Anna Matheson (2026), in her short paper entitled Agency, place and the real-world dynamics of health inequality, provides a great example, in my view, of engaging with the world as richly and deeply complex. Matheson builds on the work of Brian Castellani and Jonathan Wistow (2026) who adopt a ‘case-based complexity approach’ to uncover the dynamics of health inequality.
What I think Matheson’s paper does so well is to articulate how all that is there — intended, designed, embedded, emerging, happenstance — in other words culture, policy, practice, power, resources, vagaries of history and particularities of place — weaves together to co-create social outcomes. Her focus is on health, but her commentary is equally relevant to food security, conflict, populism and any other complex systemic social issue.
The determinants of health include, as is well established, access to resources, education, housing and job opportunities. But Matheson explains that disadvantage on its own does not explain the variation, by place, in the achievement, or not, of improved health outcomes. There are other factors at play too: these include entrenched, long-standing institutional factors such as racism, or cultural attitudes to exercise or to a distrust of public services. Place-based, contextual factors impact the ability to “convert social conditions”, and Matheson explains that this is due to variations in “organisation, responsiveness and capacity to adapt”. She continues: “places with similar socioeconomic profiles follow markedly different health trajectories, depending on how local systems are configured and how they evolve over time.” [my italics]. There is an emergent configuration of relationships amongst institutions, infrastructures, communities and processes of governance — and it is through these patterns of relationships that health outcomes are produced. Thus, as she says, interventions need to both understand and then address these “relational architectures”.
How do you do this? What provides the agency to address such relational architectures? Matheson explains this requires the ability to “influence relationships, align resources, coordinate action, interpret signals, and adapt in response to changing conditions”. And the processes adopted to achieve this will inevitably themselves become part of the weave, and shape and be reshaped by the underlying, shifting dynamics. The whole mix — historically-based entrenched attitudes and capacities and cultures, the ‘measurable’ determinants such as housing and jobs, together with any imposed policies and interventions and more global shifts in conditions — will weave together to produce “patterns of coordination and fragmentation” and also patterns of behaviours and relationships in response. This ever becoming, shifting, patterned mix is what will shape emerging outcomes (in health, in social norms, in reactions to intervention) and these outcomes themselves will both evolve over time and feed back into the mix.
This view of the complex world — as processual, systemic, patterned, shaped by history and context and yet always evolving — is the stuff of which I write. And Matheson’s short paper brings these differing, dynamic, interwoven factors to life in relation to health inequalities. Building on the case-based research of Castellani and Wistow, it demonstrates the limitations to policy if real-life complexity is ignored.
The question, then, is what does this mean for policy making and for designing interventions? Clearly it makes policy and structuring of responses much more complex to design than if measures of deprivation are considered to be the main driver.
How can policy be sensitive to differences in place and history, and, equally, be adaptive as factors evolve in the wider context and emerge locally in response to policy interventions? How can interventions be fair in the sense of working towards more equal outcomes and yet respond not only to the particular local measures of (in this case) deprivation but also to the particular qualities and capacities and histories of each place?
The starting point, I would suggest, is for policy makers to ‘get’ complexity — and evidence from research, as in Matheson’s example, helps to land the point that more conventional approaches have failed to reduce inequalities. ‘Getting’ complexity predisposes those designing interventions to be more likely to spend time on understanding the dynamics and capacities of local contexts, more willing to try out different approaches in response, and more accepting that things will not just unfold as hoped and ongoing research, review and adaptation will be needed.
One thought I’ve been playing with, suggested by a colleague, is that designing and working alongside such interventions requires a form of complexity-savvy ‘entrepreneurship’. More on this later.