 humans and their health requirements THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 5, Number 6, 1999, pp. 495-502 Mary Ann Liebert, Inc. EDITORIAL Diseases of Meaning, Manifestations of Health, and Metaphor “The biggest disease today is not leprosy or tuberculosis, but rather the feeling of being unwanted, uncared for and deserted by everybody” Mother Theresa of Calcutta (1910-1997) The Observer, October 3, 1971, London United Kingdom "Unipolar major depression will be the world's second most debilitating disease by 2020. As a cancer is a malignant growth, so depression is a malignant sadness." W. Christopher Murray Head of Epidemiology, World Health Organization The Economist, December, 19, 1998 ABSTRACT Disease and health are commonly thought of as distinct opposites. We propose a different view in which both may be seen to be facets of healthy functioning, each necessary for the other, each giving rise to the other. Thus, disease may be thought of as a manifestation of health. It is the healthy response of an organism striving to maintain physical, psychologic, and spiritual equilibrium. Disease is not necessarily to be avoided, blocked, or suppressed. Rather, it should be understood to be a process of transformation. The process should therefore be facilitated because it is an integral part of the dynamic equilibrium that we ordinarily think of as health. In many cases, perhaps all, people get ill because there is something going "wrong" in their lives. This could occur in a whole range of ways— relationships, environment, food, or job. Our view, however, is that disease is a meaningful state that can inform health workers how to help patients to heal themselves. In this way, instead of being meaningless, people's problems become diseases of meaning, enabling people to see that things are not necessarily "going wrong" but are, in fact, helping them become stronger, to live more fully and with more understanding. Seen from this perspective, depression; cancer; heart disease; neurodegenerative and autoimmune disease; dementia; and conditions such as community violence, genocide, and the problem of environmental devastation are "diseases of meaning." World Health Organization forecasts make it clear that diseases of meaning will continue well into the next millennium to be the major cause of suffering and death worldwide. To deal with them, the world needs to reformulate the biomolecular paradigm that has been exploited in the last two centuries. It does not address the reasons why these diseases arise, attending mainly to their molecular consequences. A paradigm that includes the importance of meaning must now be given top priority. The concept that diseases are a manifestation of health—a call to a different relationship with ourselves and our environment, both animate and inanimate— is in itself a different approach. Programs for care and education based upon it would have immediate application in medicine, industry, education and ecology. We believe that this model would have far-reaching consequences for the understanding, treatment, and prevention of diseases and behaviours that lead to violence and environmental destruction. In the fall of 1998, a small group of medical care professionals, business people, biomedical researchers, and futurists, met at the Institute for Alternative Futures (IAF) in Washington, D.C., to explore in depth some of their emerging ideas on the origin and causation of disease and their implications for research, practice, and policy. These ideas, expressed in the title of this paper, were explored further with a group of professionals from medicine, science, industry, government, education, healing ministries, commerce, and management, at Dartington Hall in Totnes, England, United Kingdom, in June 1999. In part, these ideas reflect the rising prevalence of chronic physical, mental, spiritual, behavioural, and social pathologies, which we have called "diseases of meaning." This term reflects a functional shift in perception whereby disease can be seen and acknowledged to be a manifestation of health rather than some alien entity afflicting, or seeking to destroy, the individual or community. Its meaning is neither arbitrary nor random. It draws attention to our restricted understanding of disequilibrium, be it physical, perceptual, or spiritual. Disease is seen to be the healthy expression of a restricted sense of meaning or understanding in life, often with roots in a person's distant past, or that of their family, their genetic heritage. There is evidence from two important arenas. First, there is the increasing interest by people in formal and in informal spirituality, affirming the importance of meaning to health status and to ecologic and industrial practices (Larson et al„ 1997). Second, there is the growing interest by the public, health care professionals, and policy makers in the integration of different forms of medicine and approaches to health care (Coates and Jobst, 1998; Eisenberg et al., 1993; MacLennan et al, 1996; MacLeod and Macintosh, 1998; IAF, 1998; Gaier, 1998) along with an exponential growth in access to, and use of, health information resources online, particularly those about complementary and alternative medicines (CAM) (Gruner, 1999; Price, 1999). Furthermore, those individuals who are seeking CAM help hold different view's, not only about the meaning of their diseases, but also about their relationships with practitioners (Cassidy, parts I and II, 1998). Public health policies and medical science have enabled people in affluent cultures to survive acute threats to health, only to go on to suffer chronic physical and psychiatric illness and the prolongation of life, irrespective of its quality. The term diseases of meaning is proffered to describe these globally prevalent diseases. They include depression, cancer, heart disease, neurodegenerative and autoimmune disease, and dementia, but also encompass such conditions as community violence, genocide, and the problem of environmental devastation. However, the dominant concepts and policies in science, medicine, and politics will perpetuate and continue to be reservoirs for these conditions unless, and until, the importance of meaning to the quality and expression of human life in health and disease is understood. Depression is perhaps the most graphic paradigm example. The Economist reported in December 1998 that 330 million people now suffer depression worldwide. Ten to twenty percent (10-20 %) of people in the world's population will develop depression at some point during their lives. According to the head of epidemiology at the World Health Organization, (Murray and Lopez, 1996; The Economist, 1998) unipolar major depression will be the world's second most debilitating disease by 2020, eclipsed only by heart disease. The rising prevalence of depression feeds a $7-billion market for antidepressant drugs, led by Eli Lilly’s Prozac, which earned the company $2.6 billion in 1998. A Massachusetts Institute of Technology study determined that, in the United States alone, depression costs society $44 billion per year of which $12.4 billion is for treatment and $7.5 billion for the economic costs of suicide. The remainder represents the cost of lost productivity. (The Economist, 1998). Adverse drug-related reactions and fatalities from routine "therapeutic” pharmaceutical interventions follows close behind (Lazarou et al., 1998). Thus, "intended interventions" have become one of the most significant factors affecting health. They alter the relative importance of heredity, environment, and behaviour. Thus, although unintended, many of this epoch's diseases are the direct results of the intellectual, social, economic, and political forces, or consciousness, which created greater affluence and knowledge: i.e., they are diseases of meaning. How did this come about? Many forces contribute to causing diseases of meaning and a lack of aspirational/inspirational health. Here, we cite six major causes. First are the unintentional consequences of imperfect social, economic, and political policies. Second, the accelerated technological development of society, which, while freeing many people from the burdens of physical toil and historical circumstances, nevertheless gives rise to alienation. Third is the intentional manipulation of scientific, social, economic, and political systems, sustaining ignorance of meaning in systems for health for financial and political motives. Fourth is the focus on the individual at the cost of the sense of meaning inherent in an inclusive local or global community. Fifth is the neglect of the contribution of environment to health and the relationship of human beings to other life forms in the biosphere. Sixth, and perhaps most important, is our conditioning. We are conditioned to see disease as something bad, to be gotten rid of, eradicated, fought against, blocked, and beaten. This is the case for the many conditions listed above. However, this can be countered. Disease can, instead, be viewed as the healthy response by which the organism builds immunity and sequesters toxicity, be that environmental, chemical (nutritional and genetic), or psychologic and spiritual. Seen thus, not only is the process of disease someone's way, physiologically, to restore balance and to heal, but this process also reflects a person's sense of meaning, positive or negative. For example, any stimulus that evokes fear will cause systemic physiologic changes. If perpetuated, the chronic changes may be reflected somatically in a host of disease states ranging from hypertension and migraine, to cancer, bowel disease, premenstrual tension, immune disturbances, and arthritis. The meaning for individuals of any event or stimulus—from seeing a black crow on the horizon or a raised hand or hearing the sound of a pistol to realizing the implications of pesticides in fruit or genetic modification of foods—has real psychophysiologic consequences. Thus, what is perceived to be disease reflects the internalization of the metaphors adopted by individuals and communities. High blood pressure is a good example. The stress that has given rise to manifestation of disease in one person may be the source of well-being in someone else. In the one, the metaphor is one of threat whereas, in the other, it is one of creative challenge and hope. Most often, this process is unconscious. However, if it can be brought to awareness, it can enable people to progress beyond their current physical states. More importantly, it can help to further their mental and/or spiritual understanding. This would give people more insight, knowledge, and wisdom. In other words, awareness of this process would shift their consciousness to enable disease to be seen as a manifestation of health, a change in perspective that totally alters the relationship of the individual and health care workers to the whole process of disease (Jobst, 1990; MacLeod and Macintosh, 1998). This can lead to profound changes in psychosomatic, and therefore physiologic, processes and applies equally at individual, community, and global levels. It reflects a drive inherent in the disease process itself to generate positive individual and social attitudes. This process we suggest should be called "aspirational or inspirational health." The proposition that disease is a manifestation of health links diseases of meaning and aspirational health creatively: aspirational health being the means of transformation of diseases of meaning through changes in understanding and perception and consequently changes in behaviour, relationships, and physiology. This idea offers insights for the prevention and treatment of all diseases. Critical to the negative spiral that gives rise to the diseases of meaning listed above, is the perception that the "disease" (the origins of which may be social, industrial or ecologic, as well as being medical/physiologic) is unavoidable and can only to be remedied by being excised, eradicated, pharmacologically blocked, or genetically modified. Our experience is that, if this perception can be transformed, a totally different healing scenario emerges. There is growing evidence for this with far-reaching consequences for education, practice, and policy, whether in health care, industry, politics, or ecology (Bodian, 1991; Brown, 1998; Dethlefsen and Dahlke, 1990; Dossey, 1993, 1999; Fulder, 1996; Gaier, 1998; Harrison, 1990; Jobst, 1997, 1998; Kearney, 1997; Kabat-Zinn, 1991; MacLeod and Macintosh, 1998; Ornish, 1991; Oz, 1998; Schulz, 1998, Spiegel et al., 1989; Watkins, 1997; Whitehouse et al„ 1999). Why, in the most advanced, affluent, educated, and liberal era of history are people so ill with chronic and largely incurable diseases? Although, in part, this is because of ageing and increased longevity, this is not the whole story. The work of the psychiatrist Victor Frankl (Frankl, 1988, 1998) and the architect and leadership consultant Roger Fritz (Fritz, 1991) provide some insight. From his time in concentration camps. Dr. Frankl concluded that it was having a sense of meaning that determined survival. This led to his developing logotherapy (Frankl, 1988). Mr. Fritz developed the idea of "empowering" and "disempowering" systems operating to determine behaviour and outcome in individuals and communities. Empowerment occurs when aspirations include a sense of meaning and the will to create a preferred future. This arises from, and is sustained by, "profound learning." Profound learning occurs as a result of exchanges, often frictions (suffering), between circumstances and aspirations, which lead to changes in understanding about how the world works and about essential human values and feelings (MacLeod and Macintosh, 1998). When aspirations embrace individual and global well-being, these goals generate aspirational health, one of the hallmarks of which is a positive view of the future. Disempowerment therefore, is a fundamental disease of meaning and the cause of many others. It occurs when inner and/or outer circumstances prevent aspiration and learning. When this happens, feelings of hurt, fear, guilt, pain, and hopelessness (i.e., negative meaning) emerge instead of creative growth. Then, individuals and communities seek only to escape as rapidly as possible. Short-term solutions and avoidance, even self-destruction, become the only aspiration, because of this restriction of meaning. Paradoxically, these diseases of meaning are nevertheless healthy responses. They are symptoms, alerting mechanisms to the restrictions, the consequences of more primitive meaning, and the need for its transformation, just as hunger drives someone to search for food. In other words they are the only way that the organism can manifest, given its existing level of understanding and consciousness. However, the miracle is that when disease is seen for what it is, the level of consciousness changes. Such a perceptual shift, on its own, may sometimes cure the problem, by prompting radical changes to behaviour. Thus, depression does not merely reflect disease in a negative sense. Instead, it reflects the healthy psychospiritual and physiologic responses within the individual to unconsciously held, destructive, and disempowering meanings from which there appear to be no escape. A change in perception, of meaning, can totally transform the landscape in much the same way that the infinitesimal exposure to light transforms a photographic plate, or the way an enzyme affects the reaction it catalyzes. Just as the catalyst is not changed, neither are the circumstances causing the disease of meaning. But the response of the organism, the symptoms of disease, may alter profoundly, sometimes disappearing altogether, so that what was once destructive becomes a source of life, growth, and vigour. We believe that the widespread and largely unconscious adoption by individuals, communities, and societies of disempowering paradigms are the primary "pathogens" of diseases of meaning. Because of them, disease and death are perceived to be failures, rather than opportunities to learn, evolve, and grow not only physiologically but more importantly in being and understanding, as well (Kearney, 1997). Furthermore, diseases of meaning are not succumbing to treatment with biomedical, behavioral, or social science approaches. Even the concept that breakthroughs in biomolecular and genetic intervention will permit lasting solutions to acute and chronic medical problems has the inescapable seed of disease within it. Not only is the current pharmacologic and biomolecular paradigm the cause of a huge disease burden (Lazarou et al., 1998), but the consciousness of such thinking inescapably gives rise to fresh diseases by paying no attention to meaning. Witness the evolution of bacterial resistance to antibiotics, tolerance to antidepressants and antipsychotic treatments, and the growing recreational use of drugs. We should be investigating why one person becomes infected when others around that individual are not, when, to all intents and purposes, they are similar? The proposition here is that perceived meaning and the way it affects how life is lived is at the root of all disease. While biomedical science will find genetic dimensions to depression, substance abuse, and violence, we cannot ignore that social and cultural factors are critical contributors and that non-molecular or pharmacologic, extrinsic intervention can ameliorate and cure disease. This is only a matter of perception, however, for ultimately all interventions, whether through changes in perception and meaning or whether through pharmacologic or even surgical methods, are ultimately manifested in molecular and chemical changes. There is no thought, feeling, or perception without molecular and chemical reaction and change. Thus, diseases of meaning are manifestations of health, i.e., they are healthy protective or alerting responses, arising to protect individuals and communities ultimately by leading to the transformation of meaning. Clearly, then the complex human adaptive system can either give rise to diseases of meaning or to aspirational health, depending on the scope and context of perceived meaning. Our current approaches in science, medicine, and policy do not address diseases of meaning adequately because proponents of these approaches are not asking questions that will create aspirational health and transform meaning. Rather than being empowering, the exponential growth of information and knowledge, but not wisdom, disempowers the majority. Witness the stranglehold desired by the major industrial conglomerates such as Monsanto, in close alliances with governments, through the creation of genetically engineered terminator seeds (The Ecologist, 1998) or the emergence of new and sometimes fatal diseases, such as human bovine spongiform encephalopathy ("mad cow" disease). It is not enough simply to unravel the human genome. We must ask in addition what it means to understand the human genome, what it might mean to manipulate and propagate fundamental coded genetic changes in a matter of seconds, in a virtually infinitely complex and interconnected system that has taken millions of years to evolve. In this context, the concept of diseases of meaning recognizes not only psychophysical but also psychospiritual etiologies in the causation of disease that, like micro-organisms, can be transmitted. For the most part, our institutions have no psychospiritual evolutionary perspective with which to create aspirational health and to understand and work towards treating diseases of meaning (Stevens and Price, 1996). Although some people do recognize the need for a broader perspective (Whitehouse et al., 1999; MacLeod and Macintosh, 1998), it is our contention that the current "Western," scientific, reductionistic approach is inevitably blind to the dimension of meaning in human experience. The "medicalization" of diseases of meaning ensues, an example being the search to "find the gene" or "design the drug" to disrupt the disturbance, ignoring the inherent power of a change in meaning to alter the individual's biochemistry and physiology by itself. What one seeks to treat is ultimately the chemical/molecular manifestation of the way someone sees and interprets things. The argument is that, if this perception were understood and transformed early enough, the situation might even be prevented. Thus, the perspectives of our institutions are integral to the problem (MacLeod and Macintosh, 1998). They reinforce a system of values that cannot allow people to appreciate the significance or meaning of inspirational health. Instead our institutions train health professionals, industrialists, and policy makers to address all pathologies as if they were physically caused without recognition for the central importance of meaning to their causation. So what can be done? The future may be influenced by some current trends, such as the growing interest in integrative health care (Coates and Jobst, 1998; IAF, 1998; Jobst and Stacey, 1998; Jobst 1998), the "re-spiritualization" of people and industry (Larson et al., 1997), the increasing awareness of the interconnectedness of the environment and health from global to individual levels, the "shrinking" of the world via telecommunications and computers, the growing body of literature that can be marshalled to explore diseases of meaning (Dethlefsen and Dahlke, 1990; Dossey, 1993, 1999; Frankl, 1988; Hahnemann, 1996; Harrison, 1986; Kabat-Zinn, 1991, Ornish, 1991), and the end of the cold/mass war period of human history. However, sectarian genocide, industrial profligacy with genetic modification, and environmental devastation remain as some of the most grotesque reminders that we are far from achieving the global transformation of meaning that we cherish. We can foster the growth of an international community that acknowledges the fundamental importance of meaning. We can help to promote it as a rubric for education, research, policy formulation, and transformation. This will help to establish a global dialogue to ensure that learning systems are created that can lead to practical down-to-earth problems being addressed and transformed. Language is all important as the vehicle for these ideas. Metaphors are powerful linguistic tools for understanding and comparing complex systems. In pursuing their professional and social aims, physicians and surgeons, for example, adopt metaphors such as "warring against cancer." This is but one example of a pervasive metaphor of fighting against diseases. The use of such parallels permits us to think of pathogens as enemies and doctors and scientists as valiant soldiers with battles to be won or lost. These metaphors foster alienation and polarization. Equally powerful and destructive, is the metaphor of medicine in the marketplace where consumers purchase their health care, promoting money as the ultimate arbiter and value. Better healing metaphors are needed. Ecologic metaphors would portray disease in an interconnected and interdependent world of which human beings are a part and in which values such as sustainability can be emphasized (Goodwin, 1994). We need to see that, because disease is a manifestation of health, we can work with disease processes, gain understanding from them, and so use their energies to facilitate the healing responses that they invoke de facto. Our culture, as evidenced in medicine, is out of touch with creative meaning about life and death because of the use of unhealthy (diseased) metaphors. This is not the case for some medical systems with their origins in other cultures and branded as "alternative and complementary" in our own (Jobst and Stacey, 1998). It follows, therefore, that disease as a manifestation of health is a potentially radical transformation of metaphor, which could be the core component in turning destructive diseases of meaning into aspirational health. The demand for change in how we educate our children and how we select, train, and oversee professionals, is being heard throughout the world. While many people seek incremental change in the care of acute and chronic diseases, there is now an opportunity for a quantum change through understanding the importance of meaning to the experience of illness and the manifestation and treatment of diseases. Indeed, health may be to our age and the new millennium, the revolutionary force that reading was to the renaissance. For this there must be dialogue—dialogue capable of creating meaning and which recognizes that the potential pandemic of diseases of meaning that lies ahead is paradoxically a great opportunity to engage in how we might prepare for the future better. 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