if any, who resist the experiment?

These are just a few of many questions that this article excites in a field that, perhaps more than any other, recognizes the possible contribution complexity thinking can make. I hope this journal makes an effort to begin getting some of the answers.