Where Is Health Born?

From Pathogenesis to Salutogenesis

A medical sociologist studying how women adapt to menopause came upon a fact he could not explain at all. Among women who had survived Nazi concentration camps, some were living remarkably healthy lives, their will to live intact, despite having endured that terrible suffering. His name was Aaron Antonovsky. The medicine of the day answered skillfully the question of why people fall ill. But this minority could not be explained by that question. Under conditions in which anyone ought to have broken, what on earth had kept these people alive?

The history of medicine has been built for the most part on a single question: what causes disease? That is pathogenesis. Find the cause, remove it, cure the illness. Discover the bacterium and make the antibiotic; find the genetic mutation and develop the targeted therapy. There is no denying that this paradigm drove the dazzling advance of modern medicine. But Antonovsky inverted the question. Not what causes disease, but what gives rise to health. He called this salutogenesis — joining the Latin salus, health and wholeness, with the Greek genesis, origin.

His famous image is the river. Existing medicine pulls people out downstream after they have fallen into the water and been swept along. This is admirable work. But Antonovsky asks: why do these people fall into the river? And, more importantly, how might we teach them to swim? Health is not being pulled from the river; it is the capacity to swim within it.

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

I have lived this perspective in my body all my life, because my field, exercise oncology, stands on exactly this logic. We do not try only to remove the disease from a cancer patient. We try to build the body’s strength to live with the disease and after it — the capacity to swim. Antonovsky called this capacity the sense of coherence: the feeling that the world is comprehensible, manageable, and meaningful. Here Antonovsky’s insight meets the earlier chapters. The health he speaks of is not sterile safety. His premise is that life is always exposed to stress. It is the same thing hormesis said, and the same as the strength to pass through the threshold’s anxiety.

This turn of the question changes the very definition of health. In 1948 the World Health Organization defined health as a state of complete physical, mental, and social well-being. For its time it was a revolutionary sentence, for it said that the absence of disease alone is not health. But one fatal word sits inside the definition: complete. By that standard almost no one on earth is healthy for a lifetime. The body always wavers, relationships always creak, the mind always rises and falls. The moment health is defined as a state, most of us become patients.

Here one misunderstanding must be addressed. Emphasizing health this way can make health itself the goal. Today we exalt health as a new idol — because when life loses meaning and story and shrinks to bare survival, all that remains is the goal of “a healthy body.” Yet the element Antonovsky named most important among the three components of coherence was meaningfulness — the sense that life is worth living. Paradoxically, health becomes an illness precisely when it becomes an end in itself. Lose sight of what the health is for and with whom it is shared, and even health management becomes one more achievement gnawing away at us. Health is not a goal but the ground that lets us love, work, and live out meaning. As the prologue asked: only when there is an answer to “Why do you want to be healthy?” does health finally become health.

The psychologist Abraham Maslow placed at the top of human wanting something pointing the same way. He called it self-actualization — the shifting of weight from a life spent filling what is lacking to a life that brings the possibility within oneself into flower. Antonovsky’s meaning and Maslow’s self-actualization say, in the end, the same thing. Health does not end with making up a deficit. It becomes whole when it grows toward meaning.

I learned this in Boston. When I first went there my intention was clear: to research alongside world-class scholars, publish the results in renowned journals, and make my name known. Honestly, that was the goal of that year.

And yet what remains most vivid from what I actually did that year was not a paper. It was serving as an assistant in an exercise program for people who had come through cancer. Not the instructor, not the principal investigator. Ordinarily it was the kind of work one would hand to an undergraduate practicum student. As that year drew to a close, Nancy, the exercise physiologist who taught the classes with me, buried her face in my shoulder and wept aloud for close to five minutes. I still do not fully know why she wept. We took photographs together, and several of those participants have since passed away.

A distinction I came to then: splendid work and important work are different. We mostly chase splendid work — work that is noticed, work that leaves a name. But what saves a person is generally not splendid work. Being beside someone. Moving the exercise equipment. Work that leaves no name. Since then, when I choose a study, I ask this question first: is this splendid work, or important work?

Still, I want to add one thing to his insight. Antonovsky located this sense of coherence inside the individual. But I believe it is born not inside the individual but between people, in relationship. Coherence does not arise in a vacuum. It grows out of secure attachment, of someone trustworthy, of a community that shares meaning. In more than twenty years at the bedside I have seen it again and again: the patient with someone beside them endures longer and better. Health is not the strength to stand alone; it is an event born together at the boundary. This story continues in Part Four. For now let us hold only this. Health is not the absence of disease but the capacity to be born anew, moment by moment, at the boundary. Then what is that “moment by moment”? When a boundary enters time, it becomes rhythm. Let us move on to Part Three.

Notes for this chapter

World Health Organization definition of health (1948) · Aaron Antonovsky (salutogenesis) · Abraham Maslow (self-actualization) · Byung-Chul Han, The Burnout Society