This paper primarily argues that Epidemiology is Ecosystem Science. It will not only explore this notion in detail but will also relate it to the argument that Classical Chinese Medicine was/is Ecosystem Science. Ecosystem Science (as instantiated by Epidemiology) and Ecosystem Science  share these characteristics: (a) they do not subscribe to the monogenic conception of disease; (b) they involve multi variables; (c) the model of causality presupposed is multi-factorial as well as non-linear. Biomedicine exhibits two paradigms of explaining disease. The monogenic conception of disease, which is the dominant paradigm, embodies the standards and criteria of scientificity for Biomedicine. In contrast, Epidemiology is considered to be the Cinderella as its paradigm of explanation and scientificity is different and hence, held, at arm’s length, if not with outright suspicion.1The two paradigms differ ontologically and methodologically. The monogenic conception of disease upholds the thesis: one causal agent, one disease entity. It rests on thing-ontology. Its implied model of causality is Humean, monofactorial and linear . On the other hand, Epidemiology understands disease not so much as a disease entity but more as a pattern of interrelated events which may lead to a pattern of ill-health in the population. It rests on process-ontology. Its model of causality is non-Humean, multi-factorial and non-linear .2While the monogenic conception of disease is rooted in the Gold Standard of the Randomised Controlled Trial (RCT) and of late its related Gold Standard of Evidence-based Medicine (EBM), Epidemiology proceeds more in the manner of Ecology as a field science. Ecology explicitly studies ecosystems: the biotic and abiotic components which make up a particular ecosystem, the relationships between these with the ecosystem as a Whole, not to mention with other ecosystems. This kind of science is necessarily non-Reductionist as the Whole in terms of its causal inter- as well as intra-relationships are reciprocal in character; this complicated network of causal relations means that properties emerge from the Whole which cannot be predicted by simply adding up the contribution of each of the component parts of the Whole. Epidemiology is, hence, Ecosystem Science.Medicine : CCM is a science which is Wholist5If one cares to do some comparative history of science, the model of Ecosystem Science/Thinking and Systems Theory/Thinking can be said to be found in Classical Chinese Epidemiology.In a very brief extension of the theme at 4, this contribution looks at how CCM perceived/perceives epidemics and whether it had/has any grasp of what today we call Epidemiology. The conclusion is positive, although to mark the differences in spite of the similarities between CCM and modern Epidemiological thinking, the CCM discipline will occur in italicised form, namely, This contribution explores the thesis that Epidemiology should be considered as Ecosystem Science; it does this through an examination of the following sub-themes.This conception is basically about infectious causal agents and how it has attained its prestigious status primarily through the work of two medical scientists, who are commonly recognised as intellectual giants, Pasteur (1822–1895) and Koch (1833–1910). Their research ushered in not simply the Age of Bacteriology but the era of “truly scientific medicine”. Pasteur is commonly acknowledged to be the father of the germ theory of disease which covers not merely harmful bacteria but also viruses. Koch was famous for his discovery of the tubercle bacillus as the cause of tuberculosis. Furthermore, he is associated with four methodological postulates which constitute the so-called Gold Standard for determining etiologically defined diseases in terms of infectious agents.7The rich theoretical crop of discoveries of infectious agents together with the new “magic bullet” of antibiotics has seared into the consciousness of the medical establishment as well as that of the lay public as a “golden age” in medicine and succeeded in putting Biomedicine upon an altar before which everyone bows low and deeply with the greatest awe and reverence. The Nobel Foundation in 1905 bestowed on Koch its award in medicine for his identification in 1882 of the tubercle bacillus as the cause of tuberculosis.natural…”. At a stroke it destroyed the very old religious view that the cause of diseases was an expression of divine displeasure as well as its therapy in terms of prayer/miracle. Simultaneously, it also overturned the Hippocratic/Galenic account in terms of “fluid” medicine. “Solid” medicine became the new paradigm in medical thinking. A new research programme came into existence, a programme which after more than a 100 years is still regarded as “progressive” in spite of growing numbers of serious anomalies it has produced in its wake.Koch said: “diseases are best controlled and understood by means of causes, in particular, by causes that are He said: “each disease is caused by one particular microbe—and by one alone. Only an anthrax microbe causes anthrax; only a typhoid microbe can cause typhoid fever”.The bacteria must be present in every case of the disease.The bacteria must be isolated from the host with the disease and grown in pure culture.The specific disease must be reproduced when a pure culture of the bacteria is inoculated into a healthy susceptible host.The bacteria must be recoverable from the experimentally infected host.Koch strengthened the above by setting out his guidelines or methodological rules for ascertaining the cause which are sometimes called the Koch–Henle postulates:Koch also forcefully articulated the monogenic conception of disease in 1901. It suffices here to comment on only three aspects:Although these postulates have run into anomalies, nevertheless, they continue to be regarded as canonical, exercising a compelling hold over research in Biomedicine.9Postulate 1 is key to understanding the monogenic conception of disease, as it holds that every disease has a single cause and that the cause is universal and necessary. This implies a notion of cause which is monofactorial and linear. This causal paradigm was simply borrowed from other successful Newtonian sciences such as physics and chemistry. It is said to be Humean which is also presented as the Billiard-ball account. This image is apt as it brings out certain features which are pertinent to the context of Biomedicine. The infectious-agent conception of disease as earlier remarked is “solid” medicine; the cause can be a bacterium/virus/fungus/poison. The cause, just like a billiard ball, is a solid object which can be seen , collected and measured/quantified, or removed, and cultivated elsewhere outside the human body. Billiard balls left to themselves would not move without the introduction of an external force, that applied initially by the player via the billiard cue hitting the first billiard ball; analogously, the infectious agent is an external pathogen which invades the human body setting off a series of motions within.10axiom of homogeneity. However, this axiom, in reality, fails to obtain except by resorting to the device of deeming participants/patients to be homogenous, save in one respect only. As a matter of fact, patients are heterogenous, not homogenous as a group. As a result, the RCT-EBM-approved-“efficacious” treatment may turn out to be irrelevant to their concern. Individual patients are not artefacts which can be ordered from a factory to conform uniformly to a very specific set of common characteristics. Randomisation as the key methodological/analytical technique can undoubtedly take care of allocation bias, but not other sorts of bias, such as selection bias. RCT’s inability to eliminate the latter type of bias renders its results at best statistically relevant and at worst clinically irrelevant. While hospital management in general and organisations such as NICE (in the UK) are interested in statistical relevance in respect of a drug’s efficacy, the “field” doctor who is concerned with individual patient care is interested in clinical relevance: a drug which passes the test of statistical relevance (via RCT-EBM) may be of no help to the doctor-and-her-patient, whereas a drug which has failed to pass such a test may be of help to the individual doctor-and-her-patient .axiom of homogeneity suffers from severe methodological limitations.Although RCT and EBM constitute the Gold Standards of scientificity in Biomedicine as already observed, the former is not above challenge as it relies on randomisation to eliminate bias from its experimental set-up.Definitions of epidemiology vary, but include some common elements, especially the phrase “distribution and determinants of disease.” I define “epidemiology” as the study of the distribution and determinants of disease and other health states in human populations by means of group comparisons, for the purpose of improving population health. … Epidemiology is a discipline that essentially involves documenting the way health states occur in human populations, and trying to explain the documented patterns of occurrence. … Most epidemiologists, though not all, will also accept that the purpose of epidemiology is to improve population health. … the history of epidemiology definitely links it to both medicine and public health.Broadbent , p. 9314Epidemiology is, as confirmed by above, generally said not to be so much interested in the fate of individuals as patients but more in preventing the emergence of disease patterns amongst communities and populations. Certainly, the nineteenth-century pioneers such as John Snow vibrio cholera.16The fall in the cholera mortality rate had nothing to do with the kind of knowledge celebrated by the monogenic conception of disease. Snow could only infer that there must be something unsavoury about that pump which made people fall ill upon drinking water contaminated by such a source. It was not till 1884, 30 years after Snow’s pioneering work in 1854, that Koch discovered that the infectious causal agent was the Epidemiology did not emerge as a distinct field until the latter part of the twentieth century, and indeed teaching approaches and career paths are still not finalized. (Perhaps they will never be.)Time has moved on since the nineteenth century. Epidemiology, today, is said to be a young, developing science, whose “ancestry” is very recent indeed. Broadbent , p. 93 wThe new pioneers may be said to be Austen Bradford Hill and Richard Doll whose research work is generally acknowledged to have put epidemiological investigations on an impeccable scientific footing from the methodological point of view. . Their work in establishing that tobacco is a crucial factor in the production of lung cancer led to the banning of smoking in public space and other measures to discourage smoking.The causal model invoked by this kind of epidemiological research (in the context of tobacco smoking and lung cancer) implies a more sophisticated variant of Epidemiological Thinking which may be represented by the image of the Triangle of Causation,There are three main variables: Host, Agent and Environment between which the causal arrows indicate reciprocity. This advanced causal model obviously differs from that exhibited by the monogenic conception of disease . Below is a quick comparison between the two models.Note that in the smoking-lung cancer example not only is it the case that there are three main variables involved in the model of causation, but that each of these three main variables is internally complex.20Host includes several variables, such as the smoking and/or the alcohol drinking habits of the individuals, their respective genetic inheritances, general state of their health/age/nutritional status/occupational status.Agent includes the carcinogenic nature of not only one chemical, but the many chemicals found in tobacco smoke, of which nicotine is only one.Environment includes whether the space in which the individuals dwell/work consists of smokers, even if they themselves do not smoke, whether the space is enclosed or not, and if enclosed whether adequate ventilation obtains, and if not enclosed, whether the air outside is polluted or clean, and so on.Of late some researchers appear to want to develop this more refined characterisation of Epidemiology Thinking even further, to approximate it closer to what this contribution calls Ecosystem Science, which Systems Thinking claims also to encompass. For instance, O’Connor and McDermott  distingu21Ecosystem Thinking/Systems Thinking is keen to point out that the relationship between events/processes involves complicated systemic linkages, drawing out clearly such a methodological implication of Wholism. One can re-cast the enhanced Triangle of Causation in terms of nesting ecosystems: the Host (the person) as Ecosystem 1, the Agent  as Ecosystem 2, the Environment as Ecosystem 3. Indeed, 1, 2 and 3 may be said to form another more-encompassing ecosystem, namely, Ecosystem 4. See Fig. Because the effect of a given input depends on other conditions in the system, emphasis shifts from isolating the causal effect of a single factor to comprehending the functioning of the system as a whole. Complex systems typically include heterogeneous agents at various levels, contact structures between agents, adaptation, nonlinear dynamics, and stochasticity. These features lead to the emergence of patterns at various scales. . In a system, when changes in a factor/variable provide feedback into the process, generating feedback loops which may produce positive or negative impacts. Suppose high taxes on cigarettes would reduce the number of smokers. The next step to pursue is to see if higher taxation would lead to changes over time in social attitudes to smoking which may then make it possible to increase enforcement of public smoking regulations. If it does, then this would be a positive feedback impact. On the other hand, raising cigarette taxes would mean the treasury has less money to render smoking cessation programs accessible to help individuals to quit the habit. This then would lead to a negative feedback impact.In other words, Systems Thinking embodies a Wholism whose processes constitute a dynamic system with very intricate feedback loops which can reinforce the processes of change or dampen them. Under the former, a new equilibrium would eventually be reached; under the latter, equilibrium would be restored. Wholism accommodates both instability and stability; both positive and negative feedback loops can occur in a system.With that brief outline about Systems Thinking in place, let us then look at Ecology as post-Newtonian science whose key concept of the ecosystem has given rise “eponymously” to what may be called Ecosystem Science/Ecosystem Thinking, which emphasises the importance of feedback loops (both negative and positive) in the history of ecosystems.The discipline called Ecology became accepted as a science in the way understood today only after the Second World War, especially through the work of Eugene Odum.23Ecosystems do not come labelled as such; scientific investigators have to identify and delimit them for the purpose of their study at hand. However, this does not mean, that they are abstract theoretical entities with no bearing to reality on the ground. Some have clearly identifiable boundaries , others are not so obviously the case. Some can be very big, such as Antarctica or the Arctic, others infinitesimally small in comparison, such as a handful of soil.Any ecosystem, such as that of Yellowstone Park or the Gobi Desert, occupies a certain portion of time and space which has a historical dimension both in terms of time and space. For instance, neither Yellowstone nor the Gobi had existed from time immemorial, nor historically would the space they each commanded be necessarily identical to that they each now respectively occupy. It is sometimes possible, though not frequently, to ascertain the precise beginning of an ecosystem, such as the sudden throwing up of a small island in the middle of an ocean as a result of an undersea volcanic eruption.1, a particular item predominates, at time t2, that item may have retreated somewhat, its predominant position taken over by another item. For instance, in a shoreline ecosystem at t1, large cliffs stand out, but at t2, some of the cliffs might have collapsed into the sea below, generating a new landscape with changes for the ecosystem involved, even to the extent of perhaps creating two related but different ecosystems.An ecosystem evolves, changing all the time—at time tOvertime, one ecosystem may evolve into a distinctively different ecosystem. For instance, take a lake. Of all the geological formations, lakes are said to be the most ephemeral as they evolve and change the quickest. A lake would shrink , and would dry out completely, eventually evolving to become a meadow. Inland seas too shrink such as the ongoing shrinkage of the Aral Sea.Ecology studies ecosystems. The notion of an ecosystem may be spelt out in some detail as follows:5.An ecosystem may be defined in terms of all the organisms of each species living in community interacting with other communities as well as with all the abiotic factors in their habitat. As far as the latter is concerned, the dynamics of an ecosystem involve three key abiotic processes which cannot be caught simply by population processes and phenomena: these are energy flow, hydraulic flow, and chemical cycling with which the population interacts. In an ecosystem, the complex interplay between the numerous variables operating within it determines the characteristics of the population in question.6.Every ecosystem is necessarily an open system. It is in principle an open system as ultimately it requires input from outside Earth, that is to say, from our Sun, as we have seen, to supply it with sunlight (energy) to maintain it. It cannot violate the laws of thermodynamics.7.Every ecosystem must be grasped as a Whole; an ecosystem Whole cannot be understood in a reductionist manner. In other words, this Whole has properties which are over and above, not simply the sum of the properties of all the constituent parts. Let us briefly look at this implication of Ecosystem Wholism by considering a handful of soil. The soil consists of both biotic  as well as abiotic elements, such as water, air, chemicals . The character of the soil (such as its texture) cannot be accounted for solely in terms of the properties of each of its constituent components—it may be said, therefore, to be an emergent property of the Whole system, born of the complex interplay between all the variables involved in that handful of soil and the micro-climate of which it is a part.8.This complex inter-play may be displayed through considering a hypothetical potential creation of an ecosystem as follows: first, a hair-line crack occurs in a rock, conceivably produced by the difference in temperature between day and night, summer and winter (A); next, water (B) enters the crack, turning into ice in the winter, thereby enlarging the crack in the process; a seed in the autumn floats by, lodges itself in the crack and the following spring begins to grow (C); C together with B cause A to widen, which in turn permits more water and ice to enter, giving more space for C to grow by widening the crack still further and thereby allowing more rain and frost (B) to enter and erode it, and so on. These processes of change and development show that the causal paradigm at work is dynamic, historical, reciprocal (with positive feedback), synergistic, multi-factorial, non-linear.(See points VIb and VIIb which contrast with VIa and VIIa in section above.)9.An ecosystem may display negative feedback loops—the prey-predator relationship is one such example. Imagine the population of foxes increasing in a particular habitat. Foxes prey on rabbits. Increase of foxes would mean decrease of rabbits, but as rabbits are eaten up by foxes, the predator would suffer from a shortage of prey. As a result, the fox population would decline; the rabbit population would instead increase. As a result, equilibrium is restored between predator and prey, equivalent to a negative feedback loop. It is seen to be at work in regulating populations in ecology. An ecosystem would be de-stabilised if its populations  exceed its carrying capacity.10.An ecosystem also exhibits positive feedback loops which are responsible for the sudden appearance of rapid changes. Positive feedback involves a circular set of effects which are self-reinforcing. For instance, an ecosystem primarily of grasses with few shrubs may be stable for five to ten or more years. Yet such an ecosystem may change over time and the change would occur within a relatively short period of time. Shrubs which started off by being few and far between amongst the grasses, take a much longer time than grasses to establish themselves in the ecosystem, as their roots go deeper and initially competed unfavourably for rain water with grasses, whose roots are in the topsoil. Hence the ecosystem remains basically a grass ecosystem. However, over time, the shrubs, having established themselves, albeit slowly, would begin to grow taller, overshadowing the grass. Then seemingly suddenly, the grasses would be at a disadvantage in the competition for sunlight, fade and not flourish as well as they have done in the past. The grass ecosystem would have then turned itself into a shrub ecosystem. As established shrubs are more successful in capturing the available water and sunlight than the grasses, these will decrease dramatically. Positive feedback loops act as forces of change and are a source of instability.This brief sketch of Ecosystem Wholism makes obvious a very important ontological point: it focuses not so much on things (biotic and abiotic), as on relationships between them which involve events and processes. Ecosystem Thinking occurs within the framework of what may, then, be called process-ontology whereas the thinking behind the monogenic conception of disease occurs within the framework of thing-ontology. The latter (monogenic conception of disease) differs profoundly from the former  which may be said to be a type of Ecological Thinking. Things are the objects of study by Newtonian Science; these are macroscopic objects, with definite boundaries, varying in actual size from a planet/heavenly body to microbes and atoms. Things/macro-sized objects possess the following characteristics: they are visible , touchable, impenetrable, have form, shape and size, and are measurable. On the other hand, post-Newtonian sciences (such as Ecology and Epidemiology) involve process-ontology and the rejection of Humean linear causality, as already observed.primacy over things. Substance is subordinate to process: Things are simply constellations of processes.Process has priority over substance. Things are always subordinate to processes because processes inwardly engender, determine, and characterize the things there are. But processes as such transcend the realm of things since there are also substance-detached processes.Process has priority over process. The only sort of processes…are (sic) those involved in the doings and comportment of things.Substance has Substance has primacy over process. Indeed, substance is all there is; all processes and changes are simply a matter of how things appear to certain (mind-equipped) substances.Process metaphysics as a general line of approach holds that physical existence is at bottom processual; that processes rather than things best represent the phenomena that we encounter in the natural world about us. The doctrine takes a position within the spectrum of competing following contentions:The first two of these competing contentions represent process philosophy respectively in its stronger (Heraclitean) and weaker (Empedoclean) versions. By contrast, the substance approach which process philosophy rejects is represented by the last two contentions. This approach also has a weaker (Democritean) and a stronger (Parmenidean) version.In a nutshell, the succinct differences between thing-ontology/substance-ontology and process-ontology may be spelt out in the words of Rescher , p. 2 as(See point VIIIb in contrast to point VIIIa in section above.)philosophy, in particular by the Laozi which is Daoist or Daojia philosophy.In this movement, there is NO Thing. Rather, things are abstracted out of the movement in our perception and thought, and any such abstraction fits the real movement only up to a point, and without limits. Some ‘things’ may last for a very long time and are fairly stable, while others are ephemeral as the shapes abstracted in perceptions of clouds.In the history of Western philosophy, the dominant metaphysics is thing-ontology; hence, it is not a surprise that Newtonian sciences are based on that ontology. Process-ontology made a brief appearance in ancient Greek philosophy, primarily in the fragments of thought left by Heraclitus; Leibniz (eighteenth century) is considered to be the next contributor. However, it is only in the twentieth century that process- philosophy has been systematically articulated in the later writings of Whitehead; and even then, it has not been taken up by scientists, only by some theologians. In quantum physics, Bohr implicitly introduced process-ontology via his notion of complementarity; but Bohr was not so much influenced by Leibniz as by ancient Chinese philosophy, as found in Daojia philosophy  rests on process-ontology, based on Qi as the fundamental ontological category , and all the five organ-systems constitute in turn a larger ecosystem (Ecosystem 4); this is because although different and separate as anatomical entities (or things), in terms of their physiological functioning (as events/processes), they are intimately intertwined. To illustrate this point in greater detail, take Ecosystem 3: it is about the relationship between the yin organ and the yang organ, such that each visceral organ-system/Zangfu/脏腑 has a yin as well as a yang component. For example, the Spleen (yin) pairs with the Stomach (yang) as piwei/脾胃, the Heart (yin) with the Small Intestines (yang), the Lungs (yin) with the Large Intestines (yang), the Liver (yin) with the Gall-bladder (yang), the Kidneys (yin) with the Bladder (yang). This Ecosystem is then an instantiation in CCM of Yinyang Wholism, a fundamental Wholism. As already observed, the yin organ is called Zang/脏, and the yang organ Fu/腑. Together, they are often called Wuzang-liufu/五脏六腑. It suffices here to point out that in Chinese numerology, wu/five, being an odd number, is yang in character, while liu/six, being an even number, is yin in character; therefore they also form part of Yinyang Wholism as Ecosystem 3.Although Fig. Ecosystem 5 indicates that for CCM, the concept of person is a primitive one, that is, the person embodies both physical and mental/emotional characteristics or what may be called Mind–Body Wholism, implying the rejection of Mind–Body dualism which underpins modern Western philosophy (since Descartes) and, in turn, Biomedicine . It also implies that for CCM, all illnesses have, in principle, a psychosomatic dimension and that treatment must take this dimension into account.27Ecosystem 8 reinforces the point made by Ecosystems 5 by emphasising that individual psychology is not itself independent of the value system of the individual’s community/society.Ecosystems 7 and 10 embody another larger Wholism within which the individual person is embedded. Qi in the individual person (Microcosm) is affected by Qi in the universe (Macrocosm).28Ecosystem 9 indicates that the individual person, her community/society are all part and parcel of another Whole, namely, the greater physical/natural environment within which the community/society lives and works.Ecosystem 3 and 4 As far as illness is concerned, if the yin organ is affected, its yang counterpart may also be affected, and vice versa. If one visceral organ-system is affected, it is likely that, sooner or later, another organ-system would also be affected, as all members of this greater Whole are governed by Yinyang–Wuxing.29Wuxing’s five phases are:Wuxing invokes two main modes of operation: the Mutually Engendering and the Mutually Constraining. Let us focus first on the former. Water stands for Winter (when yinqi is at its maximum) but as water is an indispensable requirement for Life and Life’s activities, Water is said to generate Wood. Wood stands for Spring (when yinqi begins to retreat and yangqi to rise) and therefore for all Life and its activities. Wood in turn is said to engender Fire . In turn Fire engenders Earth; Earth permits organisms to thrive but when these die, they decay and are returned to Earth itself, or when wood burns, all that is left is its ashes which become soil). Earth stands for a period when yinqi and yangqi are in equilibrium. Earth engenders Metal . Metal stands for Autumn . Metal/Autumn generates Water/Winter (as yangqi decreases even further until it reaches its minimum and yinqi reaches its maximum).Wood constrains Earth. Heavy rains could cause floods; to prevent flooding, one could use earth to build dykes and dams—in this sense, the ancient Chinese postulated that Earth constrains Water. To prevent a fire from spreading, one would need water to damp down the fire—in this sense, it could be said that Water constrains Fire. To make implements such as an axe, a sword, one would need fire to melt the metal before one could cast or mould it—in this sense, the ancient Chinese held that Fire constrains Metal. An axe  would be useful in chopping down trees which in turn would provide wood to fuel fires—in this sense, the ancient Chinese postulated that Metal constrains Wood.We next look at the Mutually Constraining mode. The ancient Chinese clearly knew that vegetation was vital to prevent soil erosion and soil loss, especially during heavy rains when exposed soil with no vegetal cover could be washed away; by growing trees on such surfaces, soil erosion would be prevented. So in this sense, they postulated that Wuxing is really about the relationship between yinqi and yangqi in the course of a year (or of a day). A normal relationship means that in Winter, yinqi is at its maximum and yangqi is at its minimum, and that in Summer, the reverse relationship obtains. However, illness occurs when the relationship is not normal for the time of year in the individual person as ascertained by feeling the mai . But in this context, let us understand Wuxing not so much in CCM but in general in the context of applying it to explain ecological phenomena. Abnormal relationships between yangqi and yinqi are mediated by two sub-concepts called Deficiency (buzu) and Excess (taiguo). We see these concepts at work clearly in the Mutually Constraining as well as the Mutually Engendering modes. Look at Fig. Fire constraining Metal. When Fire is in excess, this means that Metal would be over-constrained by Fire; such over-constraining would provoke Metal to “fight back” not, however, directly against Fire, but against Water instead, as Metal engenders Water. One could then say that Fire has, ultimately, “met its own come-uppance” or achieved an “own goal”, as Water constrains Fire. Let us call this Example A.While the above explication may be helpful, one should not forget that Fire, let us see what happens when its qi is in Deficiency—. This would result in Water taking advantage of such a weakness to damage/undermine Fire as well as in Metal reacting by “insulting” Fire, leading ultimately in this chain of reactions to Earth being undermined, as Fire engenders Earth. Spelt out a bit more fully, it runs as follows: Water constrains Fire or Fire is constrained by Water. When Fireqi is deficient, Fire would be unduly constrained by Water and thus, Water would undermine/damage Fire. Fire constrains Metal or Metal is being constrained by Fire. However, as Fire itself is undermined and weakened by Water, Metal, in reaction, would take advantage of Fire’s weakness and turn round to undermine Fire. In the Engendering cycle, we know that Fire engenders Earth; but here Fire itself has been weakened and its weakened state would in turn impact upon its process of engendering Earth. Earth constrains Water, but weakened Earth would let Waterqi be in excess. Waterqi in excess, in constraining Fire, would weaken Fire even more.Using the same instance of Wuxing Thinking. Cast in the language of Wuxing, it would run as follows: Excess of Woodqi (increase in fox population) would over-constrain Earthqi, resulting in decrease in the rabbit population; this leads to Deficiency of Earthqi, which in a state of humiliation would hit back “insulting” the stronger party, resulting in a decline in the fox population.The post-Newtonian sciences of today such as cybernetics, systems theory, ecology and others are said typically to display feedback mechanisms, both negative and positive. The section above have already cited examples of both negative and positive feedback loops in Ecological Thinking. The prey-predator relationship has been cited as an instance of the former; here we can use it to illustrate the relevance of an aspect of Wuxing could be presented as follows: Metal constrains Wood. When excessive tree cutting occurs, Wood would be adversely affected (with fewer trees left standing). Wood constrains Earth; with fewer trees around, Wood’s ability to constrain Earth would result in Deficiency . Earth constrains Water, but with soil loss/erosion, Earth can no longer perform adequately the role of holding back water, owing to its qi Deficiency. Water engenders Wood; but when Earth can no longer constrain Water, Water in turn, in this context, would result in Deficiency, and Water would be unable to engender Wood. When Water’s capability of engendering Wood is adversely affected, the end result of this chain of Wuxing reactions would be an even greater loss/erosion in soil than the initial loss.30Example B could be illustrated by considering the relationship between vegetation, earth/soil and Water. One can present it as follows: Cutting down trees excessively causes soil erosion/loss; less soil brings about less regeneration of tree growth; fewer trees cause greater loss of water/moisture in the soil; more soil loss/erosion … This positive feedback loop which involves a vicious (rather than a virtuous) circle in the language of philosophical  foundation.philosophical-cum-methodological framework has also consistently embraced all domains in which ill-health manifested/manifests itself both at the level of the individual who fell/falls ill or at the population level when whole swathes of people fell/fall ill such as during epidemics.The section above has set out in very brief outline the claim that CCM is Ecosystem Science. CCM, ever since its beginnings, has suffered no paradigm shift in its dayi/大疫, ji·yi/疾疫 or li/疠 amongst others. These include in today’s nosological categories from the Chinese medical standpoint wenyi/瘟疫 (febrile epidemicsliuxing ganmao/流行性感冒 (influenza), mafeng bing/麻风病 (leprosy).ji·yi/疾疫 or dayi/大疫 recorded in Chinese history was during the Zhou dynasty (1046-256 BCE). The number of occasions throughout the various dynasties from the Zhou to the Qing dynasties is listed as: Zhou, 1; Qin-Han (221 BCE-220 CE),13; Wei-Jin (220–420 CE), 17; Sui-Tang (581–906 CE) 17; Song (960–1279 CE), 32; Yuan (1279–1368 CE) 20; Ming (1368–1644 CE), 64; Qing (1644–1912), 74.Like all societies, Chinese society in its long history has suffered epidemics from time to time. The ancient Chinese referred to epidemics as Medicine as just below the Yellow Emperor who is commonly said to have had a hand in writing, if not considered to be the sole author of the foundational text, the Huangdi neijing/The Inner Canon of the Yellow Emperor. Zhang Zhongjing probably completed his book, the Shanghanzabinglun/《伤寒杂病论》/Discourse on Cold Damage and Other Illnesses, a few years after 200 CE.Historical Records/Shiji mentioned 22 natural disasters—drought, floods, landslides, earth-quakes, locusts, famines, dykes bursting. It also coincided with a long period of unrest, with continuous wars, including those before the Three Kingdoms period (220–265 CE) as well as those occurring during it. This meant that the economy suffered, production went down. The conjuncture of natural disasters, economic chaos and war would inevitably lead to all sorts of unimaginable social ills. People were driven from the land, and therefore, into poverty, hunger, illnesses, and even cannibalism, with death and corpses everywhere throughout China’s heartland. Under such circumstances, epidemics naturally flourished. Zhang Zhongjing wrote, in the Preface to his book, that of his own extended family/clan which included more than 200 people, two-thirds had died; 70% of those, who perished, had died from the epidemic raging then from 196 CE. Historians have calculated that roughly half of the Chinese population could have perished in total. As a result, Zhang Zhongjing was not only determined to help relieve suffering but also seize the opportunity to study the epidemic, to collect as much information as he could, including the prescriptions which were used by physicians at large to handle effectively some of the cases involved.36Let us take a look at Zhang Zhongjing/张仲景 (150–219 CE), a practitioner-cum-theorist in the late Han dynasty, ranked in the history of Chinese Epidemiology to mark both the similarities as well as the differences between them. What is further needed to add force to this general argument is to talk briefly about how the ancient Chinese physicians had recognised features which were/are distinctive of epidemics in order to cope adequately with the phenomenon of epidemics itself.No suspicion, naturally, would be cast on the appearance of epidemics in Chinese history; but the sceptical may immediately doubt that the ancient Chinese might have the concept of epidemiology at all, even if the ancient concept would not be as sophisticated as the one which Broadbent (cited earlier) has written about. The quick way to quell this doubt has already been just given, namely, that as CCM suffered/suffers no rupture of any kind, it follows that it embodied/embodies Ecosystem Thinking and such Ecosystem Thinking would cover all domains of its theory and practice. In other words, this means that in treating the phenomenon called epidemics, CCM would have used that very framework which Epidemiology today (this paper argues) deploys. This, in turn, would mean that CCM would have grasped the concept of epidemiology whether one deigns to use the term “epidemiology” or not; but as is the wont of this author, the term would be used but italicised, namely, it would appear as Zhouli/《周礼》,Two strategies immediately come to mind, deployed by the ancient Chinese physicians to cope with epidemics, which are relevant to the preoccupation here. These were: (a) the proper disposal of the dead to prevent further spread of the epidemic; (b) quarantine to contain the epidemic. They implied/imply that the physicians understood that illness in an epidemic could be a contagious matter, that is to say, that such an illness would spread to more and more people via direct contact with those already afflicted. The preparation for the burial of those who had died from it and the presence of corpses which no one in the larger family or even clan could bury as families and clans themselves were dead or dying, was a task left to the state. The first record of such intervention occurred during the pre Qin–Han period—in the Hanshu/History of the Han Dynasty, in the chapter about the reign of the Emperor Ping/《汉书·平帝纪》. The Hanshu is attributed to the historian Ban Gu/班古 (and various members of his family). The passage reads: 元始二年,旱蝗,民疾疫者,舍空邸第,为置医药 which may be rendered (by this author) as: “In 2 CE, a plague of locusts ravaged the land, followed by an epidemic which swept through the population. The government of the Western Han dynasty (206 BCE–9 CE) made available residences  to house the afflicted (as a form of quarantine) as well as to treat them.” By the time of the Northern and Southern Dynasties (386–589 CE), quarantine had become routinized—during the Xiaoqi period (420–581 CE), a crown prince (太子长懋) and others established six specialist quarantine quarters.We next look at the strategy of quarantining those affected. The first recorded attempt is found in the Han dynasty, in the The Records of Lord Zhao’s Disaster Rescue Attempt.) In 1089 CE, an official famous for his poetry, Su Shi/苏轼 in Hangzhou also set up similar accommodation. The practice became entrenched in government policy in the dynasties which followed, although it must be observed that its expansion was not the norm, instead sometimes, it even shrank. The vacuum in many instances was filled by charitable bodies.In the Tang dynasty, the government mainly used Buddhist monks to organise medical aid for beggars who became ill, to house the afflicted in quarantine quarters. In the Song period, the state ran on a big scale homes for the afflicted which doubled up as quarantine establishments. An example of this occurred in 1076 CE; in Yuezhou/越 州, in the spring of that year, an epidemic occurred to which the government responded by building a large home/hospital for the ill and to quarantine the afflicted. , its archives recorded (《晋书.王彪之传》) the following edict in 356 CE: “朝臣家有时疫, 染易三人以上者,身虽无疫, 百日不得入宫” which is rendered (by this author) as: “Should three members in any family of the court officials be affected by the epidemic, it is forbidden for such officials to attend court for a 100 days.” The epidemic referred to here was leprosy, a highly contagious illness which was rampant in earlier times.38dayi or jiyi satisfies this dictionary sense in English.An epidemic in the medical context is commonly defined in dictionaries as: A widespread occurrence of an infectious disease in a community at a particular time (see Oxford English Dictionary). The ancient Chinese use of The ancient Chinese physicians  implicitly recognised that an epidemic could involve an illness which was infectious but which could also be an illness called contagious in today’s medical language; hence to stop the spread of the epidemic, they realised that one must dispose of the victims properly.While the ancient Chinese physicians did not abandon, as we have seen above, the use of medicinals to help individual victims, nevertheless, they realised that the best strategy was isolation, hence quarantine.Contagious illnesses necessarily involved/involve a community, a population. In other words, the best strategy, namely 3 above really implied/implies that CCM had an implicit grasp of the concept of epidemiology as their strategies appear to be concerned with “the distribution and determinants of disease”.chong/虫, gu/蛊, nüe·ji/疟疾The ancient Chinese physicians were aware of the determinants of illness in an epidemic because: (a) they had observed that not only the features already mentioned above were relevant, but that since very early times, they knew that an external pathogenic factor was involved. In the late Shang dynasty (1600–1046 BCE), the Oracle Bone script referred to Ecosystems 6, 7, 9 and 10 set out in Fig. As CCM is Ecosystem Science, it was/is well aware that any human population must live within bigger ecosystems which include the greater natural environment, that is, Epidemiology.For the reasons set out briefly above, it may be appropriate to say that CCM had/has some grasp of the concept of epidemiology, even though its version might not be identical with modern Epidemiology. Hence it might be appropriate to refer to it as Chinese tianhua/天花, which had evolved and developed from the long-held CCM idea of using toxin to fight toxin. Its first successful use was recorded in 1653. This may be cited as evidence for Epidemiological thinking in CCM. The strategy consists of infecting persons with a mild form of smallpox which would not kill them but instead render them immune to the illness in all its normal ferocities. CCM talked about cultivating different types of attenuated smallpox  for the purpose. Following news of success, the Japanese and the Russians introduced the strategy into their countries. The Turks also came to know about the new treatment of inoculation/variolation as Lady Mary Montague, wife of the British ambassador to the Ottoman Court in Istanbul learnt about it and in 1717, she successfully used it on her own children. When she returned to Britain in 1721, she introduced the idea/technique to the Royal College of Physicians who naturally rejected it; but she persuaded Princess Caroline to test it. Small scale trials were carried out, in one case involving seven death-row convicts at Newgate prison who were offered reprieve provided they agreed to take part in the trial which they did and all survived. However, later trials showed that one in eight of the treated died of the very disease they were being protected against; this still, however, compared favourably with the going rate of about 30 percent of the disease’s untreated victims. This paved the way for Jenner (1749–1823)’s vaccination technique. The point here is not to trace the historic link between the Chinese and the Western attempts at immunology, but simply to say that the former’s attempt implied/implies a grasp on the part of CCM physicians that a contagious illness such as smallpox could in principle be contained.Apart from the two looked at above, a third relevant strategy needs some brief consideration. This pertains to that of containing the devastating effects of smallpox/Epidemiology which covered/coversPreventive Medicine which encompasses the more specific concepts of yangsheng/养生 or yangshen/养身and of shiyang/食养. The former refers to how to live, nurture, nourish yourself both physically and spiritually in order to lead a long and healthy life; the latter, how to eat properly in order to maintain a long and healthy life.  in the Context of CCM as Ecosystem Thinking; Chapter 8: Fang and Food.) In other words, Epidemiology and Epidemiology share this same basic goal and roughly the same way forward in achieving that goal.So far the discussion has only touched on Chinese The two strategies set out briefly above are especially relevant to any attempt to throw light on the understanding of the nature of epidemics on the part of the ancient Chinese physicians and on whether they had any grasp at all of what we call Epidemiology today for the following reasons:medicine as Newtonian Science and non- or post-Newtonian Science.42The text box below summarises the main ontological and methodological differences between medicine/The dominant conception of disease in Biomedicine even today is the monogenic conception implying its hallowed paradigm of scientificity in terms of the twin Gold Standards of RCT and EBM. Although Biomedicine has an impressive list of achievements to its name, and remains a still progressive research programme, nevertheless, it has run into anomalies. Furthermore, it is a case of doing science within the Newtonian framework of thing-ontology and whose model of causality is Humean, monofactorial and linear .In contrast, Epidemiology is perceived to lack the “kudos” of the monogenic conception, as it departs from the paradigm of scientificity of its senior partner. For instance, RCT is irrelevant to its methodology. It focuses on disease population patterns rather than on disease-bearing individuals who succumb to diseases. It rests on process-ontology (events/processes); the enhanced/sophisticated versions of its causal model are multi-factorial, non-linear (with feedback loops), reciprocal and synergistic. Instead of relying on drugs or surgery as treatment, Epidemiology relies on public health measures such as ensuring water and air sanitation, discouraging certain lifestyle habits (such as smoking or consuming too much sugar).Ecology is Ecosystem Science/Thinking and is a variant of Systems Theory/Thinking whose philosophical framework Epidemiology Thinking appears to share both in terms of ontology and the model of causality which its Wholist orientation implies. Ecology, too, studies populations rather than individual organisms. They may all be regarded as post- or non-Newtonian sciences.durée of human civilisation, their philosophical presuppositions when made explicit can be said to have a history of at least two and a half thousand years. This is for two reasons: (a) CCM is an instantiation of ancient Chinese Science and it has an uninterrupted history of at least two and a half thousand years; (b) CCM, too, rests on process-ontology, and instantiates a causal model which is multi-factorial, non-linear and reciprocal. At all levels of theory-and-practice, of organisation and analysis, it is Wholist in orientation and is fiercely non-Reductionist in its methodology.Although all three  are pioneering non-Newtonian sciences (beginning in the twentieth century), in the long This contribution has tried to set out the following theses:11. Have there been cultures that have wholistic systems thinking?Yes, there are. In Chinese culture everything is comprehended within the conceptual frame of Yin and Yang that is a holistic system. Yin and Yang are counterparts for negative and positive or female and male. Yin and yang are co-dependent. Within such a system, the notion of absolute independence makes no sense. A human relationship is also a state of interdependence; both extreme dependence and independence are seen as dysfunctional. Yin and yang also complete each other; neither is fully realized without the other. For humans, full individuality is realized in the context of the other. And when yin and yang are combined together, we get the Tao, a synergistic emergence and co-creation; something new emerges that transcends the parts.On the subject of CCM and Systems Thinking, Hejazi  writes:1Science and CCM as well as Chinese philosophy underpinning them do not differ from post-Newtonian sciences such as Ecology/Ecosystem Science, Systems Theory/Thinking and Epidemiology in several other ways. It might not be out of place to remind readers yet again of such differences which undoubtedly exist, although not emphasised here; to mark them, terms such as “Wholism/Wholist”, “Science”, “Medicine”, “Epidemiology” and “philosophy” are italicised when used in the Chinese context.5.Based on the above comments and arguments, this contribution feels justified to come to its main conclusion that Epidemiology (today) could be considered as Ecosystem Science/Ecosystem Thinking, and hence, of Systems Theory/Systems Thinking.6.Epidemiology and to refer to the modern form as Epidemiology.Furthermore, based on the historical evidence found in Chinese history in general and CCM canonical texts in particular, one may plausibly conclude that CCM down the ages had/have an understanding of epidemics and a grasp of some of the key concepts of epidemiology. However, similarities apart, there are obvious differences between the ancient Chinese understanding, on the one hand and modern understanding on the other. To mark both the similarities as well as the differences, it seems fitting to cast the CCM version in italicised form as However, this should not be taken to mean that Chinese


We use a community based participatory research approach to examine the processes of collaboration and communication, as well as the relational interactions of one community focused health promotion coalition, the Community Faces of Utah (CFU). We assess the evolution, structure, successes, and challenges of the coalition, comprised of five distinct cultural communities, a state health department, and a university. Researchers from the university collaborated with the coalition to find that CFU is an equitable, collaborative partnership of diverse leaders that functions successfully. Shared values and trusting relationships emerged over time, forming the basis for group interaction. A community liaison to facilitate interaction and collaboration was an essential element of the success of this partnership. The experience of CFU can guide other multi-sectoral partnerships in developing functionality consistent with achieving community driven objectives. Previous research has described the key factors for coalition formation and functioning to effect change. However, investigators have called for systematic study of the interactions and dynamics of coalition members in long-term, real-world relationships . Gaps reHere, we describe a study that builds on the coalition literature by investigating the relational dynamics and communication of one community-focused health promotion coalition. The Community Faces of Utah (CFU) brings together organizations representing five culturally diverse ethnic communities, an academic medical center at a university, and a state health department. Over time, CFU members became aware that they had established a functioning multi-sectoral coalition in which members with competing demands and priorities could collaborate around common interests. All partners expressed interest in sharing CFU’s approach so others could learn from their experiences, which led to the study reported here. We framed our research around the following questions: (1) What is the CFU model? (2) How was the coalition formed? (3) What were early successes, challenges and solutions experienced during the formation of this partnership? and (4) Which organizational aspects of the model have changed across time? Our study examined the establishment and ongoing functionality of the CFU partnership, with a focus on relationship building, to serve as a model for guiding other multi-sectoral partnerships.Community coalitions—defined as alliances of different organizations, such as community groups, universities, businesses, and local government officials working cooperatively and synergistically—are widely used and effective vehicles for improving local community health . AchieviThe process of coalition formation impacts eventual success . Coalitimember capacity ; (b) relational capacity ; (c) organizational capacity ; and (d) programmatic capacity .A standard measure of coalition effectiveness is community wide change. Research is clear on the key contributing factors to effective coalitions. The findings of CFU is a long-term partnership among five diverse culturally based community organizations (six members); the Utah Department of Health ; and the University of Utah School of Medicine . The participating community partners are the Best of Africa (African), Calvary Baptist Church (African American), the Hispanic Health Care Task Force (Hispanic/Latino), the National Tongan American Society (Pacific Islander), and the Urban Indian Center of Salt Lake (American Indian/Alaskan Native). One or two community leaders represent each of the five community organizations in CFU. The members representing UDOH were, at the time, staff for the former Utah Diabetes Prevention and Control Program. In 2013, this program was combined with the Heart Disease and Stroke Prevention Program, the Physical Activity, Nutrition and Obesity Program, and School Health to form what is now the Healthy Living through Environment, Policy and Improved Clinical Care (EPICC) Program. The UUSOM members include the faculty co-directors and community liaison of the Community Outreach and Collaboration Core of the Utah Center for Clinical and Translational Science.CFU was established in 2009 when the UUSOM received funding for a one-year Community Genetics Forum project that supported education in diverse communities about the link between genetics and health. The Forum project built on a previous five-year Consumer Genetics Education Network (CGEN) project . The UUSWhen the funding opportunity for the Forum project was announced, the UUSOM principle investigator met with the HHCTF and NTAS leaders to discuss whether they would be interested in collaborating on such a project, and if so, how to structure it. They expressed a strong interest in the project and recommended that it involve several community organizations, each of whom would receive a $5,000 mini grant to hold community education events, culminating in a Forum with all of the communities (a Forum event was required for the funding). After the project was funded, five organizations in addition to HHCTF and NTAS were invited to participate. During 2009–2010, each community group held one or more “mini forums” for its members, focusing on family health history as a way to identify hereditary health issues in families, and providing education about common chronic diseases that have an inherited (genetic) component and are of highest concern in their community. The leader from the Urban Indian Center coined the term “inherited health,” since the word “genetics” had negative connotations in his community, which the other communities adopted.The community organization leaders, UDOH and UUSOM partners met each month to share what each organization was planning for its mini forum(s), share lessons learned from these events, and to collaboratively plan the culminating, all-day Genetics and Health Forum . The comCommunity Faces of Utah (CFU) is a nexus of communication between resource sources and those who need a voice to achieve better health. CFU is dedicated to creating partnerships and engaging in opportunities for entire communities to become healthier. We work together to better provide health promotion and education for all people who face health disparities. During the retreat, CFU established the following goals: (a) build capacity within communities; (b) tailor communication within communities/partnerships; (c) provide health education for communities/partnerships; (d) provide health access by linking communities and partners to resources; (e) provide interpretation and translation services for communities/partners; (f) impact health policy that creates a healthier environment for communities; (g) reduce health disparities; and (h) become a self-sustaining organization. The mission statement and goals were initiated with a brainstorming session in which everyone’s ideas were recorded on a large white board. These ideas were then grouped and refined through a facilitated discussion.An important part of the process for solidifying CFU was the collaborative development of the group’s mission statement, written during its first retreat, several months after the coalition was initiated: In 2011, approximately seven months after the Forum project ended, CFU was approached by the UUSOM Center of Excellence in Women’s Health who proposed a partnership with CFU in applying for a six-year Office of Women’s Health grant to address obesity among women from communities facing health disparities (one-year planning and five-year implementation). The CFU community leaders identified obesity as a health challenge in all of their communities and agreed that the proposed project was consistent with the CFU mission. The investigators used an inclusive approach throughout the Coalition for a Healthier Community for Utah Women and Girls (UWAG) project by engaging CFU in collecting preliminary information from each community, planning and conducting the project, analyzing the data, and disseminating the findings . SeveralWe initiated a study to examine the formation, functionality, challenges, and successes of CFU in 2012. A UUSOM researcher and a graduate student facilitated the research. The lead researcher holds a Ph.D. in educational psychology, with training in qualitative, quantitative, and mixed methods research, and had served as an external evaluator for some of CFU’s earlier projects. The graduate student was in the UUSOM genetic counselling master’s degree program and had a graduate assistantship at UUSOM. The researchers became close to the CFU members during the course of the study and eventually felt accepted as an extended part of the CFU “family.”All 11 CFU members from the three types of partner entities—community groups (n = 6), UUSOM (n = 3), and UDOH (n = 2)—were study participants. Members were classified as those who attend the CFU meetings regularly and who were responsible for making decisions on behalf of their communities. Two of the UUSOM members include the UUSOM faculty member and community liaison who initiated the coalition.We used the framework of community based participatory research (CBPR) to conduct this research, from identifying research questions to publication . CBPR coWe developed the research instruments collaboratively through group discussion. The researchers presented suggestions for appropriate data collection measures and received input from CFU. We agreed upon three measures, which the researchers developed: (a) individual interviews; (b) focus groups; and (c) a survey that was completed anonymously. We used the three data sources for triangulation; each measure elicited information from a different angle or perspective. The qualitative data (interviews and focus groups) provided the richness and depth of responses, while the survey provided anonymously collected data that helped to decrease response bias.To gather evidence for content validity , two UUSThe eight-item, semi-structured individual interview protocol allowed the researchers to gain an in-depth understanding of individuals’ perspectives of the CFU processes See . The 1 tcurrently and how they would have responded at the time they first joined CFU  member participation; (3) participating organizations and diverse communities; and (4) technical support.The lead researcher administered a 39-item CFU Partnership survey to the CFU members via pen-and-paper during a monthly CFU meeting. The survey used a 5-point Likert-type scale , which asked participants the extent to which they agree with each statement  CFU See . The sur CFU See  informedApproval from the UU Institutional Review Board was received in March 2012 (IRB_00055016). Consent documents were reviewed with participants, and consent was obtained prior to formal participation.t tests and Wilcoxon signed-rank tests to assess changes across time. When applicable, the survey results confirmed themes already developed in the qualitative analysis, and we resolved disconfirming evidence through clarifying discussions with CFU members. The researchers refined themes based on this feedback, CFU reviewed them a monthly CFU meeting, and additional revisions followed.We used qualitative techniques to analyze the interview and focus group data. First, the researchers identified broad categories in the data by reviewing interview and focus group transcripts, and as they reread the transcripts they refined the categories . For eacThe CBPR approach inherently fosters data validation because of the significant community member involvement in the research process. We used data triangulation, including three methods of data collection, and a mixed-methods design to further support the validity and credibility claims in this study .While the CBPR literature is robust, a minority of these publications describe coalitions where community partners contribute to each phase of the research process, especially in issues of authorship. The group collaboratively decided on authorship guidelines, informed by community engagement professional journal guidelines, which the lead researcher presented to the members at a monthly CFU meeting. Authorship was defined as contributing to study design, discussion of qualitative themes, and revisions to the written manuscript. All 11 partners met the criteria for authorship.The following sections describe the themes that emerged from the data and provide representative quotations. Themes associated with the CFU approach, including structure, function, and evolution, are described first, followed by those associated with CFU successes and challenges. The survey results follow.Members reported that CFU is a true collective with shared goals, concerns, values, and a group identity.The key for CFU success is considering each other and respecting each other. We believe that each side, either University, Communities or Health Department, has something to contribute. Each side brings their strength, opinions, information, and we put it together, instead of going just with one side .The Community members are bringing…their expertise in their communities. The University side is bringing resources, money…the research skills that help us get the bigger grant money…. The Health Department brings its expertise in engaging the public in improving health.The partnership shares a deep commitment to equity, defined by the group as valued the same but allowing for different contributions among all members. Each member described feeling valued by the group because of his or her unique contributions. As Louisa (UUSOM) explained:Members explained that the differences in their skills and backgrounds have been essential to the success of CFU. For example, “We all bring a different set of qualifications, a different kind of experience and information, a different kind of training, but everybody’s listening to everybody, and we find that all of that has value in making good decisions” .When we have something to discuss, we put it on the table. We discuss and make sure everybody understands and agrees. We treat each other with respect and I feel like we have equality, like when there is something to discuss, we don’t vote. We keep on discussing it and finally come to an agreement .The focus on equality is evident in the structure and organization of the monthly meetings. “We don’t have a formal structure—we don’t have a chair, vice chair, secretary. [The community liaison] creates the agenda and our meetings basically run themselves” . Decisions are made by consensus, following the standard of group congruence rather than majority based voting. Final decisions usually involve a blending of ideas:In other words, decisions are made by congruence, not compromise. Participants reported feeling respected by others in the group and having their voices heard. “My opinion matters in whatever decision we take” . Dorienna, a community member, added, “Everyone has their own opinion, everything is weighed.”CFU evolved from a group of organizations brought together to carry out a single project, as previously described. One UUSOM faculty member had previous links to the community organizations and was respected as an advocate for community health promotion. Sylvia, a community member, explained, “It was important to trust the person that’s recruiting [from the UUSOM]… It was my [already established] relationship with Louisa that did it and a total trust in what she was doing.” After the project was funded, Louisa hired a community liaison, Heather, who had previous experience as an elementary teacher in a Title I school serving students with diverse demographics, as a school administrator, and as a clinical instructor in the UU College of Education. Heather brought strong interpersonal communication skills to her work, including her ability to facilitate conversations and negotiations with multiple types of individuals  and build safe classroom communities with students from many cultures . She also was aware of social determinants and how they can impact a child’s health and ability to learn. While she is employed by UUSOM, her primary orientation is that of a community organizer; the CFU community members trust her to advocate for them and serve as their voice when they are not present.When CFU was in the process of formation, the community liaison recruited additional community leaders to participate. These leaders were identified through contacts made in her prior work and via referrals by a UDOH staff member. She met with each community leader, described the project, and invited them to participate. Members were already well-known and respected leaders in their communities. They are “the community gatekeeper… people that are so well connected to the community that they could take a message back to the community” . Another member explained the necessity of having established leaders: “If you’re not known in your community, it’s going to be very hard to get something like CFU started…it would be like pulling teeth to get somebody to come along” . Established leaders know their communities well and know what will and will not work for them.CFU leaders share certain key qualities, including a willingness to risk doing something new and different. Ed, a community member, explained, “The leaders are self-actuated—they don’t wait around to be told what to do.” They are humble and are willing to listen and learn from one another. Community member France described the members as “open-minded, humble people who really want to work together, collaborate, share resources, and not come with an agenda.” Leaders have passion and commitment toward improving the lives of members of their community and see the CFU partnership as one way of accomplishing that. “Everyone is in the organization not for their own good or aggrandizement. They’re here because they’re committed to what they do” .We always do the things in the way we agreed on doing it. That’s how I build my trust…. Information can come from [the UUSOM and UDOH] and we are able to come to an agreement because we trust each other. Because of that trust we can agree.The CFU partnership was built on a strong foundation of trust. Trust was established and reinforced through continuous positive experiences with members following through on promises and being accountable for actions, having goodwill toward one another, working to contribute to the betterment of other members’ communities, and having one another’s best interest at heart. Valentine, a community member, explained:We like each other. We get along. We know each other. We’re interested in each other. We have the other members’ best interest at heart. They have ours. That’s something that I think can’t be overstated, in terms of the importance of building those relationships .Another member explained:Further, trust grew because the members understood that growth and success takes time and that it is not always a smooth process.We jumped on this because they came with an open mind already. They wanted to work with us to develop this partnership where everybody is equal…. [None of us] wanted to be used again…by groups that just wanted to be associated with the Community and then we never heard from them again .When asked why they made the decision to join, Community members reported recognizing that the UUSOM faculty member and community liaison intended to form an equitable partnership. The community members explained:Additional reasons for joining included positive previous experiences with the UUSOM leaders, a current relationship with some of the other community leaders, and one member indicated an interest in genetics.A community liaison is critical because nobody else in the group has that time. She meets with people individually. Before every meeting she’s already talked to everyone about the agenda and prepared them for the meeting so there aren’t any surprises… People are prepared to have a thoughtful discussion. We increasingly have people who want to talk to CFU so Heather meets with them and educates them about working in a community engaged way .The findings unambiguously revealed the importance of an effective community liaison to facilitate the partnership’s work. For CFU, the liaison’s primary role is to ensure that relationships among the partners are supported. Her tasks include communicating with members about CFU’s work; organizing meeting agendas; scheduling additional meetings; facilitating CFU members’ work on projects; and meeting with current and potential external researchers and collaborators to discuss projects along with educating them about CBPR and working with communities; and helping resolve any issues that arise. She communicates constantly with CFU members via email, phone, text messages, and in-person meetings. She also attends events in each community:You have to check in on people: ‘How’s your day going? Are you still able to attend?’ I think that’s an important lesson for people to realize when working with the different communities. It requires more intense communication and a lot of different modes [of communication]…. Also, it’s key to have that agenda to get through the two hours we have monthly.Fahina, a community member, explained, “She is the point of contact in all things—it’s quick and easy.” Heather (UUSOM) described her activities as:Having a starting project  provided a framework to develop the CFU group identity and process. “We needed a strong goal…that solidified CFU and gave us credibility and a common identity” . The goals identified by the group typically aligned with the goals of the separate community member organizations. As CFU evolved, it was able to undertake several projects, including the large-scale project on obesity reduction that further defined and refined the partnership, its mission, and its work as a united entity.Other factors that contributed to the growth, cohesiveness, and productivity of the partnership included requiring members’ regular attendance at all meetings, and having a consistent and welcoming place in which to hold meetings. It also has been important to hold CFU-sponsored events, such as health fairs, at locations that are convenient for the members of the communities the leaders represent. Next, we report on the successes and challenges the group has experienced.Each partner reported that his or her community benefits from involvement in the partnership. It is understood that knowledge and available resources are shared. By being exposed to the diversity of people and organizations represented in CFU, all members feel they are broadening their resource base. The community members reported increased health awareness and knowledge of available resources, among other benefits for their respective communities. “There are resources and all kinds of things that we, as community, tap into” . Further, members from the communities are experiencing a growth in trust and comfort with members of other communities. As Doriena, a community member, explained, “Our communities are becoming more trustworthy with each other as well as the [leaders] trusting one another.” Ed (Community) explained, “It’s been an opportunity for me to take the stories of [members of my group] and their situations out of their circles.”The UUSOM members and some of their colleagues have gained opportunities to understand how UUSOM resources could be leveraged to serve communities. Louisa (UUSOM) explained, “This certainly raised awareness within the CFU UUSOM leadership as well as the colleagues we interact with here at the university, about health disparities.” The university members have been better able to make meaningful connections between academia and communities. Fahina, a community member, observed that this “is a rare opportunity where researchers on the university level have the community readily available and can implement research and evidence-based programs directly.”I think just listening to some of the challenges and barriers that people in CFU face has really been an eye opener…. It’s been very helpful for us to step back and rethink and look at our interventions again and let the community have more say and more voice in what we try to implement to help people become healthier.UDOH members and some of their colleagues have gained an understanding of effective strategies and methods for attaining their public health goals in underrepresented communities. Further, they have learned to alter their goals in response to the reality of the needs and cultural specifics of the communities. Brenda, UDOH, explained:Further, members have shared this knowledge with receptive UDOH colleagues.I became a better leader because I’m able to provide more resources and more information to my community. I feel stronger because I have people who are supporting me, people I work with, people who can advise me. I feel better that I have support from CFU .Members felt that they gained important and meaningful lessons in leadership and intercultural skills through their participation in CFU. For example, “Working with other communities and seeing how they handle things has helped me to better myself and how I handle different programs or obstacles” . Some reported an improvement in their leadership skills. One community member explained:The benefit we get out of this is that while we understand the academic and scientific world and the theoretical world of health, what we and other universities have failed to understand is the day-today reality of health for the people that we’re supposed to be serving…. So it’s coming together with these communities and hearing that voice and that feedback that allows us to truly face…what the reality is and have our partners help us understand what it is that we need to be doing to serve the needs of our society .The UUSOM members felt they increased their understanding of the health needs, challenges, and other realities of the communities represented by CFU. This gained knowledge has enabled them to more genuinely and effectively serve the needs of these communities. One UUSOM member explained:It’s given me more of a sense of inclusion, of the need to work with people who have, at least on the surface, differences. And it’s also helped me to understand better that we have more in common as human beings than we have that’s different. And so I think I’m striving to be a better leader in that sense, and a leader that does not make decisions based on a particular group or community organization, but rather to be more inclusive of other groups.CFU members reported they have become more open toward and tolerant of others who are members of different ethnic communities. “My view used to be that this is a Black issue, or this is a Hispanic issue, but no longer is that the case” . Some have experienced an increased comfort level with other groups, including ethnic communities, UUSOM people, and UDOH people. For example, France, a community member, explained:Additional feedback from other CFU members suggested that individuals have become more humble through engaging in the CFU interactions. Others have gained new personal strength. Several members have been inspired to further their education.When I think of what describes my feelings for our group, a Maori word comes to mind, ‘Aroha.’ It’s one of those words that cannot be adequately translated into English…it means love in the fullest context of the word. It means respect, honor, caring, comforting, connecting, embracing…and more.The CFU members consider one another good friends, or even family. Ed, a community member explained:There’s actually power in numbers and so for [our individual communities] to complain about something, we get labeled as ‘there they go again,’ but when all of us come together…. it’s very powerful when five groups of us, you know, are raising the issue .CFU members felt that there were goals they could accomplish as a group that they could not achieve individually:Because of their unified goals and message, members, in different ways, felt they gained legitimacy and credibility, and that their voices were now being heard by policy makers and other decision makers. Further, the community members felt they could represent their communities in the public sphere more effectively because of the partnership. “Coming together from different points of view and perspectives, and not just one group yelling and making squeaky noises, but all five groups making a noise and together…. We squeak in harmony!” . UUSOM and UDOH members felt they were bolstered by working closely with people in the communities. Therefore, their messages to their colleagues were representative of realistic community needs and challenges.CFU’s reputation has grown significantly. Groups—including other community organizations, researchers, and program leaders—regularly request some level of partnership with CFU. As Fahina (Community), explained, “CFU has the option to accept or reject [requests for partnership] based on pros and cons.” Thus, the group is gaining recognition and credibility for its productivity and successes. CFU members regularly submit funding applications as a single entity, a process that leads to stronger applications and higher chances of funding. Some CFU community groups have emulated the CFU partnership model with other groups within their community. “Other people are following this model in their communities, which shows that it is spreading and really working” .The partnership has been spreading its message. CFU has provided a “forum for our voices…. It’s opened other doors with other organizations and health sciences” . The group is making powerful impressions. It is regularly invited to present and/or to participate on panels at meetings and conferences, and several members have made local, state, national and international conference presentations on the strengths and successes of CFU and its work. “We’ve gotten invitations from the [UUSOM members’] colleagues to some of their conferences that we would not have been considered for prior to CFU. They wouldn’t have known us and even if they did, they would have ignored us” . Grant, from UDOH, described how its division director has attended CFU presentations: “She’s listening and she’s a good one to advocate for the group.”As with any important relationship, learning to trust took considerable time, c ommitment, and effort. It took several years for the members to develop the level of intragroup trust currently experienced. “We were feeling out to what extent we could rely on the other folks around the table. That developed over time, to the point that we can now deal with some pretty tough stuff” . One community member described his initial uncertainty about working with UUSOM leaders: “One of the reluctances that we had at the beginning was that the people at the university were going to do a show up, ask questions, collect information, and disappear. And it took us time to establish the relationship with them” .In a meeting now, it would take five minutes to make a decision. It probably took us two months to get through that process at the beginning. We came out the other side recognizing that here are some new ways we could do things to help avoid that in the future .All members invested their time to learn to make decisions that were mutually agreed upon. Over time, the group has become more efficient. “We brainstormed a lot at the beginning of CFU…to find out what we all had in common with health issues” :Some of the first efforts took time and we had people get upset, we had side meetings, we had to work through a lot of things, we had to work with individuals…. Now it’s to the point where if someone has an issue they’ll just say it and we have this sort of trust built up…a shared knowledge base that we all draw from.The group experienced growing pains as the partnership developed. As may be expected, bringing so many different perspectives together opens the door for disagreements. The community liaison described her role during the evolution of CFU as averting potential conflicts:The community liaison addressed issues and challenges as they arose by contacting members, often individually. “When there was any type of feeling of conflict or tension, [the community liaison] would immediately speak to one of the members…communication, clarification, ask the questions again and again and it seems to allow that conflict to not happen” . Potential conflicts, therefore, were readily addressed by quick communication and clarification. From the beginning, the community liaison set the tone and reinforced a group norm of equality and equity. “She keeps her finger on the pulse of everything, she ensures that everybody feels equal…. She set this tone saying everybody has the same voice, everybody feel free, we’re not going to judge and we’re going to respect everybody” .Some leaders felt that they needed to prove to their own organizations that their time commitment and effort in CFU was justified. Sylvia, a community member explained, “When we first started and I introduced it to my organization I had people say, ‘Why would you want to do work to better the lives of other people when our community is not doing well?’” However, as CFU began experiencing successes and the benefits of this partnership spilled over into individual communities, fewer members questioned the leaders’ participation.CFU members consistently reported that time and funding are in chronic short supply. All of the members hold positions outside of CFU, and therefore the time required is difficult to add to their already busy schedules. “I have heard from everybody that they’re also facing the challenge with time” . Securing adequate funding to conduct the work CFU would like to accomplish is a persistent challenge.organizational practices category indicated that participants either agree or strongly agree with all items (range: 4.0–5.0) . The results for member participation  indicated that participants’ responses averaged toward strongly agree (range: 4.6–5.0). When asked if CFU prioritizes the needs of any one partner, response averages were between strongly disagree and neutral (range: 1.5–2.7). For the category of participating organizations and diverse communities, participants agreed or strongly agreed that CFU impacts the health practices of members’ communities; CFU helps raise public awareness of health issues; CFU develops collaborative relationships with external organizations; partners are focused on creating positive health changes for their community/organization (range: 4.1–5.0). Finally, in the technical support category, results revealed that participants were neutral on whether they had sufficient funding and enough space to conduct their community activities (range: 3.1–3.5). They agreed there was enough space to conduct CFU meetings and that members had sufficient training (range: 4.4–4.5).The survey results for each category for present-day CFU membership (how members felt at the time of the study) supported key findings from the qualitative data. Response averages for the Participants’ retrospective survey results, which compared responses from when they first joined CFU to to the time when the study was conducted three years later, revealed statistically significant increases over time at an alpha level of .01 for each subscale See .One exception was the CFU member participation category, which showed a small, non-significant increase over time. CFU members, then, perceived coalition growth and change in three key areas  from its inception to three years later as a functioning, successful coalition. The members perceived little change in the category that asked about the presence of bi-directional learning, all partners having input in CFU decision making, prioritization of one group over another, and consistent patterns of communication and decision-making. Implications for these findings are described in the following section.In this study, we employed a CBPR research framework to: (a) identify and describe the formation and functionality of one successful community coalition that can be used as a model for developing similar coalitions, (b) examine and describe the interpersonal dynamics of group membership to address gaps in the literature, and (c) advance the science of developing health-focused coalitions by investigating the successes and challenges of CFU. The results suggest that CFU is an equitable, cohesive, and collaborative partnership of diverse leaders and organizations that functions productively to achieve group goals. CFU reports high member satisfaction, shown to be linked to leadership skill, staff skill, communication, and task focus .CFU members have experienced important, meaningful successes that include increased awareness of available resources, professional and personal growth and empowerment, group recognition, a local and national presence, and close friendships. The group’s successes impact all five health disparity communities, most of which are large enough to contain sub-communities that also benefit from CFU’s successes. Further, this partnership has allowed diverse communities to be heard as a unified voice. This is particularly important in a state with a population that is predominantly non-Hispanic White (78.5%) with smaller percentages of other races/ethnicities – 14.0% Hispanic or Latino, 1.1% Black or African American (non-Hispanic), 1.0% American Indian or Alaska Native (non-Hispanic), and 1.0% Pacific Islander (non-Hispanic) , . The stuThe partnership faced challenges, or growing pains, as it developed into today’s productive and cohesive group. The challenges included developing trusting relationships, resolving potential conflicts through communication, learning to work together and agree on common goals, navigating constraints and allocation of limited time and funding, and maintaining accountability to the communities the members represent. These challenges at times threatened to impede achievement of the group’s goals. Most have been resolved; nevertheless, members continue to face the challenges of insufficient resources.organization, programmatic, membership, and relational capacity. In the organizational and programmatic categories, CFU focused on building capacity during formation through initial connected, committed, visionary leadership that allowed the group flexibility to define itself over time  were already a strong presence in the first few months of membership and did not change significantly over time. These findings, along with the qualitative findings, suggest that the presence of these relational elements is key at the inception of a coalition and acts as the “glue” that binds a coalition together in the early years as it works through challenges.Developing the “glue” of CFU’s relationships was a process that required effort, diligence, and a focus on relationship building from all members. Factors that contributed to this included maintaining a willingness to work through initial challenges, having accountability for commitments, maintaining goodwill toward one another, keeping others’ and the group’s best interests at heart, employing patience to allow successes to begin incrementally and build in momentum, practicing humility, preserving open-mindedness, and sustaining a willingness to learn from each other.Many of these research outcomes align with the recent work of a multi-sectoral coalition in one city that worked to eliminate disease disparities in Asian populations . SimilarInitially, seek out members who share similar values, such as equality .Include members who are well known and respected leaders in their community or organization.Establish, practice, and commit to equity  and congruity among partners.Expect member dedication, time, effort, and commitment to the group.Understand that trusting relationships are built over many years of working together.all participating communities.Commit to working toward the health goals of Ensure support for, and access to, a capable community liaison who can facilitate communication and collaboration among all partners and who is skilled in carefully and respectfully working with coalition members to resolve any conflicts.This study provides qualitative, personal descriptions of members’ experiences during coalition formation and over several years of participation. The findings describe the process of relationship building and the collaboration process of one multi-sectoral coalition that could be adopted as guiding principles for other groups interested in developing a similar partnership. Guiding principles include the following:In sum, this research focuses on the processes of forming and maintaining a productive, cohesive p artnership among multiple, diverse communities and extra-community collaborators. CFU serves as an example of a Community-Academic Medical Center-Health Department coalition that has achieved group goals and whose members and communities experienced growth and increased capacity through their affiliation with the group. This coalition provides a model for others seeking to build such a partnership.Appendix AAppendix A. CFU Study: Semi-structured Interview Guide for Individual Interviews. Link: https://s3-eu-west-1.amazonaws.com/ubiquity-partner-network/up/journal/coll/coll-2-1-29-s1.doc.Appendix BAppendix B. CFU Study: Semi-structured Interview Guide for Focus Groups. Link: https://s3-eu-west-1.amazonaws.com/ubiquity-partner-network/up/journal/coll/coll-2-1-29-s2.doc.Appendix CAppendix C. Community Faces of Utah Partnership Survey. Link: https://s3-eu-west-1.amazonaws.com/ubiquity-partner-network/up/journal/coll/coll-2-1-29-s3.doc.