Wishes for a Salutogenic New year

Salutogenesis is…” an approach to human health that examines the factors contributing to the promotion and maintenance of physical and mental well-being rather than disease with particular emphasis on the coping mechanisms of individuals which help preserve health despite stressful conditions.”

The Merriam Webster Dictionary

As we enter 2021, the COVID 19 vaccine offering hope to contain the pandemic, it is clear that the enormous damage it inflicted on individuals and communities will be manifest for years to come. Recent CDC data on drug overdoses (1) show the largest number of drug overdoses for a 12-month period ever recorded. In particular, the report highlights a concerning acceleration from March 2020 to May 2020, coinciding with the implementation of widespread mitigation measures for the COVID-19 pandemic. The salutogenic model is an explanatory framework for understanding and intervening to achieve optimal health along the continuum between well-being and disease. Utilizing the model can provide a path forward as we continue on the path of increasing social and economic fallout that is likely to impact the most vulnerable Americans. The recognition of the potential role of the salutogenic model in addressing the consequences of economic deprivation, social stress, and alienation is not new. Sir Harry Burns, the former Chief Medical Officer for Scotland, in a 2014 TED talk, shares his experience addressing the challenges associated with alienation and marginalization caused by economic dislocation. As a holistic model in its conceptualization of health, it is well suited for our current public health challenges.

In 2019, the word Salutogenesis was added to the Merriam Webster dictionary. Derived from the Latin salūt-, salūs "safety, well-being, health" + -genesis origin, salutogenesis is “a newer way of thinking about health...a manner of monitoring health by promoting well-being rather than measuring disease.” Salutogenesis as a concept was formulated by Professor Aaron Antonovsky, an American-Israeli medical sociologist, in 1979 to answer a foundational question: “What causes health?” Salutogenesis’s initial focus was on an individual's sense of coherence, the ability to have a comprehensible manageable meaningful outlook in a complex world. It evolved into a more comprehensive framework that more fully capture the causes of health, as well as recognizes antecedents to pathology in order to promote coping with life’s challenges. In the nearly five decades since its introduction in the health promotion community, the salutogenic formulation has been studied in various populations and has been applied to a number of social domains such as architecture, communities, organizations, ethnic conflict resolution, and informed policy.

The Handbook of Salutogenesis(2), published in 2016 and available online, provides an extensive overview of the development, salient features, research, and other aspects of the current state of the salutogenic model. Although salutogenesis as a concept is being recognized as a model for health promotion mostly in Europe and Israel, it has not gained much recognition in the United States. The challenges presented by the COVID 19 Pandemic and the ongoing crisis characterized by “Deaths of Despair” continue to demonstrate the limitations and failures of our public health ecosystem. A complex approach to health(3), and public policy that recognizes the many determinants of health and well being is called for. Salutogenesis is well-positioned to provide a framework that can augment the medical model and current public health activity. The various aspects of the salutogenic model, including a focus on the sense of coherence, made up of the individual’s ability to see life as comprehensible, manageable, and meaningful, and the resources that are necessary for its positive impact; the focus on the complexity of health challenges; the recognition of the impact of “downstream” circumstances; and the importance of learning as a system, invite us to consider how the understanding, research, and implementation of policies and practices of salutogenic orientation may serve to address many challenges in the health care system in particular and society more generally. This article (perspective) provides a brief introduction to the salutogenic model and suggests a case study within the American experience--the opioid epidemic--that highlights the potential for using a salutogenic lens to tackle complex social and health challenges.

Antonovsky, who died in 1994, was intrigued by the results of his study and observation of the function of holocaust survivors in Israel. He found that while many exhibited psychological pathology associated with their traumatic experience, others appeared to function well if not thrive. He was intrigued by the paradox. Rather than trying to explain their pathology and its apparent absence, he turned the question around--asking what allowed some survivors to not merely survive but actually thrive and achieve a healthy level of well being.

He found that people with a strong sense of coherence, made up of the individual’s ability to see life as comprehensible, manageable, and meaningful, were better able to mobilize their personal resources to cope with life’s challenges and demands. In the years after the publication of his first book, he expanded the salutogenesis model to recognize the importance of general resistance resources (GRRs). These cognitive mindsets and resilience promoting tools allow for maximizing the person’s ability to achieve well being. In addition, Antonovsky stressed the important role for understanding and addressing “downstream” factors that lead to “stress” in the first place. The evolving model and the activity associated with it are well-positioned for individual coping and the ability to transcend the” chaos” of life and flourish.

As a medical sociologist, this was a natural way for Antonovsky to perceive the world: seeing humans as part of a larger context. In his second book, Unraveling the Mystery of Health published in 1987, Antonovsky described how he perceived the world. Two important things stand: (1) he saw man in interaction with his/her environment and (2) chaos and change are a normal state of life. The former calls for system theory thinking where the focus is on the individual in a context. By the latter, he perceived daily life as constantly changing: a heterostatic as opposed to a homeostatic state. For the individual, the challenge is to manage the chaos and find strategies and resources available for coping with the changes in everyday life. He recognized that in order to understand the challenges experienced by individuals in a chaotic unpredictable world and intervene the salutogenic model and related practice require a multidisciplinary approach and exploration through a complexity lens. Using a complexity lens, the salutogenic approach allows for examination and addressing “downstream” factors that contribute to “pathology” as well as to well-being. In essence, salutogenesis concerns itself with the entire ecosystem in which the individual functions. These include biological, social, psychological, environmental, and political factors. At its fullest manifestation, the salutogenic model is transdisciplinarity and involves “blurring boundaries'' between disciplines and the synthesis of a new epistemology– new conceptual and theoretical frameworks, and new methodological approaches that ultimately yield a deeper understanding of the problem being studied “as a complex dynamic system”.

In many ways, the salutogenic orientation and approach can empower individuals as political agents within their communities, state, and the nation, to address marginalization and alienation that is so toxic for individual and societal well being. Viewed with a salutogenic lens and orientation, “deaths of despair” in general and the opioid and substance abuse epidemic more specifically can be understood in a holistic manner and provide a comprehensive treatment plan to address it. Building on the strengths of the medical model and current approaches to public health, a salutogenic approach is well-positioned to provide a framework to understand and address challenges confronting our society as it emerges from the COVID 19 pandemic. Identifying the psychological, spiritual, social, economic, and political determinants of health and disease and understanding how they impact individuals and communities can help us establish early indicators of “vulnerability” for individuals and communities and develop better local and national interventions. Building on the conceptualization and research of the importance of the sense of coherence and the use of resources for individuals and communities can inform interventions that promote individual and community well being. Such resources can mitigate the inevitable stressors of life driven by external forces

As we enter 2021 may we have a salutogenic year and decade, where we create local and national environments that are manageable, and coherent for all of us. We can develop well-being indicators that reflect a salutogenic orientation to measure individual, community, national and global health. Such measurement and public reporting, will help expand our indicators beyond measuring and responding to GDP. Focusing on well being indicators can hold accountable public officials and institutions to focus on and provide "healing approaches" and tools for ongoing assessment of the impact of “policy interventions”. Operationalizing the salutogenic concept of health provides a road map for an action-oriented model that can be utilized across disciplines and most importantly by individual citizens to engage as citizens within their communities and the body politic.

1. CDC Health Alert Network Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic December 17, 2020

2. Kickbusch I. Foreword. In: Mittelmark MB, Sagy S, Eriksson M, et al., editors. The Handbook of Salutogenesis [Internet]. Cham (CH): Springer; 2017. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435840/

3. Harry Rutter, MB BChir, Natalie Savona, PhD, Ketevan Glonti, MSc, et al., The need for a complex systems model of evidence for public health. Lancet, Viewpoint | Volume 390, Issue 10112, P2602-2604, December 09, 2017 https://doi.org/10.1016/S0140-6736(17)31267-9