We’ve been doing so much work around social prescribing with Salford CVS, and salutogenesis is all over that literature. A concept developed by Aaron Antonovsky (1923-1994) for where the medical focus should lie: on how people become well, not on why they are sick. There’s some really good stuff in this sadly out-of-print book that I had to order on loan from the British Library.
It opens autobiographically — an intellectual history of Antonovsky’s work and the questions driving that work. I agree that this is the real question we need to be answering:
What are the stressors in the lives of poor people that underlie the brute fact that, with regard to everything related to health, illness, and patienthood, the poor are screwed? (3)
Given that, and all that follows, I can’t say it doesn’t trouble me greatly that Antonovsky moved from NY (and his work around studies of poverty and labour) to Israel, where it does not seem as though he undertook a study of mass Palestinian displacement into refugee camps or poverty or access to health care. Of course for him, understanding the echoes of the Holocaust in survivor’s health is clearly a driving question in his research, and this is where the example that he felt was foundational to his later theorising emerged from: In studying those camp survivors, he found that as a whole the group was unable to adapt as well as other groups to menopause. However, there were women within that group that adapted as well as anyone — so the question became to turn research around and ask why those women had adapted, and why they did so well despite their experiences? This led to what Antonovsky later came to call salutogenesis. Why people are ‘healthy’ not why they are sick. He makes the point that honestly, given how shit the world is, we should all be sick all of the time, so the real question becomes what is stopping that from happening?
It’s interesting, though, that the central concept of the book isn’t really this term salutogenesis, but what leads to it and ultimately what is at the foundation of health — what Antonovsky calls a ‘sense of coherence’:
a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that one’s internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected. (10)
This is what determines how well you deal with the daily bombardment of illness and disease. He also emphasizes that this is NOT the same as a feeling that ‘I am in control’. But more on that later.
I sit with this though. If this is true, then how thoroughly do we have to remake this world for health? Far beyond the policies I have seen Antonovsky quoted as a supporting reference for. For me, this becomes a new framework not only for the loss of my dad and many other people I have loved and lost to poverty and its many ills, but also for the millions of people now in hopelessness, precarity and movement across the planet.
Chapter One: Studying Health Instead of Disease
The problem of salutogenesis is one of the most mysterious, intriguing, and meaningful challenges for philosophy and the biological and social sciences… Pathogenesis–the origins of disease X, disease Y, disease Z–has preoccupied us … here, as in all of science, how one poses the question is crucial to the direction one takes in looking for the answers, (12)
We have looked for the origins of disease X, Y and Z and found them. He talks about the exogenous and endogenous bugs, the sets of agents that cause disease: ‘viruses, mutant cells, pollutants, or agents of physical trauma such as guns, knives, and motor vehicles, that pose a constant threat of damage…’ wait for it though, here it really comes:
And finally, there are those bugs variously called psychosocial stressors, presses, strains: alienation, rapid social change, identity crises, ends-means gaps, discrimination, anxiety, frustration. (14)
These are not, of course, considered working within a pathogenic model.
Our dominant ideological paradigm, which shapes our society’s clinical practice and scientific research, focuses on and responds to a particular disease or clinical entity. (15)
Near the end of the chapter, he gives three reasons why ‘the focus on pathogenesis is likely to handicap us in grappling with both the scientific problem of understanding why illness is far from deviant and the human problem of somewhat reducing pain… (my bullets, his words in what follows)
- the pathogenic approach pressures us to focus on the disease, on the illness, on the alteration of body fluids or structures, and to disregard the sickness… it blinds us to the subjective interpretation of the state of affairs of the person who is ill (36).
- thinking in pathogenic terms is most comfortable with the “magic-bullet” approach–one disease, one cure–which explains the resistance of many to the concept of multiple causation. … the assumption is that we are cleverer than the bugs and can eradicate them one by one (37)
- pathogenesis by definition is a model that postulates a state of disease that is qualitatively and dichotomously different from a state of nondisease…
And I’m going to separate this last bit of the paragraph out, because it better explains salutogenesis:
such dichotomization blinds us to a conceptualization made possible by a salutogenic model, namely, a multidimensional health-illness continuum between two poles that are useful only as heuristic devices and are never found in reality: absolute health and absolute illness. (38)
Chapter 2: Measuring Health on a Continuum
This returns to all the problems of thinking of health and illness as a dichotomy when the real question for Antanovsky is ‘Given the ubiquity of bugs, why does anyone ever stay alive and reasonably healthy?’ (39)
On epidemiology — I know it shouldn’t surprise me that the field of medicine is siloed within as much as without, and epidemiology is only one of those silos, and yet it does–he writes:
epidemiology is one of the major scientific disciplines that have developed in the service of the health care institution. There is no doubt in my mind that the epidemiological conceptualization of the health-illness phenomenon, the model or paradigm used by epidemiologists, is powerful and, for some purposes, far more powerful that the clinical model we have been discussing.
And continues, with bullets that are again my own
- epidemiologists are aware of the iceberg phenomenon. They assume, with adequate evidence, that for every case of a disease that has been brought to clinical attention…there are additional cases below the surface… (45)
- …they are kept in check by methodological sophistication and compulsiveness… [for clinicians] intuition, art and clinical skills are necessarily acceptable in arriving at a conclusion. The epidemiologist has the luxury of rejecting such subjectivism. (46)
- the sine qua non of the epidemiologist’s professional activity is to go beyond description and enter the field of analysis, to deal with causation. As such, it rounds out, complements, the field of laboratory and clinical research. But its core and strength are its understanding of causation as based on teh study of group rather than individual differences. (46)
Thus he gives the public health model higher marks than the clinical model (and I just read a splendid book about social epidemiology, but more on that later), yet it still suffers from this dichotomy of health and illness.
I was curious to find Antonovsky critiquing the WHO definition of health, not its utopian aspects but the way that it can’t be operationalized. He argues that this renders it harmless, and he might be right. He prefers Dubos’ definition of health (I am looking forward to reading Dubos) ‘a modus vivendi enabling imperfect men to achieve a rewarding and not too painful existence while they cope with an imperfect world (1968, p67).
Awesome definition, but I can see that not everyone would be inspired by that. Nor is this mapping of the continuum to inspirational either perhaps, but I found it useful:
As Antonovsky writes:
by defining health as coextensive with the many other dimensions of well-being, one makes the concept of health meaningless and impossible to study … Health wellbeing must be studied separately (68)
Chapter 3: Stressors, Tension, and Stress
Stressors are omnipresent in human existence … Poor tension management leads to the stress syndrome and movement toward dis-ease on the continuum. Good tension management pushes toward health ease. (71)
Everyone alive would agree with that statement. The list of stressors he gives:
accidents and the survivors; the untoward experiences of others in our social networks; the horrors of history in which we are involved; intrapsychic, unconscious conflicts and anxieties; the fear of aggression, mutilation, and destruction; the events of history brought into our living rooms; the changes of the narrower world in which we live; phase-specific psychosocial crises; other normative life-crises–role entries and exits, inadequate socialization, underload and overload; the inherent conflicts in all social relations; and the gap between culturally inculcated goals and socially structured means. (89-90)
Quite a list.
Chapter 4: Tension Management and Resources for Resistance
In moving towards an understanding of the foundations of salutogenesis, Antonovsky develops the concept of the Generalized Resistance Resource, or GRRs as those things that help keep us towards the healthy side of the continuum.
The principal individual characteristics include rationality, flexibility, farsightedness, but I’m most interested in what he calls Interpersonal-Relational GRRs, more generally known as social supports. These sit in opposition to social isolation — or what in those days seemed to have been termed ‘social isolates’ or ‘social destructs’. Goddamn, imagine being thought of as a social destruct. But we are finally working our way to understanding what Antonovsky means by coherence, ‘the GRR of deep, immediate, personal roots.’ (114) I haven’t read Malinowski since undergrad, but he’s cited here:
Malinowski says that culture gives each of us our place in the world…. In Chapter Three I defined a stressor as a demand made on one for which one does not have tan automatic and readily available response capacity. From this point of view, what culture does, in giving us our place in the world, is to give us an extraordinarily wide range of answers to demands. The demands and answers are routinized: from the psychological point of view, they are internalized; from the sociological point of view, they are institutionalized. (117)
A really fascinating way to think of culture in the abstract, but I can’t help but also think of the left’s too-often sneering attitudes to ‘identity politics’ and culture and struggle, and see how really this all ties in together. And just to repeat once again”
Ready answers provided by one’s culture and its social structure are probably the most powerful GRR of all. (119)
Chapter 5: Perceiving the World as Coherent
This is the central point of the book really, and the key idea for Antonovsky:
The sense of coherence is a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that one’s internal and external environments are predictable, and that there is a high probability that things will work out as well as can reasonably be expected. (123)
He doesn’t once, that I remember, quote Voltaire. It’s extraordinary. He continues:
A sense of coherence, as I trust has become clear, does not at all imply that one is in control. It does involve one as a participant in the processes shaping one’s destiny as well as one’s daily experience.
The crucial issue is not whether power to determine such outcomes lies in our own hands or elsewhere. What is important is that the location of power where it is legitimately supposed to be. This may be within oneself; it may be in the hands of the head of the family, patriarchs, leaders, formal authorities, the party, history, or a deity. The element of legitimacy assures one that issues will, in the long run, be resolved by such authority in one’s own interests. Thus a strong sense of coherence is not at all endangered by not being in control oneself. (128)
It’s all about power over your fate — and in fact by this argument participation in struggle could be as powerful and positive a health determinant as being lucky enough to be born in the upper classes. Of course, Antonovsky also describes the way that certain kinds of faith stand in as much good stead. There is so much to think about here.
He gives case histories of Norman Cousins and Freud himself as examples — you have to like that. In thinking about the conditions under which a strong sense of coherence emerges, Antonovsky notes that one line of research might be investigating how in the case studies given, the ‘one common substantive theme … is the continuous experience of participation in shaping one’s fate‘ (152).
Chapter 6: Relation of the Sense of Coherence to Health
A long chapter that states that as the sense of coherence has not been operationalized and therefore not tested, he is simply bringing together evidence for a ‘prima facie case for the plausibility of the hypothesis‘ (161). I think he manages.
Chapter 7: the Salutogenic Model of Health
And now back to salutogenesis, along with a helpful summary:
In Chapter One, I posed the problem of salutogenesis. Chapter Two proposed a solution to the problem of the measurement of health status consonant with the salutogenic orientation. At that point, the core of the question was put as the need to explain the location of a person near the ease end of the health ease/ dis-ease continuum. Chapter Three considered–and rejected–the hypothesis that the answer could be stressor avoidance. In Chapter Four, an initial alternative answer was presented: the availability of generalized resistance resources. The initial question was also broadened to consider maintenance or improvement of one’s position on the breakdown continuum, irrespective of location at any given time. Analysis of the nature of generalized resistance resources, of why they are hypothesized to facilitate tension management and avoid stress, led to the formulation of the central construct of the book, the sense of coherence, considered at length in Chapter Five. The final building block in which I call the salutogenic model appears in Chapter Six, which presents the evidence for linking the sense of coherence and health status. (182-183)
An amazing chart here to summarise the model. I give it to you:
And of course, as I’ve probably failed to make clear, salutogenesis really needs to be the focus of our current age, not instead of pathogenesis but after pathogenic success.
There is, indeed, good reason for the pathogenic model to have dominated thinking about disease for most of human history. The three-pronged power of stressors…which included perhaps above all nutritional deprivation and the most primitive level of sanitation, was sufficient to overcome even substantial resistance resources. When, however, the standard of living…reaches a rough level of adequacy, differences in health level no longer are overwhelmingly determined by biochemical and physical stressors (193).
Chapter 8: Implications for an Improved Health Care System
This isn’t easy, this is no ‘guide to the perplexed‘ — Antonovsky says that twice. But he has a few suggestions. One is to think of the doctor as a GRR — each encounter between doctor and patient a way to support a patient’s sense of coherence. This is particularly important as each encounter will generally involve ‘anxiety, uncertainty, unpredictability and dependence‘ for the patient. Above all this is key after a traumatic situation, when someone finds themselves, as Antonovsky writes, as generally ‘shattered‘. However routine encounters also important. For the most part, those encounters which allow the physician to see and to treat someone as a whole with a sense of their broader self and context are the best.
Near the end of the book, Antonovsky asks: ‘Can the medical profession and the individual physician engage in activities beyond the patient-doctor encounter that affect the sense of coherence?’ Yes of course, and there are four ways this might happen: ‘making health care available to all, promoting a preventive health orientation, buttressing faith in the physician, and reaching out to persons at high risk of damage to the sense of coherence‘. (217)
One of my favourite sentences:
A society, then, that has institutionalized a health care system that expresses consensus that health care is an inalienable right of all its citizens and is to be made available to all on the universalistic ground of being a resident of that society is a society that has taken a step forward in strengthening the sense of coherence of its members. (217)
Those blocked from this due to poverty or race or rural living distant from health care necessarily lack this sense.
Penultimate paragraph from the epilogue:
If we wish to see the present and future soberly in our world, we must use words like capitalism and totalitarianism. The social structures in which most of humanity lives and the daily experiences to which we are exposed in these structure are far from conducive to a strong sense of coherence…Societies with a marketing mentality and fetishism of commodities, with terror and arbitrary recasting of history, with grinding poverty and starvation cannot foster a view of the world as one that provides information and music except for the fortunate few.
It would take another book and an extensive research effort to subject to serious analysis the concrete social structures and social positions that in our world foster a strong sense of coherence. Improvement in health status is contingent on such analysis and on a program of social action that could follow. This analysis is one of the crucial tasks of social epidemiological research (227).
He hopes this book is one of the tools that makes this possible, and I believe it is.
[Antonovsky, Aaron (1985) Health, Stress, and Coping. San Francisco and London: Josey-Bass Publishers.]
