Reproduced from: https://medium.com/age-of-awareness/health-interconnectedness-and-salutogenesis-ca69c4f5366c

Health, Interconnectedness and Salutogenesis

from ‘Design for Human and Planetary Health’ D.C. Wahl 2006

So what genuine possibilities stand before us when we are considering the question of health? Without doubt it is part of our nature as living beings that our conscious self-awareness remains largely in the background so that our enjoyment of good health is constantly concealed from us. Yet despite its hidden character health none the less manifests itself in a general feeling of well-being. It shows itself above all where such a feeling of well-being means we are open to new things, ready to embark on new enterprises and, forgetful of ourselves, scarcely notice the demands and strains which are put on us. This is what health is.

— Hans-Georg Gadamer, 1996, p.112

The German philosopher Hans-Georg Gadamer offered this definition in his essay On the Enigmatic Character of Health. He suggests that Heraclitus may have referred to this enigmatic characteristic of health when he proclaimed that “the harmony that is hidden is always the stronger than that which is revealed” (in Gadamer, 1996, p.115).

Gadamer believed that we must recover this hidden harmony in order to “discover both the miracle of convalescence and the mystery of health.” He pointed out that while as human beings we are constantly subjected to challenges to our health by our environment we also need to remain aware of the existential fact that “we ourselves are part of nature and it is this nature within us, together with the self-sustaining organic defence system of our bodies, which is capable of sustaining our ‘inner’ equilibrium.” According to Gadamer, the way nature permeates us points at the “unique interplay of functions which constitutes life” (Gadamer, 1996, p.116). Gadamer emphasized what could be seen as a central presupposition on which natural, ecological, and salutogenic design for sustainability is built.

We can only oppose nature through being part of nature ourselves and through being sustained by nature. We should therefore never forget that both the patient and the doctor must join in acknowledging the role of nature if successful recovery is to be accomplished.

— Hans-Georg Gadamer, 1996, p.116

Human health and planetary health are fundamentally interconnected. As biological organisms and natural participants in nature’s scale -linking processes, all human beings can, and do, affect the health of individuals, communities, ecosystems and the planet as a whole. The fact that humanity has done so predominantly unaware of the far-reaching consequences of its collective design-choices is increasingly undeniable in the face of ecological and social disintegration, climate change and mass extinction.

We are only slowly waking up to the cumulative, time-delayed, and spatially removed effects human actions are having on the planet’s health. Since planetary and human health are fundamentally linked, preventing environmental damage and maintaining healthy ecosystems is the most effective long-term strategy to promote health in humans. In 1992, the ‘Commission on Health and Environment’ created by the World Health Organization (WHO) published a report entitled Our planet, our health. Its opening statement reads:

The maintenance and improvement of health should be at the centre of concern about the environment and development. Yet health rarely receives high priority in environmental policies and development plans, rarely figures as an important item in environmental or development programmes, despite the fact that the quality of the environment and the nature of development are major determinants of health. …

Serious environmental health problems are shared by both developed and developing countries. … Health also depends on whether people can obtain food, water, and shelter. Over 1000 million people lack the income or land to meet such basic needs. Hundreds of millions suffer from undernutrition. It is a requirement of health that global cycles and systems on which all life depends are sustained.

Population growth and the way resources are exploited and wastes generated threaten the environmental base on which health and survival depend and transmit the growing costs to future generations. The toll they extract on human health and natural resources and systems could be enormously reduced by better environmental management.

— WHO Commission on Health and Environment, 1992, pp.xiii-xiv

In other words, negative human impacts on the planetary life support system could be drastically reduced by design. In general, if there was a more salutogenic (health-generating) intention behind all acts of design, humanity could greatly improve human, ecosystems and planetary health. “Health depends on our ability to understand and manage the interaction between human activities and the physical and biological environment.” The report stresses: “We have the knowledge for this but have failed to act on it, although we have the resources to meet current and future needs sustainably” (WHO, 1992, p.xiv).

For example, the use of pesticides has increased dramatically during the last 50 years. Nitrates and phosphates used as fertilizers cause the eutrophication of rivers and lakes resulting in the death of fish and other aquatic organisms. The run-off from US farms draining into the Mississippi River and on to the Gulf of Mexico is directly linked to the appearance of a 20,000 square kilometre dead zone in the Gulf (Norberg-Hodge et al., 2000, p.18). [This is an excerpt from my 2006 PhD Thesis in ‘Design for Human and Planetary Health: A Holistic/Integral Approach to Complexity and Sustainability’.]

Many crop pest populations respond to the use of pesticides by developing resistance. There are now more than 500 recorded species of insects, which have developed resistance to at least one type of pesticide. “According to the latest estimates of the World Health Organization, at least three million and perhaps as many as 25 million agricultural workers are poisoned each year. Of these, some 20,000 die” (Pretty, 1998, p.57).

Friedrich Schmidt-Bleek, professor of physical chemistry and vice-president of the Wuppertal Institut in Germany, emphasizes that from the scientific viewpoint it is fundamentally impossible to determine, for even a single substance released into the environment, what its possible chemical, physical and biological impacts on ecological systems will ultimately be. He maintains that to investigate, simulate, quantify and give economic or even financial value to these impacts is therefore of limited use (Schmidt-Bleek, 1997, p.88). Such endeavours will mainly reflect how much complexity and context has been included in the particular study. Their effects can be at worst misleading, and at best vaguely indicative.

The awareness of the health damaging effects of chemicals bio-accumulating within the food-chain is gradually increasing. The UK government report Quality of Life Counts by the Department of Environment, Transport and Regions emphasizes that “chemicals are an integral part of our lives. They provide us with many of the consumer goods we have come to take for granted and the chemical industry is a vital part of the national economy. However, there are risks from the manufacture and use of certain chemicals and it is essential that we identify and manage them sustainably so that the environment is protected” (DETR, 1999, p.110).

The report warns, “pollutants can move between soil, air and water. Dispersed releases are especially important when pollutants build up in the environment, either because they accumulate in plants, animals or people, or because they persist for long periods. We must ensure that we do not store up problems for the future” (DETR, 1999, p.165).

Another example the report highlights are the problems associated with ozone depletion in the upper atmosphere. It states that “man-made emissions of substances containing chlorine and bromine decrease the stratospheric ozone layer, thus increasing the amount of ultraviolet radiation from the sun reaching earth’s surface, which can have consequential effects on both environment and health” (DETR, 1999, p.189).

In the late 1960s the young research scientist Dr. John Todd, who had recently received his PhD for work on the chemical communication of fish, made a discovery that directed his creative energy towards, by now, more than four decades of tireless contributions to the emergence of ecological design as a new way of learning from nature how to meet human needs while benignly or beneficially adapting to natural process. Todd discovered that if the fish species, brown bullhead (Ictalurus nebulosis), was exposed to even minute amounts of pollutants such as DDT, chemical communication between the fish would break down, and both the physical health as well as the social stability in the community would decrease.

Nancy Jack-Todd, recently wrote about the implications of this discovery: “It did not take a great leap of imagination to wonder what the steady infusion of industrial and agricultural chemicals into the environment was doing to other life-forms, ourselves included” (Jack-Todd, 2005, p.8). She recalls John’s reaction to learning that similar findings had been reported by other researchers and in other species:

It struck us that what we were observing indicated that humanity was reversing ecological processes on a global scale. To continue to ignore these biological lessons may prove, in the long run, a little bit like serving cyanide to the pilot of an aircraft while pouring champagne for the passengers. Fun for a while, but not exactly adaptive.

— Nancy Jack-Todd, 2005, pp.8–9

The long-term effects of the many thousand of new chemical compounds that humanity has released into the environment over the last two hundred years are very difficult to predict with any certainty. It is fair to assume that we already have altered the course of planetary evolution significantly and irreversibly. Yet this insight should not lead to fatalistic complacency but to immediate action.

We have to re-design the way we create, handle and proliferate new chemical substances, as well as how to employ bioremediation to responsibly deal with the harmful substances we have already created. Failure to do so effectively will turn John Todd’s words into a possible epitaph for our industrial civilization or even humanity — fun for a while, but not exactly adaptive!

Another related example for the anthropogenic reduction of ecosystem and planetary health is the erosion of soil, both quantitatively and qualitatively. The Quality of Life Counts report emphasizes: “soil is essential for the production of food and other crops, for maintaining biodiversity, for the landscape” (DETR, 1999, p. 209). It adds: “Development can have adverse effects on both the biological and physical properties of soil and can limit its future uses. The sustainable use of soil requires that a sufficient quantity of green field soil is retained for present and future needs: for example, ecosystem support, food and fibre production and the protection of cultural heritage” (DETR, 1999, p.211).

Accelerating erosion is mainly driven by the creation of human infrastructures resulting in the covering over of bioproductive areas and their soils by cities and transport roads. The widespread burying of organic wastes in landfill sites prevents it from replenishing the rapidly depleting soils of the world’s agricultural areas.

The UK Department for Environment, Transport and Regions emphasized that “the precise mechanisms by which organic matter maintains soil quality are not completely understood, but it is known that it plays a key role in maintaining soil attributes such as fertility, structural stability, water-holding capacity, and buffering capacity” (DETR, 1999, p.212).

Agricultural intensification causes soil erosion. The removal of field boundaries and hedgerows lead to a loss of 30 to 95 tonnes of soil per hectare (Pretty, 1998, p.69). “Chemical fertilizers and pesticides are destroying the very soils we depend on for our survival. Beneficial soil microbes are being lost, while soil acidification and soil erosion are increasing. In parts of the corn belt of the USA, 20 pounds of topsoil are lost for every pound of harvested grain” (ISEC, 2001). These are all examples of inappropriate, negligent and thoroughly unsustainable design contributing to a decrease in ecosystems’ health.

Without maintaining healthy and productive soils, the quality of our diet will decrease even further and with it the levels of human health. Badly designed food systems based on mass-production, chemical fertilizers and a heavily fossil-fuel intensive global agribusiness are destructive to human and planetary health.

Furthermore by destroying local, ecologically adapted and community based farming practices, we are loosing important indigenous and place-based knowledge and are destroying the social fabric of rural communities. Along with un-controlled urbanization, the unrestrained release of greenhouse gases, and a rapidly growing human population, these are some of the most damaging impacts on the health of ecosystems and the biosphere.

Gretchen Daily, an interdisciplinary research scientist at Stanford University, points out that humans distinguish themselves from all the other estimated 30,000 million species alive today by the impact we have on the planet. Humanity “controls a disproportionate and rapidly growing share of the planet’s resources” (Daily, 2000, p.228).

Daily emphasizes the truly staggering population increase and the effects of exponential growth by reporting that the human population at the time of the agricultural revolution was only about five million. Over the course of the following millennia human population grew slowly until it reached approximately 1000 million people at around 1800. The second billion was added in only 123 years, the third took another 33, the fourth billion only 14 and the fifth billon only 13 years. “ By the turn of the 20th century, in a mere 12 years, the population on Earth reached six billon” (Daily, 2000, p.228).

Daily lists a series of crucial environmental effects that this explosive population expansion has had on the Earth’s natural processes, which are summarized below.

Primary Impacts of Human Population Growth and Design Strategies on Nature

(Adapted after Daily, 2000, p.228)

• Human activity has massively altered the biogeochemical cycles of major elements such as carbon, nitrogen, and sulphur, with dramatic changes in the chemical composition of the atmosphere, water, and soils.
• Human technologies have transformed minerals such as coal, oil, and metal ores from the Earth’s crust at rates that rival or exceed geological rates.
• In particular since the Industrial revolution humans have annually dispersed millions of tons of synthetic chemicals while introducing 1,000 new ones per year to the approximately 100,000 now in the environment.
• Industrial agriculture has converted tracts of diverse natural forest and grassland to uniform, managed forests, pastures, and food crops, greatly contracting the range of most wild species.
• Human activity has inadvertently transferred species around the world while blocking (with highways, farm fields, and suburban sprawl) natural processes of dispersal.

The Quality of Life Counts report emphasizes the fact that “the pressure on all resources will continue to increase as the population increases. It provides the following detail regarding population growth and the shift in demographics that will further increase social tensions in developed countries:

The world population is growing at 1.33 per cent per year, an annual net addition of about 78 million people. World population in the mid-twenty-first century is expected to be in the range of 7.3 to 10.7 billion, with a figure of 8.9 billion by the year 2050 considered to be most likely. At the same time, fertility is now declining in all regions of the world. In nearly all the more developed countries, fertility is significantly below the level necessary for the replacement of generations. In 1998, 66 million persons in the world were aged eighty or over, or about one in every 100 persons. This number is expected to increase almost six-fold by 2050 to reach 370 millions.

— DETR, 1999, p.247

This data emphasizes how alarming the current trends actually are and poses an unprecedented challenge to humanity as a whole: Will we be able to unite humanity behind a set of internationally cooperative and locally engaged strategies to re-design the way we meet human needs in ways that increase rather than decrease ecosystem and planetary health? And if so, will we be able to do it in time to halt, and to some extent reverse, the current system trajectories aiming towards accelerating ecological and social disintegration and a drastic decrease in human and planetary health? This is the challenge faced by the salutogenic design approach.

Paul Hawken and Amory and Hunter Lovins provide a spine-chilling example of the un-sustainability of the waste-production driven by an industrial growth society. Their description of the world’s largest landfill site, Fresh Kills, near New York puts the poor design of current resource use patterns into perspective.

Fresh Kills — the world’s largest dumping ground, located in Staten Island, New York — provides a repository for the daily garbage of five boroughs of New York City. Visitors to the site are awed by a landfill that receives 26 million pounds of commercial and household waste per day. Covering four square miles and rising more than a hundred feet high, it contains 2.9 billion cubic feet of trash, consisting of 100 million tons of newspaper, paint cans, potato peel, polystyrene, clamshells, chicken bones, soggy breakfast cereals, cigarette butts, Coke cans, dryer lint, and an occasional corpse. By the time it is filled to capacity and closed in 2001, it will be the highest mountain on the eastern costal plain. But as massive as Fresh Kills is, it takes in just 0.018 percent of the waste generated in the United States daily. Americans and American Industry create or dispose of an additional 5,500 times as much solid waste elsewhere (Hawken, Lovins & Lovins, 2000, p.51).

The levels and the design of production and consumption patterns in industrial societies is damaging to both social and ecological health. We have — more or less unintentionally — designed a system that is devouring social and ecological capital at a rate which will almost certainly lead to the collapse of social systems and ecosystems within the 21st century. The urgency for a fundamental re-design of humanity’s modes of participation in natural processes cannot be over-emphasized.

A fundamentally salutogenic intention behind all design could potentially act as a rough guideline along which to undertake this urgent re-design of human practices. The scale of the diverse challenges fundamentally interconnects local and global issues, therefore the transition towards a more sustainable human civilization will require widespread citizen participation everywhere.

Healthy farming practices, healthy ecosystems, healthy food systems and healthy human communities are fundamentally interrelated issues. Salutogenic design tries to strengthen the synergistic connections between these systems to improve health on all scales (see chapter five). The WHO Commission on Health and Environment suggested:

Two concerns are vital: development addressing people’s needs, especially for health; and ecological sustainability so that natural resources are not depleted and natural systems not damaged or degraded. Meeting the needs of the present and future world population for food, water, and energy without depleting and damaging the global resource base, while avoiding the adverse health and environmental consequences of industrialization and uncontrolled urbanization, can be achieved only if people have the knowledge and the means to influence action. …

Local participation needs national and global frameworks to ensure that adequate knowledge and resources are available and that local actions do not result in an unsustainable burden on natural cycles and systems. It also requires intergovernmental agreements that limit each country’s call on finite resources and its right to dispose at will of non-biodegradable wastes. For this, people are needed whose concerns go beyond the quality of their own environment; only they can press their governments to reach the international consensus on which a healthy and sustainable planet depends.

— WHO Commission on Health and Environment, 1992, p.xiv

A sustainable future critically depends on ecosystem health. Ecosystem health critically depends on a re-design of the way human needs are currently being met or failed to be met. What exactly constitutes the definition of a health ecosystem, might have to remain to some extent a fuzzy concept to allow for accommodation of the complexity of interacting systems involved. Nevertheless, certain ecological requirements for ecosystem and biosphere health can be identified.

David Brunckhorst (2002) suggested that a sustainable future is only possible if we manage to modify human participation in the biosphere in such a way that we can maintain and, where possible, restore ecological integrity, natural capital and biodiversity. These ecological requirements are described below.

Three Ecological Requirements for a Sustainable Future for the Biosphere

(After Brunckhorst, 2002, p.5)

Ecological Integrity: The health and resilience of natural life-support systems, including their capacity to assimilate wastes and endure pressures such as climate change and ozone depletion.

Natural Capital: The store of renewable natural resources, like productive soil, fresh water, forests, clean air, and fisheries, that underpin the survival, health and prosperity of human society.

Biodiversity: Maintaining the biological and genetic variability in species, populations, habitats and ecosystems

By recognizing the fundamental interconnectedness between human and planetary health, and linking design as ‘the expression of intentionality through interaction and relationship’ with an understanding of sustainability as ‘a community based process of learning how to participate appropriately in natural processes’ I hope to provide the conceptual foundation upon which to outline a holistic and salutogenic design approach that responds to the diverse, complex and interrelated challenges associated with creating a more sustainable human civilization.

Design for human and planetary health aims to explore strategies that sustainably integrate humanity into the health maintaining and life-supporting processes of the planetary biosphere. It responds creatively to the challenges and opportunities mentioned in the WHO Commission on Health and Environment report from 1992. “There is a powerful synergy between health, environmental protection, and sustainable resource use. Individuals and societies who share the responsibility for achieving a healthy environment and managing their resources sustainably become partners in ensuring that global cycles and systems remain unimpaired” (WHO, 1992, p.xxx).

Ultimately, the shift towards a sustainable human civilization and increased human and planetary health will require a majority of global citizens to assume full responsibility for their co-creative involvement in shaping humanity’s and the planet’s future. To a greater or lesser extent, we are all designers of this future. I propose that if the basic intention behind human design — expressed materially as well as through the interactions and relationships we have with each other and the more than human world — was salutogenesis — the improvement of health throughout the wider system that contains us — we would be able to facilitate a drastic shift towards more sustainable practices at the local, regional, national and international scale.

The salutogenic model of health and the associated concept of salutogenesis was first discussed by the sociologist of health Aaron Antonovsky, in his book Health; Stress and Coping (Antonovsky, 1979). Antonovsky distinguished between a ‘pathological orientation”, which “seeks to explain why people get sick, why they enter a disease category,” and a “salutogenic orientation (which focuses on the origins of health)” (Antonovsky, 1987, p.xii).

Antonovsky’s own discussions of the concept do not go into detail regarding the environmental foundations for a healthy society. His focus is mainly on the social and societal dimensions of the phenomenon of health.

Antonovsky hypothesised that “generalized resistance resources” like “money, eco- strength, cultural stability, social supports, and the like” were providing individuals with the ability to resist against the continuous stressors their environments exert. Variable resistance to omnipresent stressors “ranging from the microbial to the societal-cultural levels” explained why some people can be healthy in conditions that lead to the manifestation of disease in others.

Antonovsky proposed the “sense of coherence concept (SOC)” to understand all community based processes that improved the “generalized resistance resources” of individuals and their communities. The common element among these processes is that they provide all participants with a way of “making sense out of the countless stressors with which we are constantly bombarded.” Doing so repeatedly over time allows for the emergence of a strong sense of coherence (Antonovsky, 1987, p.xiii). It is this sense of coherence that makes individuals and societies more resilient and healthy.

Antonovsky suggested that one key component of a high sense of coherence is the extent to which a safe and healthy future could reasonably be predicted. As far as such prediction is at all possible, I would suggest it will be strongest in people who live in highly socially cohesive and place-based communities of human scale, who have an intimate knowledge of their local environment and a long tradition of successfully adapting to environmental changes and meeting their needs effectively without damaging their local environment. “Salutogenesis”, according to Antonovsky (1987, p.9), “leads us to focus on the overall problem of active adaptation to an inevitably stressor-rich environment.” He described salutogenesis as a strategy that counteracts the universal decay towards greater entropy. Antonovsky explains:

The key term becomes negative entropy, leading to a search for useful inputs into the social system, the physical environment, the organism and lower-order systems down to the cellular level to counteract the immanent trend toward entropy. … [Salutogenesis] opens the way for cooperation between biological and psychosocial scientists … When one searches for effective adaptation of the organism, one can move beyond post-Cartesian dualism and look to imagination, love, play, meaning, will, and the social structures that foster them. Or, as I would prefer to put it, to theories of successful coping.

— Aaron Antonovsky, 1987, p.9).

A salutogenic intention in design could be expressed at a variety of different temporal and spatial scales. The spectrum of entry points of salutogenic design ranges from the creation of healthier products, buildings and cities, to healthier processes of production, construction, and consumption, all the way to creating healthier, more meaningful and more rewarding life-styles. A central element in all of these attempts is appropriate participation in natural process — the meeting of human needs without jeopardizing ecosystems and therefore human health.

In the way that Antonovsky described the “salutogenic orientation”, it is derived from “the fundamental postulate that heterostasis, senescence, and increasing entropy are core characteristics of all living organisms.” Based on this postulate Antonovsky described a number of characteristic of a salutogenic orientation, which are summarized in the below.

Characteristics of Antonovsky’s Salutogenic Orientation:

(Based on Antonovsky, 1987, pp.12–13)

1. It leads us to reject the dichotomous classification of people as healthy or diseased in favour of their location on a multidimensional health ease/disease continuum.
2. It keeps us from falling into the trap of focusing solely on the aetiology of a given disease rather than always searching for the total story of a human being, including his or her sickness.
3. Instead of asking, “What caused (or will cause, if one is prevention-oriented) a person to fall prey to a given disease?” — that is, instead of focusing on stressors — we are enjoined to ask, “What are the factors involved in at least maintaining one’s location on the continuum or moving towards the healthy pole?” that is, we come to focus on coping resources.
4. Stressors come to be seen not as a dirty word, always to be reduced, but as omnipresent. Moreover, the consequences of stressors are viewed not as necessarily pathological but as quite possibly salutary, contingent on the character of the stressor and the successful resolution of tension.
5. In contradistinction to the search for magic-bullet solutions, we are urged to search for all sources of negative entropy that may facilitate active adaptation of the organism to the environment.
6. Finally, the salutogenic orientation takes us beyond data obtained from pathogenic inquiry by always looking at the deviant cases found in such inquiry.

While Anotonovsky’s exposition of salutogenesis was focussed on human health, it is equally applicable and relevant to ecosystems and planetary health. When working along the spectrum that reaches from positive health and resilience to ill health and disease, it is always possible to either focus on treating the symptoms of already manifest disease or to focus on systemically increasing the health and resilience of the organism, community, and ecosystem by taking a salutogenic approach.

The salutogenic approach tries to strengthen the ‘hidden harmony’ of health. Antonovsky emphasized that there was clearly a “complementary relationship” between a pathogenic and a salutogenic orientation. He argued for “a more balanced allocation of intellectual and material resources” to both approaches (Antonovsky, 1987, p.13).

In linking individual health to the health of social and ecological systems that contain the individual, Antonovsky acknowledged his indebtedness to Arthur Koestler’s discussion of biological hierarchies (Antonovsky, 1987, p.26), yet Antonovsky did not use the term holarchy in his own writing. Nevertheless, Antonovsky’s contextualizing and process and relationships oriented understanding of health maintenance clearly saw the individual and its community within the wider context of life’s scale-linking holarchy.

In his famous tight-rope metaphor, Antonovsky described health as a form of dynamic homeostasis (or heterostatic disequilibrium) which “can be likened to a man walking a tightrope from one end to the other, balancing himself even while he changes clothes and takes on and discards a variety of objects.” He expanded on this metaphor: “We begin to lose our balance and recover it; or slip, catch the rope, and return to a standing position; or fall into a net and again regain the rope, or fall, hurt ourselves acutely or are damaged chronically; or we are destroyed. Some complete the course, with ups and downs, but successfully and — what a glorious exhilarating experience it has been, whatever the sadness that it has ended.” Antonovsky believed this metaphor to be “useful in conveying the flavour of the salutogenic image of life” (Antonovsky, 1987, p.89). He explains this in other words:

The fundamental philosophic view of the human organism as prototypically being in a dynamic state of heterostatic disequilibrium is at the heart of the salutogenic orientation. Whether the source of the stressors is the internal or external environment, whether they are daily hassles, acute or chronic and endemic, whether they are imposed on us or freely chosen, our lives are replete with stimuli to which we have no automatic, adequate adaptive response and in the face of which we must respond.

— Aaron Antonovsky, 1987, p.130

Antonovsky acknowledges that all individuals are fundamentally embedded in and affected by the social and ecological systems that contain them. They are participants of a process to which they have to respond constantly, even if they cannot predict to what extent individual actions will feedback negatively on their environment and the individuals themselves.

These systems support and nourish their participants in ways that enable them to respond resiliently to the inevitable stressors and challenges to positive health that result from participating in these systems. In other words, by participating in social and ecological systems we will inevitably be affected by these systems in ways that both challenge and support our individual health.

Such is the reality of being an active agent of change through participation in a fundamentally interconnected process, that we have to act and affect without being able to predict and control the full effect of our actions on the system or process that contains us. Precaution and a salutogenic intent cannot offer guarantees for survival — no design strategy will ever be able to — but by increasing flexibility, responsibility, and adaptability, such an approach will increase the diversity of options available in the future and therefore provide better resilience and health — a higher probability of survival.

The central suggestion of a salutogenic design approach, is that by adopting a mode of participation that increases social and ecological health, we are ultimately engaging in preventative health care for ourselves. Healthy ecosystems and healthy societies will confront us with far less life-threatening and health-damaging stressors.

To really understand the phenomenon of health as a system wide, scale -linking property and as an emergent property of appropriate participation, the emphasis has to be on the interaction and relationships between the diverse participants. Focussing on the health of individuals will only provide a limited understanding of the complex dynamics that connect the health of individuals, communities, societies, ecosystems, and the planet.

Health as a holistic and integrative concept will always elude approaches that are only based on the manifestation of ill health in individuals through the symptoms of particular disease. To understand the complexity of health we have to employ a diversity of epistemological approaches and study it at both the individual and the collective level, as well as across various spatial scales.

With regard to the feedback cycles between healthy societies and healthy individuals, the work of the British social epidemiologist and health scientist Professor Richard Wilkinson is extremely informative. Wilkinson has studied the epidemiological profiles of different societies and compared them with a variety of other factors describing those societies economically and socially. He believes: “As health and society are so closely related, learning about society tells us about health, and learning about health tells us about society” (Wilkinson, 1996, p.14).

Looking at health from the standpoint of society rather than of individuals can lead to a radically different view of the determinants of health. Instead of looking to see what makes one individual healthier than another, our aim [is] to see what makes one society healthier than another. … From the point of view of practical politics and public policy, or indeed of its sociological interest, it is the health of the whole society which matters. The overriding issue is how to increase the sum total of health enjoyed by a society.

— Richard Wilkinson, 1996, p.16

Wilkinson argues: “what really moves the health of whole societies, adding to or subtracting from the sum total of health, may be factors which account for only a very small part of the individual variation in health and so escape detection.” Furthermore, “factors responsible for major differences in the health of whole populations may be invariant among individuals within each society and so, once again, go undetected in studies of individuals” (Wilkinson, 1996, p.16).

As suggested in chapter one, reductionistic approaches (focussing on individuals, isolated parts and mechanisms) and holistic, contextual and systemic approaches (focussing on interactions and relationships in complex dynamic systems) are complementary and provide important insights in their own rights.

A truly holistic and integral understanding of health has to include and integrate. Health can only be understood as an integral property and concept if we approach it from all four of Wilber’s quadrants, the individual and the collective, as well as the inner and the outer (see Wilber, 2001). Among the important results of Wilkinson’s comparative health studies — focussed on the collective/outer quadrant — are revealing insights about the impact of income levels, income inequality, and dis-empowering or oppressive social hierarchies on mortality rates within different societies.

The powerful effects of relative income [on life expectancy and population mortality rates] and their inherently social nature present a formidable challenge to conventional economics which has based itself largely on maximizing the asocial pleasures of material consumption. The extent to which social needs are primary and must be taken into account by the system through which society satisfies its material needs has not been adequately addressed by economic science. Although economics is far from exclusively asocial, the weight of the application of rational choice theory has grossly underestimated human social needs and the fact that their satisfaction should often take precedence, particular in affluent societies, over the demands to maximise individual consumption. There is a missing social economy of well-being.

— Richard Wilkinson, 1996, p.109

These findings pose interesting challenges with regard to re-designing local, national and international economic exchange systems with a salutogenic intention. The modern economic system is so easily accepted as a ‘given’, yet it is the relatively recent product of design decisions that are always up for revision, if a democratic society chooses to do so.

Wilkinson points out: “the monetary economy, rather than being a permanent feature of human society, has only become the dominant force in the lives of most of the world’s population during the last half century.” He argues: “With few exceptions it was — even in most developed countries — only a few generations ago that the world consisted predominantly of small farmers producing largely for their own consumption without more than a marginal involvement in commerce” (Wilkinson, 1996, p.137).

Modern economics, since Adam Smith, has fundamentally re-designed important patterns of interaction and relationship within civilization. To achieve lasting sustainability and increased human and ecosystems health, it will be necessary to assess and re-adjust, or fundamentally re-design, the monetary economy along salutogenic principles. We need to create economic systems that improve the health of individuals, communities and ecosystems, rather than affecting them negatively.

An important aspect of the market and wage labour is the individualism which it institutionalises. At the centre of the concept of individualism is the practical separation of each person’s interests and identity from those of others. Indeed, individualism is most fundamentally expressed by the role of cash in a market economy as we earn and spend our ‘living’, opposed as buyers and sellers in the marketplace. Dependent on individual incomes, my income is for my needs and any acknowledgement of your needs endangers the sufficiency of my income and so of my security.

— Richard Wilkinson, 1996, p.144

Wilkinson argues that a large part of our daily lives are now animated by the economic necessity of earning and spending. He points out that it is the “logic of possessive individualism which grows out of the opposition of marketised ‘interests’” that “provides economists with the rational choice theory” (p.144).

We are in a situation in which “the self-interested individualism of the marketplace” has spilled over “into other areas of social life. If we come to know ourselves through the market, then we behave as if its motivations were inherent deep within us. The nature of public life changes and human interaction becomes dominated by the asocial values of the market” (Wilkinson, 1996, p145). The re-design of the market place and human systems of resource acquisition, sharing, and exchange is a meta-design tool that fundamentally affects individual self-perception within societies and therefore modes of participation.

Wilkinson offers a very incisive analysis of the wider social effects that are entailed in the design of our current market economy. It would add that true sustainability will require a salutogenic re-design of the system along lines that encourage cooperation and social symbiosis, rather than incite competitive individualism.

Most of the current crisis of sustainability is to some extend caused by the chain effect initiated through designing a monetary economy along principles that increase competition, division, inequality and greed. We are now facing the results of the piece-meal thinking employed by most economic theory of the last 200 years — a tragically consequential mistake in our society’s guiding meta-design.

To anchor the guiding and explanatory story, we tell about ourselves, in an institutionalised individualism and focus on resource scarcity and individual and national competition for these limited resources, was fundamentally the wrong approach. The planet’s resources could be held in responsible stewardship by all of humanity, enabling present and future generations to meet their needs sustainably.

The economists of the 21st century are faced with the salutogenic design challenge to create appropriate economic systems at the appropriate scale. Such economies would nurture the social cohesion and cooperative structures that serve to maintain the health of society as a whole.

It is important to recognise that through most of human history and prehistory, human societies have made a point of avoiding some of the economic causes of social disharmony and have preferred more egalitarian social systems. The fact that we have had, throughout most of the existence of our species, what is by modern standards a remarkably egalitarian mode of social organization, suggests that we may not be psychologically well adapted to inequality and individualism.

— Richard Wilkinson, 1996, p150

As individuals who are fundamentally interconnected through culture and nature, we are more likely to engage in salutogenic design if we create economic practices that reconnect us to each other, to our communities and to the natural environment. Salutogenic design is design for cooperative structures and social and ecological symbiosis. It is synergistic design.

“A number of studies have shown the beneficial health effects of more, and better quality, social contact between people at home or in the community” (see Wilkinson, 1996, p.182 for list of references to these studies). More ecologically and socially appropriate economic systems would improve both social and environmental health, improving quality of life without a need for economic growth or increased resource consumption.

Wilkinson also highlights the effect of oppressive or stressful social hierarchies, based on income or power inequalities, on health. He cites physical evidence from autopsies that have shown consistently that individuals from poorer background have been found to have larger adrenal glands at the end of their lives, which indicates a life-long level of stress significantly higher than that of people from richer background who are found to have smaller adrenal glands (Wilkinson, 1996, p.176). This clearly indicates that the basic stress levels throughout their lives were consistently higher. So much so that the gland producing hormones in response to this stress grew larger.

Other studies on baboons and Vervet monkeys have indicated that individuals of lower rank in these hierarchical primate communities show permanent changes to the enervation within the hippocampus. This suggest that consistently being in a socially submissive role causes a positive physiological and endocrinological feedback loop that over time alters brain structure in such a way that the level of stress hormones in the bloodstream is constantly higher and a region of the brain that is vitally important in learning and memory becomes permanently damaged (see Wilkinson, 1996, p.194).

While such studies can clearly only provide indicative results, they do suggest a profound physical health effect of being submitted to oppressive social hierarchy and inequality. Wilkinson’s central emphasis is on the “primary importance of social relationships to us as social beings.” He argues: “at all stages of human societies, whether rich or poor, the quality of social relations has been a prime determinant of human welfare and the quality of life” (Wilkinson, 1996, p.211).

Such results indicate that by re-designing patterns of social organisation — turning dominator into growth hierarchies — with the aim of creating more equitable societies, we are likely to improve health at the societal scale and are therefore engaging in salutogenic design.

Health understood as a system-wide emergent property of the interactions and relationships between the system’s participants is fundamentally about reconnecting the system to itself and strengthening the individual holons of each scale of the holarchy that connects cells, organs, organisms, communities, societies, ecosystems and the biosphere.

From the perspective described by this thesis, health and design are fundamentally related, since health is understood to emerge out of appropriate interactions and relationships among the diverse participants of a complex dynamic system, and design is understood as an expression of intentionality through interaction and relationship. The holistic perspective recognizes the fundamental interconnectedness of nature and culture. From this point of view all design affects human and planetary health, therefore we are better advised to make the contribution to positive health an integral intention behind all efforts of design.
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[This is an excerpt from my 2006 PhD Thesis in ‘Design for Human and Planetary Health: A Holistic/Integral Approach to Complexity and Sustainability’. This research and 10 years of experience as an educator, consultant, activist, and expert in whole systems design and transformative innovation have led me to publish Designing Regenerative Cultures in May 2016.]