This is the inaugural article for my new open-science journal venture, Orgcomplexity. It was published as “Uncertainty, health and the teetering social contract.”

I am excited to be the Founding editor. This is is a free-to-publish journal for intellectual misfits that do not shy away from the complexities of health (broadly defined) and are not afraid to write about it.

This journal is housed by PubPub at

You can also follow the journal on Twitter at @orgcomplexity and on Facebook.

While the call for submissions and author instructions will not be publicly available until early to mid 2017, this article gives of flavor of what the journal will offer.

This commentary is based in part on a podcast discussion with All Things Risk in August 2016. [1]


There is nothing more uncertain for people than why they are not well. In the physical world, the perfect state would be absolute absence of error and total resilience to uncertainty. While we cling to what a perfect conception of our health can be, the margin of error between the conception and achievement of that health is tied in part to risk and uncertainty. If the uncertainty of health is framed as something that is inherent to social systems that should not be feared but harnessed, I contend that the public can confidently uncover the resilient patterns of health that make us infalliably, wholly human.

Damn social complexity–Why can’t we be Golgi bodies?

I once said that health is a personal narrative. That we see ourselves like a history of all of our life events’ stories in our bodies. I still agree in part but I think that there is more to this. We are more than passive vacoules waiting to filled up and fired up upon command. We are not cells; we are composed of them. Our bodies are acted upon from the inside and outside all the while synchronally operating as social agents with oblique intentions. Once our bodies come in contact with a foreign environment, these once insulated, lurker agents are no longer closed off or unblemished. Once the lurker agents enter the world, they must contend, along with other blemished bodies, with the social uncertainty and the effects of collective risk in the open social system. Health is not merely a deterioration of bodies. How well these biological cells work as systems may indicate physical sanctity, however health indicates how each of us stack up to clinically and socially accepted parameters of well versus sick. Human fallibility is a universal state of living flawed in imperfect physical, political and organizational states. Thus, our universe is wrought with doubt and ambiguity forcing us to deal with risk and uncertainty as a civic collective.

Uncertainty is elemental to social complex systems. Midgley [2] revisited four distinct domains of complexity that he introduced in the early 1990’s. They remain:

1. Natural world complexity–Biological systems with some element of expected regularity and accuracy in process and outcome, or as Midgley calls it, “what is.”
2. Social world complexity–A war of intentionality versus actual action, or “what ought to be.”
3. Subjective world complexity–The counselor’s comfy couch for society to get at its feelings and ethics, or “self or another.”
4. Complexity of interactions–Slap together the first three domains and you have a “small” universe that is not so random after all.

The massive uncertainty of being well involves all four of these domains. Imagine for a moment the immensity of harnessing all four of these to stay well. This is what we are expected to do to stay “healthy.” I love Albert-Laszlo Barabasi’s book chapter, “Predictably Unpredictable” [3]. Barabasi [4] wrote that unlike protons that can be predicted with an acceptable level of accuracy, “humans tend to seek new experiences in a continually changing world, making it difficult to foresee their long-term actions”. Health is the epitome of uncertainty. Batty [5] made a comparison of cells to the living kind composed of them, stating that “the essential distinction between agents and cells is that agents motivate their own actions.” Our human actions are not immune from risk and uncertainty. Better yet, being imperfectly human is the quintinity of the four domains.

Uncertainty, not your run-of-the-mill gobbledygook

We live in a universe, one that is elegant, ordered and sophisticated, while unabashedly, simultaneously wicked. The inherent complexities of this world bring along risk and uncertainty as travel mates. Risk and uncertainty deal with issues of doubt and ambiguity on an outcome. However, they are symbiotic but not interchangeable. Risk is when we do not know the outcome but we can ascertain with measurable precision the distribution of possible outcomes. While we also do not know the outcomes when dealing with uncertainty, we do not have the ability to know the possible distribution of outcomes. As we tire of fighting the wicked nature of the world, we hold fast to a perception of risk that allows us to sleep at night. Risk modifies perception which likewise affects our acceptance of risk. We want to increase social utility therefore we become risk averse. Or we take our chances and bet the odds that we can beat the health risk. The problem that can occur when evoking health is that the origins of risk may be too multifarious to fully comprehend. In the throws of failing health, equanamity may be less likely. But in order to be healthy, harnessing uncertainty is paramount and the unwise risks often catch up with our health with suboptimal outcomes. So what is a flawed human in a flawed public, that motley crew of meliorists hanging on by a thread to do? Plunge into the unknown, wisely but not wantonly.

In 2002, the U.S. Secretary of Defense under G.W. Bush, Donald Rumsfeld was being grilled for starting a military offensive in Iraq. Politics aside, then Secretary Rumsfeld mystified pundits and the public alike. From the most unlikely oracle came a classic understanding of complex social systems. I offer the infamous quote and CNN video YouTube link below in the refenences [6]:

“There are known knowns; There are things that we know. There are known unknowns; That is to say, there are things that we now know we don’t know. But there are also unknown unknowns. There are things we do not know we don’t know.”

Be careful to pass hasty judgment on the rhetor. Byrne & Callaghan [7], in their book, Complexity Theory and the Social Sciences, dismissed the widely propagated view that Rumsfeld’s statement was “classic gobbledygook,” advocating that we must be able to accept some “level of unknownness.” For clarification, if something is known and measured, it is a known known. If something is known to influence but cannot yet be measured, this is a known unknown. Rumsfeld tapped into the uncertainty principle (attributed to German physicist Werner Heisenberg), “the more you know where an object is, the less you know where it goes.” [8] Does not health seem so close but so far away?

Science (usually) embraces unknowns but unknowns in our health (often) make us nervous

Science as a discipline is used to uncertainty. Scientific inquiry is all about ascertaining the known unknowns [9]. When science uncovers something that is out of the ordinary, it is not immune to skeptics. Anything orthogonal falls outside of “range of known (scientific) possibilities…(resulting in) unexpected…unknown unknowns” [10]. Once the complexity leaves the natural world into the world of the social, there may be apprehension in accepting the unknown unknowns. We find comfort in static measurement of our world. At time X, we found out this, so this is our new accepted reality. We want life to follow a design, which is to say, there had better be nothing that we personally cannot control. Accepting the appearance of complexity over time should, at least in theory, easily confute simplified explanations which misrepresent social reality. There is the adage that you should roll with the punches. I am unsure how much that really applies when some of the punches are completely unexpected and are iteratively wicked.

Medical sociologist, Renee Fox [11] pioneered studying the existence of uncertainty in clinical medicine. While studying the effects of uncertainty inherent to physician training, Fox noted that a “rise in public expectation (was) paralleled by a lowered tolerance of uncertainty” [12]. In terms of medical decision making, Han et al. [13] framed uncertainty as a “meta-cognition…(a) subjective perception of ignorance (based on incomplete knowledge).” I would perhaps rephrase Han et. al. and say that uncertainty is the misperceptions to lapses to unknown unknowns coupled with lapses in knowledge to known unknowns.

The big take home

There is a difference between discredited and discreditable health realities, the seen versus the unseen. It is a part of the human experience that we are uncomfortable in the world. Some elements that marginalize and impress our lives must be worked over to figure what might be likely to happen. When uncertainty charges forth at odds with the life that we want, we never had pure certainty. In addition to all the unseen factors bearing down out health, there are also social, ethical and behavioral expectations that people must navigate successfully. Health is so personal. If it is not our health that we are worried about, we worry as caregivers and concerned others. Uncertainty be damned, we want to leave this earth on our own terms, having lived a life that aligned with our providence of a “good, fulfilling life.” We want to control how we navigate and vacate this earth. Mind the gap between intentionality and what actually transpires. Comfort may be harder to conjure up if the discreditable and wicked cracks to the mandible land squarely. We just pray for a slight abrasion and a quick recovery.


[1] Sometime I “think” better when I am yapping out loud to a captive audience. Thank you to Ben Cattaneo of the All Things Risk Podcast (@RiskThings,, iTunes, Soundcloud) for the sounding board. This commentary is based in part on episode 20 dated 23 August 2016: “Michele Battle-Fisher: Systems Thinking, Uncertainty, Public Health and Policy and of course, Puffins.”
[2] Midgley, G. (2016). Four domains of complexity. Emergence: Complexity and Organization. 1. doi: 10.emerg/10.173576ffd4f1cee07b1eab0d5ellf6522261b.
[3] Barbasi, A-L. (2011). Bursts- the hidden patterns behind everything we do, from your e-mail to bloody crusades. New York: Plume Books.
[4] Barbasi, A-L., ibid.
[5] Batty, M. (2007). Cities and Complexity. Cambridge: MIT Press.
[6] “Rumsfeld/knowns”. CNN. YouTube
[7] Bryne, D. & Callaghan, G. (2014). Complexity theory and the social sciences. New York: Routledge.
[8] Barabasi, A-L., ibid.
[9] Logan, D. (2009). “Known knowns, known unknowns, unknown unknowns and the propogation of scientific enquiry.” Journal for Experimental Botany. 60(3), 712-14.
[10] Logan, D., ibid.
[11] Fox, R. (1980). “The evolution of medical uncertainty.” Milbank Memorial Fund Quarterly/Health and Society. 58(1), 1-49.
[12] Fox, R., ibid.
[13] Han, P., Klein, W., & Arora, N. (2011). “Varieties of uncertainty in healthcare- a conceptual taxonomy.” Medical Decision Making. 31(6), 828-38.

Featured image courtesy of Pixabay.

About The Author

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Adjunct Assistant Professor, Wright State University Boonshoft School of Medicine

Michele Battle-Fisher is an Adjunct Assistant Professor at the Wright State University Boonshoft School of Medicine and the author of Application of Systems Thinking to Health Policy and Public Health Ethics: Public Health and Private Illness (Springer), a 2016 Doody's Core Title. Ms. Battle-Fisher is a Health Systems/Complexity scholar and bioethicist. She has researched and taught in the medical and policy fields, ranging from public health, science and technology, bioethics, systems theory and its application to health. She was a speaker at TEDxDartmouth 2018 where she discussed the "Paradigm Shift" of Health Systems Science curriculum in health and clinical medicine. She was selected as a finalist in the 1st annual MIT Press “Pitchfest”, the “Shark Tank” of book publishing.