The art of simplicity is a puzzle of complexity.

Douglas Horton

Have you ever done a Sudoku puzzle? Not a spoiler alert but one wrong guess or entry can collapse the entire board. I felt like the game was playing ME this morning.

But instead of a pad of paper or a book of puzzles — the game board was the U.S. “healthcare system”. Let’s quickly review the idea of the game and I will tell you how the logic here can be broadly applied to systems in real life.

Rules of the game must be followed at all hierarchy levels. For example, the smallest division is inside a single 3x3 block inside a zoomed out larger 9x9 space. The vertical columns and horizontal rows can only be used one time and can only contain numbers between 1 and 9.

Sudoku came to mind today because I have been reading and contemplating the work of Mario Giampietro and colleagues. Specifically an article published in Ecological Informatics, titled Analogy between Sudoku and the multi-scale integrated analysis of societal metabolism.

In fear of over simplification, the point is to combine constraints defined at different scales. The information inside each cell is shared information between the hierarchy of the remaining cells. The more complete the grid, the fewer options that remain. Imagine flows (energy) and funds (technologic capital) required to “add up” across different levels of hierarchy similar to the rules of Sudoku.

Pivoting back to U.S. healthcare, a family member called to say they were calling an ambulance to bring my mom to the emergency department. She was stuck in a seated position and was unable to stand. Bless her little cotton socks she ended up having a posteriorly dislocated femur.

Wanting to avoid the 3rd world vibe of one of the ED options, my brother directed them to bring her to another facility within the same system. They took one look at her medially rotated leg and sent her to the disorder and chaos of the facility we were trying to avoid.

Each little block in the sudoku puzzle of that morning was disrupted. Calls I made as mom’s durable power of attorney located 518 miles away were not answered for hours. Somewhere along the journey of “the best health care in the world” her last name was misspelled so the scholar that made the mistake simply created another MyChart for her in Epic meaning unless someone intuited the misspelling they would not be able to access any of her medical history. An error in a small grid was now palpable at all levels of care. Any bigger grids requiring the misinformation entered at the smallest level would be dysfunctional.

…each time we introduce a number in the grid we dramatically reduce the degree of freedom for the remaining numbers to be entered. In this way, the information accumulated in the Sudoku reduces the option space of viable numerical patterns. Indeed, the numbers entered in individual cells of the grid (local scale) constrain the overall numerical pattern (bottom-up causation), whereas the partial overall pattern already present constrains the entry of new numbers in the grid (top-down causation).— M. Giampietri, S.G.F. Bukkens, 2015

The direct application of Sudoku to the work with multi-scale integrated analysis of societal and ecosystem metabolism is a topic I will be exploring in the Open-Source Geospatial Substack if you are interested.

Clearly, accumulation of internal constraints may lead to lack of a solution if numbers are place in an invalid position generating a subcritical unviable Sudoku (rules of the game are violated by provided options)—M. Giampietri, S.G.F. Bukkens, 201

Thankfully after hours of phone calls, emails, and texts mom is now home resting comfortably.

It shouldn’t be this hard. But yet here we are with eraser marks across big and small grids simply trying to get it all to add up.