by Aaron Antonovsky
I am deeply moved and grateful to Professor Kohler and to the Faculty of the Nordic School of Public Health for the high honor which you have conferred upon me today. Since I am not a modest Swede, and my name is not common, I cannot protest that you have made a mistake. In fact, in my moments of megalomania, a thought has occurred: I have not yet been several hundred kilometers northeast on a similar occasion only because of the limited vision of those who give the awards there. They have not recognized that the salutogenic concept is a revolutionary advance in medicine.
There is another reason for my pleasure on this occasion. I am a child of the 1930s depression, and old enough to have been disenchanted very early from the so-called world of tomorrow. Ever since, Scandinavia has been for me the world's best hope for the vision of the Biblical prophets of a society which is decent and compassionate. My sabbatical year in Sweden in 1988 brought me closer to reality, but did not tarnish this hope. Add to this the fact that my work has been taken up in the Nordic countries proportionately more than elsewhere, and you can understand my deep pleasure at being with you today.
Wisdom, according to the Psalmist, is only attained at 80. I still have a few years to go. Forgive me, then, for taking the risk and suggesting that what I have to say on this occasion contains words of wisdom. Justification lies only in the fact, newly annointed doctors, that I have more experience than you. (As a scientist, I must add that it is not clear whether years add more to foolishness than to wisdom.) I address my words, then, primarily to my new doctoral colleagues. You will be the judges of how wise they are.
As I sat in Jerusalem to plan what I would say in Goteborg, two stark images persistently came to mind. They are worlds apart, yet I deeply sensed that both were pertinent. First, I recalled a story (Address delivered on the occasion of the conferment of an honorary doctorate by the Nordic School of Public Health, 21 August 1993, in Goteborg, Sweden) most of you know: "To Kill a Child" by Stig Dagerman. "For life is ordered in so pitiless a fashion," he wrote, "that one minute before a happy man kills a child he is still happy, and one minute before a woman screams with horror she may have her eyes shut and be dreaming of the sea..." The second image is, as we say, from another planet: Just six weeks ago I stood on the very spot in Auschwitz-Birkenau where selections took place: left to the gas chambers, right to slave labor, to live for a few more moments. (Some of you are physicians. We must always remember that those who made the selection had taken the Hippocratic Oath.)
Why, preparing for this happy occasion, did these two images burn in my mind? The answer, I believe, is that ever since my study of concentration camp survivors over two decades ago, the question that has dominated my research has been: How is it that, given the range from the troubles of everyday life to the unimaginable horrors of Auschwitz, some of those who have not been killed manage to rebuild their lives? Or, to use the concept which I was led to invent, the question of salutogenesis. You have studied public health which, in most of the world, has still only taken a small step in this direction, wondering how to prevent disease. But if one studies how the man who has inadvertently killed a child, or the child's parents, or someone who has unbelievably survived a concentration camp, rebuild their lives, we might learn something about movement toward health. The technical word for this is autopoiesis, defined as the reorganization of a living system after a trauma. I am sure that even those among the guests today who are not health professionals have often pondered the question. We all know people to whom life has dealt harsh blows, from the care of an aged parent to unemployment to the burdens of the single woman who works and cares for her children -- and yet who do well.
We have all wondered -- but only systematic research can lead to understanding. Let me give you an example of how we still over- whelmingly do research which helps but little in answering the salutogenic question. A week ago an article appeared in an Israeli paper. The heading read: "One third of recent immigrants from the former Soviet Union suffer from emotional distress requiring care." Forget the problems of such a study: How was "distress" conceptualized and measured? How good was the sample? Was there an appropriate control group? The heading, I happen to know, accurately reflected the report presented by the researchers. Now, had I written the heading, it would have read: "Two thirds of recent immigrants from the former Soviet Union are in reasonable shape emotionally." For, just imagine: These are persons who, first, have all the life problems of all human beings. Second, they share with all other Israelis the troubles of a not very peaceful society and region. Third, they are immigrants to a strange culture and language, often without jobs or housing. And wonder of wonders, two thirds are at the very least in reasonable emotional shape. Now, I do not write newspaper headlines. But I do conduct research, and know that how one poses the research question is decisive for the data one obtains.
Now, with your permission, let me turn to some thoughts occasioned by the titles of the five dissertations whose authors we are honoring today. I apologize if the fact that I have not yet read them leads me astray. But first let me make two preliminary remarks which are really one, lest I be misunderstood. When I ask the salutogenic question of how some people cope well with all the vicissitudes of life, I face the danger of what is called "blaming the victim". Nothing I say should be construed as saying "it all depends on the person, on her or his free choice to cope well". First, it is most important that we work to construct a society in which these vicissitudes of life are decreased, e.g., a very low level of unemployment, or an educational system which encourages boys to be morally responsible for their sexual behavior, and not place the whole burden on girls. Second, it is primarily the responsibility of the society to create conditions which foster the strengths which allow successful coping, strengths which I call a sense of coherence, a concept to which I shall return. I am deeply disturbed when I encounter a view particularly widespread among many of our American colleagues in public health, namely, that all one has to do to stay healthy is to choose not to smoke, to eat wisely and to exercise. This is good upper middle class advice, which rationalizes a failure to confront issues which are at the very least as important in promoting health as so-called healthy behavior.
Let me turn first to Drs. Victor and Scheutz, whose dissertations deal with the terrible plague which has beset humanity in the last decade: AIDS. In 1979, when my first book presenting the salutogenic model was published, neither I nor anyone else had heard of AIDS. But the concept led me to write four unhappily prescient words: "the bugs are smarter". By "bugs", of course, I meant psychosocial no less than microbiological threats, unemployment as well as TB bacilli. In other words, I suggested that the idea of linear progress, of conquering one disease after another until we all live fully healthy lives, was a utopian illusion. Yes, we must learn how to destroy specific bugs which threaten us. But the fundamental problem, I proposed, was to learn how to acquire the strength which helps us cope well with whatever bugs, old and new, attack us.
Extensive though far from adequate resources have been invested in research for a cure to AIDS and in services aimed at making life as bearable as possible for those who have been identified as HIV positive or as patients with AIDS. The recent Berlin congress of thousands of researchers, practitioners and persons who suffer directly testifies to the concern we have for the problem. I find a most hopeful sign in that both Dr.Victor and Dr.Scheutz, in the titles of their dissertations, used the same word "care", the one referring to the society, the other to an occupational group. Indeed, without caring, there is no hope. (I may say, parenthetically, that I was struck on my recent visit to Poland by the signs that the collapse of a perverted society will lead to one in which, enchanted by the free market, no one cares.)
There is, however, one phenomenon which, as far as I know, no one has studied closely, a phenomenon which may prove to be vitally central on every level of understanding. I am not an expert in AIDS. But I have heard from several experts who have very recently observed that there are women and men who were identified as HIV positive a decade or so ago who have not succumbed to the clinical disease. Who are these people? What is it that has enabled them to go on functioning, biologically, psychologically and socially, despite the virus? This is the salutogenic question which is so seldom asked. This is the same question as the one I posed in studying concentration camp survivors. Has a caring society, Dr. Victor, enlisted the possible knowledge of such persons in formulating policy and practice? Or, turning to Dr.Scheutz's study, who are the dentists who have had the strength and courage to give priority to patient care, in spite of the frightening occupational risks?
As one with experience in directing doctoral dissertations, I know that candidates often aim at solving all the problems in their fields, and my job has been to bring them down to earth. I am, then, not in the least critical that you may not have asked the salutogenic question. My hope is only, in planning future research, or in your role as practitioners, that you think salutogenically.
At the risk of being repetitious, can this mode of thinking be usefully applied to Dr.Kollberg's study of mothers registered as mentally retarded? Traditionally, we view a harsh developmental disability such as mental retardation in a family member as a tragedy, compounded by the social stigma which is attached to it. And indeed, no one would choose such a situation voluntarily. Having said this, I would make two comments. First, one of the profound implications of my way of thinking is to see health problems on a continuum. The pathogenic medical mode of thought is to dichotomize. One either is or is not mentally retarded, without any awareness that mental retardation, as well as other disability or disease phenomena are culturally constructed and rooted in social situations. Yet how often has my wife said to me "I don't understand how someone as smart as you can be so dumb". Second, and much more important, we have always dismissed as denial or rationalization when, occasionally, families report positive benefits from having a family member with a disability. Yet some recent studies have suggested that such reports express a positive adaptation. Who, then, I ask, are the families in Dr.Kollberg's study who do not see themselves as victimized, who courageously confront a harsh reality and do not succumb? And, I may add to those of you who are not as handicapped as those Dr.Kollberg studied and have raised a child: Is it not a miracle worth studying that some of the children grow up to be happy and healthy?
Dr.Agostino studied abortion crossculturally. Having always been fascinated by how our lives are shaped by the national cultures in which we live - not surprisingly, for I am both, or possibly neither, American and Israeli, having lived just half my life in each society - I look forward to reading her work with pleasure. For social scientists, abortion is a field fraught with the danger of value judgments distorting our understanding. We all have strong beliefs on the matter. I am no exception and am strongly in what in America is called the pro-choice camp. Yet I must point out that I have little patience with the insensitivity of some in this camp who regard abortion as a routine technical matter. The choice is always agonizing.
The salutogenic question in this field is dual. First, given the consideration by a pregnant woman and, I hope, the father, of the possibility of abortion, what are the cultural, social and individual factors which promote a successful confrontation with this agonizing dilemma, whatever the decision and action be? Second, and of greater significance, what are the factors which promote responsible sexual behavior so that the dilemma need not arise? Several years ago I engaged in a public debate with a colleague and friend who is a senior figure in the Israeli medical world who is strongly in favor of limiting abortion on religious grounds. He was surprised at how much I agreed with him on the undesirability of abortion. But he had no answer when I challenged him to say what he had done, when he held a relevant position of power, to support the availability of contraception. The saluto- genic approach leads one to insist on this question.
Finally, I turn to Dr.Cernerud's dissertation. Reading the title, I was reminded of the classic Aberdeen, Scotland studies on social class and growth parameters of children in the 1960s. In that decade, as some of you may know, I played some role in calling attention to the relationship between social class and a wide variety of diseases. I showed, for example, that, contrary to received opinion then (and, I am afraid, to some extent now), the middle and upper classes did not have higher rates of coronary heart disease. My thinking, however, in those years was pathogenic. I only asked: Why is it that the lower social classes have higher rates of almost every malady? I do not know Dr.Cernerud's findings. I can only hope that in a society such as Sweden, social action has at least blunted class differentials. But again, I now ask different questions. Why is it that the higher social classes have lower rates, when they do, of disease? How can we explain the fate of deviants, that is, of children who, despite their being in those social groups with poorer overall patterns of development, nonetheless thrive?
Once again, I tender my apologies to the conferees for having ventured to express thoughts having only seen the titles of their dissertations. And to all of you for your patience in listening to me when, in reality, I have only had one idea to express: the exciting possibilities for understanding and action opened up by asking salutogenic questions. In science, the question is always what is crucial. With your permission, however, I will keep you from the musical and culinary pleasures which await us for a few more moments, with some words about my answer to the question.
As some of you know, I call this answer the sense of coherence (SOC). This concept refers to the extent to which a person, or a family, sees the world as comprehensible, manageable and meaningful. That is, do I tend to see life more as making sense or as chaotic? Do I tend to think that resources are at my disposal which will allow me to cope well with all the "bugs" that beset me? And to what extent do things make sense to me emotionally, how much am I motivated to confront the bugs? The hypothesis, then, that I have proposed is that the stronger one's SOC, the more capable will one be to cope successfully with the stressors of life and move toward health. And, what must never be forgotten, the more that a society, or an institution such as a health care system, or a family strengthens the SOC of its members, the more salutary the outcome.
I have been most gratified that this hypothesis has been well received by many colleagues. And it is even more gratifying to report that the results obtained in a wide variety of studies -- more than a few in the Nordic countries -- suggest that I am not altogether wrong. But I would like to close on a finding that seems to be emerging. The data are not yet clear, and I mention it with caution. What seems to be the case is that of the three components of the SOC, meaningfulness is emerging as decisive. Note, it is not the content of what gives meaning to one's life that matters, but the fact that there is a strong belief that one's life does have meaning. With meaning, one is impelled to impose structure and to search for resources, that is, to strengthen the other two components.
If this indeed proves to be the case, then, my dear new doctors, the core problem becomes how meaningfulness can be enhanced in the lives of mothers registered as mentally retarded, who are HIV positive or have AIDS, who care for such persons, who engage in sexual behavior, in Italy or in Sweden, and those who are Stockholm school children. Somehow -- and here I return to what I said at the outset about my feelings about Scandinavia -- I have a hunch that the key lies in a society and in people who care about others. I can think of no more appropriate place to say this than in the Nordiska Halsovardshogskolan. Thank you.