©2011, Nathan Daley, MD, MPH

Why focus on health and not disease and dysfunction?  The main reason is that all disease, dysfunction, and most other major challenges in the world are the consequence of impaired health.  Of course, one must question what I mean by disease, dysfunction, and major challenges.  I do not mean all things unpleasant or outside a utopian ideal.  I do not mean all things counter to economic and technological growth either.  What I mean, most simply, by these words is persisting imbalance, unsustainability, fragmentation, fragility and any variety of experiences of discomfort, dis-ease, inadequacy, and discontent.  Health, then, offers a single entity from which the millions of different diseases, dysfunctions, and challenges diverge.  Moving toward health is moving away from disease, toward balance, resilience, and efficacy, and still further beyond to the full realization of living and being, all in a single act.  The attenuation or prevention of disease, on the contrary, is not synonymous with greater health but simply less disease.  The draining and often antagonistic efforts to address the innumerable concrete concepts of disease or dysfunction can be synergistically consolidated into a single process oriented concept of health. “Turn toward the sun and all shadows fall behind.”  While the attempt to innumerate and define concepts of disease or dysfunction exponentially and infinitely spirals into a complicated reification of reality, health drives towards an increasingly cohesive, holistic, and simple experience of reality (simple is consistent with complex while complicated implies fragmentation).  Health, true to its name, is a holistic solution to disease and a purpose for living in itself.

Some readers may recognize a similarity here with Aaron Antonovsky’s work on “salutogenesis.”  Antonovsky proposed the term to refer to the origin or generation of health, as “salud” is latin for health, as opposed to the common concept of pathogenesis or the generation of disease/dysfunction.  Indeed, this is what I am searching for as well, yet my interest is more general and inclusive of all natural systems or organisms. Therefore, my approach will be more holistic than that of Antonovsky, a sociologist.  Antonovsky was focused on the subjective perception of human health (omitting other organisms or systems) and attributed this perception to psycho-social elements (omitting eco-somatic elements and the larger natural environment).  To quote Antonovsky in Unraveling the Mystery of Health:

“My tentative answer to the question [of salutogenesis] was expressed in the concept of generalized resistance resources (GRRs) – money, ego strength, cultural stability, social supports, and the like – that is, any phenomenon that is effective in combating a wide variety of stressors.” (preface xii).

He then follows with a less tentative answer:

“The answer to the salutogenic question was the sense of coherence (SOC). What is common to all GRRs, I proposed, was that they facilitated making sense out of the countless stressors with which we are constantly bombarded.  In providing one repeatedly with such experiences, they generate over time a strong sense of coherence.  This central concept is defined as a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic, feeling of confidence that one’s internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected.” (preface xiii).

He lists three components of the SOC. 1) Comprehensibility, or the ability to make sense of circumstances.  He notes that these circumstances may be positive or negative (eg. war, death, etc.) but the polarity is not important, only the ability to comprehend and generate an explanation for what is happening.  2) Manageability, or the perception that resources (money, knowledge, time, etc.)  are available for dealing with the circumstances.  3) Meaningfulness, or a motivational element allowing things to matter and the circumstances to be worthy of engagement.  Elsewhere, he explains the basis of this definition of health,

“Let me be quite unequivocal about the two sources of the salutogenic orientation.  The first is the fundamental assumption of heterostasis, disorder, and pressure toward increasing entropy as the prototypical characteristic of the living organism.  This assumption, in stark contrast to that of the pathogenic orientation, which assumes that now and then ‘normally self-regulated, homeostatic processes become disregulated’, led me to explore the epidemiological data on health and illness, which brought me to the inescapable conclusion that disease, however defined, is very far from an unusual occurrence.” (page 2).

Antonovsky believes that disease and dysfunction are the norm and health must be generated, while the conventional view is that health is the baseline and disease is generated by causal factors.  A truly holistic perspective based on a co-evolutionary template of ecology and organism-environment concordance would see these two in a dialectic, a relationship of tension and release, an oscillation not between health and disease but between concordance and discordance.  Progress toward increasing concordance, the net course of co-evolution, would result in a trajectory toward increasing self-organized complexity, regulation, and holos.  Only with the predominance of discordance does the entropic pressure and disease observed by Antonovsky, become the norm.  His observations come from modern society in which discordance and disease is the norm indeed.  However, natural systems in balance trend away from entropy and equilibrium and toward increasing concordance, complexity, autopoiesis, homeostasis, resilience, and efficacy, all dynamic characteristics which define health rather than disease.

I would like to use Antonovsky’s sense of coherence (SOC) and generalized resistance resources (GRR) as a take off point for arguing that a more general theory of health can be achieved by applying the concepts of efficacy and resilience to any and all organisms or self-organized systems.  Efficacy is used broadly and simply means the ability of a system to acquire resources (energy and information) and transform them into itself.  Efficacy, then, is a process of always becoming.  An organism or system is sustained only through continuously becoming.  The term autopoiesis (self-making) has been used to express the same meaning and is, therefore, a synonym.  Furthermore, efficiency refers to the degree of efficacy or the effort/energy required by a system to acquire resources and transform them into itself.  An evolutionary and complex systems perspective would suggest that the term adaptation may be synonymous with efficacy, or is, at least, necessary for efficacy.  Adaptation implies that a system or organism is matched to its environment, niche, or available resources in a way that it can make efficient and effective use of them.  I may occasionally use autopoiesis, efficiency, or adaptation in place of efficacy, but efficacy is the preferred term as it is more familiar to the individual person as self-efficacy.  This is the perceived ability to meet one’s needs through action.  This is the product of Antonovsky’s sense of coherence, and he says as much:

“…Bandura’s theory of self-efficacy, which seeks to explain engagement in any behavior, including health behaviors, might well be extended to apply to successful coping with stressors.  Is it too far-fetched to suggest that the three conditions for efficacious behavior in Bandura’s theory are analogous to the three components of the SOC?  First, there is the belief that the intended outcome of a given behavior is of value to one (meaningfulness); second, the belief that performing the behavior will indeed lead to that outcome (comprehensibility); and third, the belief that one can successfully perform that behavior (manageability).” (page 59).  “…once this confidence is established – in my terms, once the generalized view of the world as meaningful and comprehensible is focused on the specific situation – one is ready to act.” (145). “An orientation toward one’s world that sees stimuli as meaningful, comprehensible, and manageable provides the motivational and cognitive basis for behavior that is more likely to resolve the problems posed by stressors than is one that sees the world as burdensome, chaotic, and overwhelming.” (147).

Similarly, the product of Antonovsky’s generalized resistance resources (GRR) is resilience.  Resilience is also used broadly to mean the capacity of a system or organism to persist and preserve itself despite change and perturbation.  This may involve absorbing, avoiding, or adapting to perturbations or stressors.  To be resilient is to be compatible with variability, oscillation, and uncertainty.  The characteristic of resilience has a long history in the medical sciences.  Claude Bernard explored the physiological “complex of functions which withstand chance” and referred to this as the “milieu interieur.”  Similarly, Walter Cannon coined the now widely accepted and applied term “homeostasis” to refer to the ability of physiologic systems to maintain rather narrow internal conditions despite wide variations in the external environment.  Homeostasis refers to nothing other than resilience.  While adaptation is synonymous with efficacy, adaptability is synonymous with resilience.  Adaptability is the potential to remain adapted to changes in the environment, niche, or available resources.  From a systems perspective, redundancy in connectivity, information, or resources is necessary for resilience.  Redundancy allows alternate routes of information or energy exchange in the event of failures or breaks in the system.  Therefore, adaptability and redundancy imply resilience and may be used as synonyms on occasion.  For resilience, redundancy, or adaptability to exist, a system’s organization and autopoietic activity must allow for it.  It is evident, therefore, that efficacy is necessary for resilience.  Yet, efficacy cannot exist without the ability of a system or organism to tolerate change.  Therefore, efficacy and resilience are interdependent features of health. They are autocatalytic in the sense that they potentiate and further the capacity of one another.  Health potentiates health, in essence.  Antonovsky’s generalized resistance resources are simply resources which give a person the perception of resilience.  Resources like money, ego, relationships, social support, power, and etc. provide a person with confidence that they will be able to respond to uncertainty and provide solutions to problems.  Is money in the bank not redundancy?  Every dollar sits unassigned and ready to satisfy demands, predictable or not, which may arise in the future.

Like Antonovsky’s definition, most other attempts to define human health seem to, directly or indirectly, suggest the elements of efficacy and resilience.  Let’s briefly explore several of the proposed definitions.  The endlessly reproduced definition of health from the World Health Organization (WHO) which goes, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” was crafted in 1948 and is obviously deeply flawed in that it simply replaces health with wellbeing.  The same problem exists with Rodolfo Saracci’s 1997 definition published in the British Medical Journal (BMJ) editorial which states that “health is a condition of well being free of disease or infirmity and a basic and universal human right.” He mentions that it is not the same as happiness yet does not define or differentiate happiness.  The WHO offered a revised definition in 1986 which is rarely referenced and states that “Health is a positive concept emphasizing social and personal resources, as well as physical capacities.” This definition is still inadequate, but begins to suggest the concept of resilience in its mention of physical capacities and social and personal resources.  Perhaps contained within social and personal resources is the suggestion of efficacy as well, but this is less clear.  Appearing in the BMJ in 2009, Vivian Rambihar, clearly inspired by complex systems science, explained that “health is the complex state or process towards wellbeing and away from disease and infirmity. It is an ever changing emergent property of the complex and dynamic interactions in the web of causation and change that lead individuals and communities towards or away from wellbeing, disease, and infirmity.” Besides the confusion and unhelpful suggestion that health leads to wellbeing, this definition squarely refers to resilience in the context of continuous change and efficacy may be implied by the requirement of “interactions in the web of causation.” This definition is one of the first to imply that health has a scale-free nature (“individuals and communities”) and is a process manifesting in all self-organizing complex systems (organisms) rather than just the human organism. Larson, in Medical Care Research and Review (1999) mentions several “models” or paradigms of health and defines them.  These include the  “wellness model” which defines health as progress toward higher functioning, energy, comfort, and integration of mind, body, and spirit, and the “environmental model” which defines health as the adaptation to physical and social surroundings— a balance free from undue pain, discomfort, or disability.  The “wellness model” clearly illustrates several attributes of self-efficacy while the “environmental model” explicitly mentions adaptation to the environment, a synonym of efficacy.  Finally, in 2009, an editorial in the Lancet, inspired by Georges Canguilhem, explicitly mentioned the scale-free nature of health and the interdependence of human and planetary health. “Human health cannot be separated from the health of our total planetary biodiversity” and “one cannot be healthy in an unhealthy society. Health is not a fixed entity. Health is defined not by the doctor, but by the person, according to his or her functional needs. The role of the doctor is to help the individual adapt to their unique prevailing conditions.”  Health is defined by the person’s self-assessment of whether “functional needs” are being met, which is self-efficacy, and the doctor’s role is to improve adaptability, or resilience, in the context the current circumstances.

I feel comfortable that the interdependent characteristics of efficacy and resilience provide a functional conceptual foundation for qualifying and quantifying health that remains in agreement with the predominate perspectives of human health.  We are now prepared to look beyond the human scale and ensure efficacy and resilience are indeed features of much larger healthy systems or organisms.  This begins my ultimate goal of explaining holos (one health, whole healing) as the scale-free (i.e. holistic) process of progressively optimizing efficacy and resilience, leading to a more cohesive and sustainable single system.  Once a general definition is sketched, I’ll need to consider the origin or genesis of health and eventually bring this discussion back to practical approaches to optimizing health (which I will do).  I will be respectfully expanding Antonovsky’s salutogenesis, which is now attached to the entity of human health, to hologenesis, or the genesis of scale-free health.  First, though, let us look at the health of ecosystems.

Like all organisms, from amoeba to bacterium to human to whale, ecosystems are self-organizing, self-making (autopoietic), and self-regulating (homeostatic) systems existing far from equilibrium. At first glance, ecosystems seem different than these other organisms because ecosystems are unbounded (i.e. open) systems of different and diverse organisms.  However, the human body is also an open system consisting of different and diverse organisms.  The human cell is a system of previously separate single celled organisms we now call organelles.  The internal and external surfaces of the human body contain billions of bacteria and fungi which are materially and energetically inseparable from human cells, organs, and physiological processes.  The human organism is an small ecosystem and an ecosystem is a large organism.  The human organism is nested in larger organisms called ecosystems which are nested in a still larger organism called the biosphere.  If one concedes that ecosystems are organisms and possess the characteristics above, namely autopoiesis and homeostasis, then ecosystems must demonstrate various degrees of efficacy and resilience, the interdependent qualities of health. Ascribing health to an ecosystem is now commonly done and the term “ecosystem distress syndrome” is used to designate the impairment of ecosystem health.  Fortunately, I will not have to attempt to position ecosystem health for quantification and relation to other scales of health.  This work has already been done by Robert Ulanowicz, at the University of Maryland, who proposed the concept of “ascendancy” as a quantitative measure of an ecosystem’s organized information.  He then proposed the concept of “overhead” as the quantitative measure of an ecosystem’s redundant, diverse, or disorganized information. Ascendancy refers to established exchanges of information and energy while overhead refers to potential or alternate exchanges which support the preservation of ascendancy. These entities are not independent but highly interdependent with considerable overlap.  By definition, this “process ecology” or systems ecology is referring to the connectivity of the ecosystem which is the cumulative product of the ecologies of nested organisms.  Ascendancy is increased by connections which are reinforced and well established.  The flow of information and energy is well organized, rapid, and efficient.  This is clearly the efficacy or adaptation (adapted-ness) of an ecosystem.  Ascendancy allows the ecosystem to acquire and organize the necessary resources to continuously remake and revise itself.  Overhead, on the other hand, consists of numerous, weak, random, and shifting connections which, at any moment, can become strong and reliable connections should the need arise.  This is clearly resilience or adaptability. Ulanowicz scales these components of health according to total ecosystem throughput, implying that the flow of greater resources or energy suggests a mature and successful system conformation which has a high degree of optimized interactions.  Such optimization occurs over time as a result of natural selection and co-evolution.  More formally, ascendancy (efficacy) is defined as the degree of mutually shared energy/information across organized relationships (negentropy) x total system throughput. Overhead (resilience) is defined as the quantity of relatively disorganized or transient relationships (entropy) x total system throughput.

Ascendancy and overhead or efficacy and resilience can just as easily be used to characterize the health of the biosphere, the emergent product of nested ecosystems. In fact, they can be applied within and across every scale which includes self-organizing complex systems from the cellular to the planetary scale.  The health of a cell, for example, is a product of its ability to acquire resources and continuously regenerate itself (repair the lipid membrane, undergo mitosis, etc.) and its ability to tolerate perturbations and variability (control oxidative damage, manage DNA replication errors, control infectious agents and host defenses, persist despite temperature and pH changes, etc.).

From where does optimal efficacy and resilience, optimal health, and holos originate?  Health has both internal and external origins when speaking relative to a specific scale.  The cell, for example, requires a suitable environment which provides the right proportions of needed resources, and must also have an innate capacity to utilize these resources in a changing environment.  It would seem that the specific efficacy an organism develops is specified internally, by the past and present organization of any organism.  This pattern of organization influences what resources are needed and how they need to be transformed into that evolving pattern.  The specific resilience that an organism develops, on the other hand, seems to be specified externally in response the variability and perturbations present in the organism’s environment. Efficacy moves from the inside out and resilience moves from the outside in.  However, it can be argued that the specific organization of any organism, traced back to the first replicating material on earth 4.5 billion years ago, was initially patterned by the environment and the subsequent array of species has been selected by the ecological niche within which the species evolved.  But I suspect it nearly impossible to differentiate the first life form from its environment and, beginning with the first life form in earth, organisms influence their environment as much as the environment influences the organism.  It has always been this dialectic and co-evolution. As mentioned elsewhere, both the organism and environment are manifested by the interaction between the two.  The interaction, or ecology, is primary.  In just the same way, health (optimized efficacy and resilience), is both environmental (external) and genomic (internal) in origin, with the manifesting process being the organism’s ecology.  Indeed, health originates through the same process which allows life to exist and persist.  Some degree of health is a necessary requirement for life.  Optimal health is equivalent to an optimized existence within the world.  It is well beyond the concept of “fitness” as defined by reproductive capacity. Health includes this, but is better represented by an organisms degree of cohesion or refined connectivity to the organisms around it on all scales (its living environment).  Health, true to its etymological root, is defined by the degree of oneness or wholeness and, therefore, defies system or organism boundaries.  As described above, efficacy and resilience depend upon connectivity, and, therefore, health, depends upon connectivity.  Holos (oneness, wholeness, health, healing) depends upon connectivity.  For the individual organism, and the human organism, this connectivity is the organism’s ecology.  Ecology consists of the interactions between organism and environment.  Optimizing one’s ecology will optimize one’s efficacy and resilience, maximize one’s experience of oneness or wholeness, and maximize one’s contribution to holos or scale-free health, person to planet.

Efficacy and resilience, or the synonyms discussed above, are not necessarily modern concepts. Likewise, the definition of health provided here and the concept of holos or scale-free health are not entirely novel.  Though independently recognized in modern scientific clothes through a transdisciplinary lens, these concepts and definition appear to have been referenced within several ancient healing systems.  This is encouraging as it suggests that a transdisciplinary systems based perspective may finally be able to reconcile modern science and philosophy with ancient science and philosophy.  Perennial wisdom, then, becomes the future destination of modern science.  Wisdom and knowledge will have to find a new integrated language which, hopefully, moves away from conceptualization and returns to the lived experience.  Let us briefly explore the concepts of health in traditional Chinese medicine (TCM) and philosophy as well as in Ayurveda.

Traditional Chinese medicine refers to “jing” as a fundamental energy which maintains life.  Jing tends to be maximal at birth and decline with age until its elimination causes death, but it can be increased or maintained by a proper way of life including optimal nutrition and exercise.  Jing supports the manifestation of “shen”, a very broad concept which includes the presence of self-control, motivation, purpose, compassion, and fulfillment.  The presence of adequate shen allows one to effectively maintain or preserve jing.  Therefore, shen and jing are interdependent.  These concepts sound very much like efficacy (shen) and resilience (jing).  Zheng is the balance of internal and external factors which influence a person, such as purpose, motivation, and emotional factors (internal) and environmental, lifestyle, and social factors (external).  These internal factors would seem to originate from shen, and these external factors help determine the preservation of jing.  Therefore, I might suggest that an optimized balance of shen and jing leads to maximal zheng, which appears to be a Chinese term for individual health.  The adequacy of shen, jing, and zheng are thought to result from the complex balance of five elements (wood, fire, earth, metal, water) and six environmental qualities (wind, cold, heat, dampness, dryness, and summer heat).  Clearly traditional Chinese medicine uses an ecological approach to prevent and treat disease.  Additionally, the interdependence of yin-yang are fundamental to numerous Chinese philosophies and systems, including the I Ching and traditional Chinese medicine.  In the I Ching, yin refers to periods of receptivity and replenishment while yang refers to periods of growth and development.  Thus, yin refers to increasing resilience and yang refers to efficacy. Traditional Chinese medicine considers the balance of yin-yang (resilience-efficacy) when assessing and treating disease processes.  Extrapolating these elements into a more philosophical perspective, an individual who has achieved the optimal balance of shen and jing, and yin-yang, not only achieves maximal zheng but lives in harmony with the Dao (Tao).  The Dao is oneness in becoming.  To participate in the holistic, harmonious, and continuous change that manifests each present moment is to be consistent with the Dao.  I believe that this way of being is consistent with a truly optimized ecology or connectivity to the whole, the biosphere. Wei wu wei is a term that means “action without action” with refers to this participation in oneness.  This non-doing is the experience of oneness or wholeness and is the experience I refer to elsewhere as ecological embodiment.  Here the zheng of the individual person combines with the Dao of everything, which is a scale-free process of autopoiesis and homeostasis synonymous with my use of the term holos.

Ayurvedic medicine also uses an ecological foundation based on five elements (space, air, fire, water, earth).  Combinations of these elements lead to the three doshas (vata, pitta, and kapha), the balance of which determines an individual’s degree of health.  Different environments (including different seasons and weather events) and environmental interactions (food, physical activity, medicinal herbs, etc.) possess different proportions and intensities of the five elements and exert different influences on the doshas, leading to changes in dosha balance. When the three doshas are in optimal balance for any given individual, that individual’s agni, or digestive fire, is also optimized.  This dynamic condition is referred to as samanagni.  Agni literally refer to the process of digesting food, but it also refers to the more general process of acquiring resources and transforming them into one’s own body-mind.  Digesting food does just that, and so the term is often applied narrowly, but the more general concept of agni is the equivalent of the concept of efficacy discussed above (which would also include digestion by the way).  Samanagni is associated with calmness, clarity of mind, confidence, motivation, and a robust digestion.  These qualities are, quite clearly, consistent with self-efficacy.  Agni generates another concept in Ayurveda called ojas, and samanagni generates ojas most efficiently.  Ojas is the vital force or the vital reserve of the body-mind.  Ojas underlies endurance, immunity, contentment, and strength and is contrasted to ama which corresponds to toxin accumulation.  Ojas, then, appears to be associated with a tolerance to stress or perturbations.  While samanagni is the efficacy of Ayurveda, ojas is the resilience.  Samanagni and ojas, achieved through a balanced or optimized ecology, and accompanied by the sensuous manifestation of mind and spirit, leads to the experience of swastha or “being totally happy within oneself.”  Could this experience also be an experience of oneness?  If not, it is likely close as being totally happy within oneself, sensuously aware, and spiritually connected would suggest that one feels completely nourished, protected, and provisioned, in a rich and vibrant environment, by something larger than oneself (like in the embrace of mother nature).

So, in summary, efficacy is simply the ability of an organism to acquire resources (energy, matter, information) and transform them into itself.  This is the action of self-making or autopoiesis.  Resilience is simply the capacity of an organism to persist and preserve its general conformation within, and as a part of, a dynamic environment.  For the human organism, the experience of efficacy and resilience involes most of the characteristics we ascribe to wellbeing, health, and happiness.  These include confidence, calmness, clarity, peacefulness, motivation, purposefulness, meaningfulness, vitality, and spiritual connection. One feels provisioned for, protected, nourished, accepted, included, and engaged by the surrounding world.  The differentiation between self and other is indistinct and often dissolved.  There is a sense of being complete, whole, and one with the animate earth. These concepts and their ecological origins provide a trans-spatial (across scales) and trans-temporal (consistent across time) functional definition of the entity of health.  See the summary chart below.  A definition, however, is only a standard from which to begin the real exploration of health.  Certainly questions remain.  What is an optimized ecology and what does an optimal human ecology look like?  Why does connectivity and ecology lead to true positive scale-free health exactly?  Can we measure health in people? For answers to these questions, look for “A Unified General Theory of Health Part 2: the origin of health” and “Part 3: the measurement of health.”