Health and Community

Biologists have long noted that all species, plant or animal, live in communities. Existence apart from others for any extensive

length of time is rare and usually futile. Literature, anecdotal commentary, and scores of research reports have set out the consequences of social isolation for the physical health of humans. Anthropologists have described the rapid onset of death in members of small tribal groups who are ostracized, and numerous contemporary statistical accounts show the impact of bereavement upon the short-term mortality rates of those who survive. A typical finding in this literature is that about 20 percent of those who die within a year after the death of their spouse do so in direct physiologic response to the psychological impact of the loss. Scientists have demonstrated the physiological mechanism by which loneliness and isolation lead to poor physical health among primates, and it is generally thought to operate similarly in humans. Recently, a large study of nine hundred forty-two Finnish men found that feelings of hostility, hopelessness, and cynicism sharply accelerated atherosclerosis in carotid arteries, a major precursor to stroke.

		Since the 1960s a large body of rigorous research has demonstrated how job-related stress can adversely affect one's health. In 1973, Work in America: Report of a Special Task Force to the Secretary of Health, Education and Welfare found that dissatisfaction with one's work was the single best predictor of a heart attack—superior to blood pressure, cholesterol, or any other traditional "risk factor." Subsequent research has been able to specify those particular job characteristics that lead to especially high risk, such as limited decision-making ability coupled with high job demands. Researchers have also identified certain job characteristics that are protective against heart attacks, such as feelings of control and commitment. Large epidemiologic studies, carried out in Britain, have clearly shown the relationship of the type of job one holds in the occupational hierarchy to be related to most major causes of death, independent of risk factors like smoking and blood pressure, or of access to medical care.

		This research has not primarily focused on the health of individuals in a clinical context. Rather, these studies have dealt with the health of populations and groups. However, the findings from these population-based community studies suggest associations that are similar to the results of the more individually-focused psychological work on social isolation described earlier. Common to both approaches is an emphasis on the interpenetration of the mental and the physical realms of life. Social relationships and events can either create distress and literally make someone sick, or relieve distress and make someone well. Health and illness exist as points on a continuum, in a constantly changing relationship to each other. Resources for maintaining health or fighting illness may exist in an individual's environment, but they must be perceived as beneficial if they are to be effective. It is perceived meaning, our thoughts, derived from the sum total of our life experience that determines our propensity to be healthy or ill. The implication of all this work is clear: the communal environment, which includes our relationships with other people, enters our bodies via the symbols and categories in our minds. As in the development of social psychology and in the studies of the placebo effect, the essence of this research is that the line between our selves and those around us is blurred. Thus, a basic tenet of the "medical" view of illness is undermined. As in the case of the placebo effect, despite having been conducted under the auspices of medical institutions, this research has had only a minimal impact on clinical practice. Regardless of conventional medicine's neglect of these ideas about the interpenetration of mind, body, and the community, such notions are quite compatible with the views held by most forms of Judeo-Christian religion, as well as various types of Eastern, "new age," and humanistic spiritual groups. The former have always been an important force within American life. The latter have come to play an increasingly significant role as the population has become more ethnically diverse, more highly educated, and more secular. Although the major religions have been very receptive towards mainstream scientific medicine, each encompasses a tradition that stresses the potential of body-mind interaction and the importance of the relationship between the suffering patient and healer, along with the connection between the individual and the community as both a source of sickness and healing. To the extent that religion and spirituality have provided a counterpoint to the dominant American values of scientific rationalism, they have also offered an alternative to scientific biomedicine for understanding health and healing. The recent ascendancy of charismatic, Pentecostal, and "born again" movements within American Christianity has greatly enlarged the number of people who know about and accept some alternative views of how healing may occur. Many Americans have become familiar with a quasi-religious perspective on healing through their contact with 12-step programs and other self-help groups. Modeled on the premises of Alcoholics Anonymous, 12-step programs require turning oneself over to a "higher power" as a condition of help or healing. Robert Wuthnow, a professor of sociology at Princeton University, estimates that there are approximately three million spiritually oriented self-help groups in the United States, many in churches and others based on the 12-step framework. The twenty-year-old New Age movement has also had a significant impact on Americans' spiritual beliefs. Respected public opinion polls repeatedly find that belief in various forms of "alternative realities" is common and positively associated with education. At least half the adult population admits to a belief in the existence of angels, and in the period between 1990 and 1995, over two hundred books concerned with the topic of angels have been published. The World Wide Web boasts approximately three thousand mystically-oriented sites. Even physicians are joining the ranks of those who believe that there is a role for spirituality in healing. According to a 1996 statement released by the Harvard Medical School, over 99 percent of the three hundred family physicians interviewed by an independent research firm reported that they "believe in the ability of religious beliefs to contribute positively to the healing process." Additionally, 80 percent of the surveyed physicians believe in the "palliative powers of meditation and prayer," and 55 percent reported that they use relaxation and meditation techniques in their practice. This widespread prevalence of groups proclaiming and promoting a spiritual or religious dimension to healing as well as the rise and ubiquity of 12-step programs reflects and reinforces beliefs about health and illness that are fundamentally at odds with the traditional biomedical worldview. Prevention versus Curing Since its earliest days, Western medicine has encompassed a range of views about how a state of health is best achieved. Dubos describes the "competition" between the Greek gods Hygeia and Asclepius. Hygeia represented the possibility of preventing or forestalling illness by living in a healthy manner, what today would be called "health promotion." Asclepius, the first physician according to Greek legend, achieved fame not by teaching wisdom but by "the use of the knife and the bandage of curative plants." There is little doubt that Asclepius's approach became the dominant view of medicine. Today his image and name are frequently represented on medical institutions. However, the views of Hygeia did not disappear completely. Those seeking the ''laws" of a healthy life, the prevention of illness, and the building of healthy communities maintained a presence within medicine, most commonly under the rubric of "public health." Although this catchall term has, for many, become synonymous with the units of state and local government that bear the name, the field is much broader. As seen in schools of public health (which originally were restricted to the post-graduate training of physicians and other health professionals), public health includes the assessment and measurement of community health, prevention of illness, and effects of environmental factors on human health, along with the administrative dimension of health care. In many respects public health schools and agencies have served as a refuge on the border of mainstream medicine for health providers working to improve the health of communities. Despite its marginalized status, public health research has consistently documented the limited role that clinical medicine and medical technology have played in reducing mortality in industrialized nations. Public health research has also provided evidence of the crucial roles played by social status, working conditions, the physical environment, and social relationships in promoting health. Removed from its bureaucratic and professional "home" in public health schools and agencies, the underlying message of public health is strikingly similar to the views held by other critics of mainstream medicine: Health is a product of community life which reflects social distinctions and hierarchies and is modifiable by environmental change and alteration in the way in which people relate to each other. Aggressive calls for the primacy of a "public health paradigm"—or a "biopsychosocial model"—over the dominant biomedical model have recently become relatively common among public health leadership. After-the-fact clinical interventions are seen as a diversion from the goal of preventing illness. In the case of problems such as chronic illness, substance abuse, and mental illness, prevention is heavily dependent upon changes in the consciousness, or the ''empowerment" of people and groups. The congruencies and convergence among public health advocates, psychologists documenting mind-body interaction, and social scientists charting the influence of the community on health are striking. Although many commentators such as Rick Carlson, Ivan Illich, and Irving Zola noted the intersecting lines of thought and saw the potential affinity between them, these critics of conventional biomedicine have carried on their work independently of each other. Yet despite their relative infrequency and isolation, these criticisms of mainstream medicine have become increasingly influential. The heightened prominence, synergy, and impact of these critiques have not been due to any newfound validity as much as to their affinity with a wholly distinct set of changes in the mainstream medical care system.