Where Is Health Born?

From Pathogenesis to Salutogenesis

A medical sociologist, while studying how women adapt to menopause, came upon a fact he could not explain at all. Among the women who had survived the Nazi concentration camps, some were living remarkably well—healthy, and undiminished in their will to live—despite having endured that unspeakable suffering. His name was Aaron Antonovsky. The medicine of the day answered "why do people fall ill?" with great skill. But this minority could not be explained by that question. Under conditions in which they ought to have collapsed, what on earth kept them alive?

The history of medicine has, for the most part, been built upon a single question. What causes disease? This is pathogenesis. Find the cause, remove it, cure the illness. Discover a germ and make an antibiotic; find a genetic mutation and develop a targeted therapy. There is no denying that this paradigm has led to the dazzling advances of modern medicine. But Antonovsky turned the question over. Not what causes disease, but what gives rise to health. He called this salutogenesis—the origin of health—joining the Latin salus, meaning health and wholeness, with the Greek genesis, meaning origin.

His famous image is that of a river's current. Conventional medicine hauls out, downstream, those who have fallen into the river and are being swept along. This is admirable work. But Antonovsky asks: why do these people fall into the river in the first place? And, more importantly, how might we teach them to swim? Health, he says, is not being pulled from the river but the ability to swim within it.

Health is not the absence of stress, but the strength to swim within it.

I have lived this view with my whole body my entire life. For my own field, exercise oncology, stands upon exactly this logic. We do not try merely to rid the cancer patient of disease. Along with the disease, and beyond it, we try to cultivate the body's strength to go on living—the ability to swim. Antonovsky called this ability the sense of coherence. It is the sense that the world is comprehensible, manageable, and meaningful. Here Antonovsky's insight meets the earlier chapters. The health he speaks of is not a sterile safety. That life is always exposed to stress—this is his premise. It is the same as what hormesis said, the same as the strength to pass through the anxiety of the threshold.

Here we must pause to clear up one misunderstanding. In stressing health this way, health itself can all too easily become the goal. The philosopher Byung-Chul Han observed that this age enthrones health as a new idol. When life loses meaning and story and shrinks into bare survival, all that remains is the single aim of a "healthy body." Yet the element Antonovsky counted as most important among the three of the sense of coherence was precisely meaningfulness—the sense that life is worth living. Paradoxically, health becomes an illness the moment it is made into an end in itself. Lose sight of what the health is for, and with whom it is shared, and even the management of health becomes one more achievement that gnaws away at us. Health is not an end but the ground that lets us love, work, and live out meaning. As I asked in the Prologue, only when there is an answer to "why do you want to be healthy?" does health at last become health.

The psychologist Abraham Maslow, too, placed this same direction at the very top of human longing. He called it "self-actualization." The shifting of one's weight from a life of filling what is lacking to a life of blossoming the possibilities within oneself. Antonovsky's meaning and Maslow's self-actualization say, in the end, the same thing. Health does not end with patching what is lacking. It becomes whole when it grows toward meaning.

Yet I want to add one thing to his insight. Antonovsky placed this sense of coherence within the individual's inner life. But I believe it is born not inside the individual but "between," in relationship. The sense of coherence does not arise in a vacuum. It grows from secure attachment, from people who can be trusted, from a community that shares meaning together. Spending more than twenty years at the bedside, I saw it again and again. The patient with someone beside them endures longer, and better. Health is not the strength to stand alone but an event born together at the boundary. This story continues again in Part Four. For now, let us hold only this. Health is not the absence of disease but the ability to be born anew, moment by moment, at the boundary. And what, then, is that "moment by moment"? When the boundary enters into time, it becomes rhythm. Now let us cross over into Part Three.

References

Aaron Antonovsky (salutogenesis) · Abraham Maslow (self-actualization) · Byung-Chul Han, The Burnout Society