Our conscious experience is often sold to us as a collection of disparate parts that we must endlessly struggle to put together to form a coherent whole. The endeavor precludes true completion because the conscious effort cannot keep apace with time, as only the present eternity can hope to accommodate the totality of existence. It is this struggle, the tiring and burdensome affair of defending the borders of the illusion of the largely Western notion of the self, that I believe to be among the factors most upstream of life and correspondingly, health, outcomes. For, as I write prior, an analysis of the present state of society and the progression of its numerous comorbidities is incomplete without an honest dialogue with history. But, of course, the approach we take to history and the lessons we learn from it are largely dictated by the terms of our consciousness. Real, sustainable change that moves the world toward justice and love requires not just alterations to the contents of our thoughts, feelings and beliefs, but rather, fundamental modifications to our understanding of the kinds of things that we are and our relation to all else that may or may not be.
A dear friend of mine struggles with depression. She has tried a number of medications, but they numb the vivacity of her character. She has thus chosen to forego pharmaceutical treatment, attempting instead to address her symptoms with Cognitive Behavioral Therapy (CBT), patience, resilience and the support of both herself and others. Highly intelligent and deeply compassionate, she is acutely aware both of what she thinks and what she feels, but nevertheless, a small portion of the time, her mind usurps the throne. What follows, in her words, is a brutal irrationality that attacks her worth, her happiness. How does the mind become pathological, and how can it be remedied? More importantly, how can it be prevented? These questions are becoming increasingly relevant in the field of public health. Lopez and Murray (1998) estimate that by 2020, unipolar major depression will be the second leading cause of global disease burden as measured by disability-adjusted life years. The etiology of depression, similar to that of many of the mind’s nemeses, is highly complex, including both biological factors and environmental factors (Saveanu & Nemeroff, 2012).
If the environment is partially responsible for the onset of an illness like depression, well, who then is responsible for the environment? An examination of mental illness and its place in society offers valuable insight as to how we treat each other, and how we may improve. Ultimate responsibility for all that happens in society is shared by all its members. Empiricism demands that particular characters are isolated as being disproportionately responsible (e.g. an abusive parent, callous peers) for particular health outcomes (e.g. mood disorders) so as to offer schema for intervention and clearer explanatory and causal mechanisms. The requirements of the culture of science, though, need not come at the expense of dismissing our collective efforts in sustaining the social game.
Responsibility is localized and handed out much like material goods, and the culpability that follows in less fortuitous circumstances is an unsurprising product of how we characterize the mind. The notion of ultimate shared responsibility is incompatible with the notion of an immutably demarcated self. A metric of the public’s health includes those maladies the existence for which the public is at least partially responsible. People that suffer from depression are people whose minds have been, to some extent, compromised by cancers of society. Such instances should produce humility and an anger borne of a commitment to make amends for the pains brought upon by a history of mistakes. Holistic models that address circumstance and volition at all levels of society, like McLeroy et al’s (1988) ecological model or Link and Phelan’s (1995) theory of fundamental causes, are evolutionary byproducts of a discipline that aims to be ever more effective in diagnosing and treating the public. Such evolutionary gains are necessary if the public’s health, if the mind’s health, is to be improved.
I thought public health might be changing as a discipline into something that it does not want to be. That is, my worry was that the greater the breadth of ‘health,’ the more it would aim to be without being much of anything at all. But, as I reflect upon the value of play, the dangers thrust upon laborers in an exploitative system, the potential for a dogmatic institution like religion to partner with the deconstructive biology of public health, and the misery that awaits older adults relegated to the peripheries of social attention due to imposed declines in productive output, I realize that public health is well-situated to work at both ends of the spectrum. Indeed, the constitution of public health may demand that it be so. Interventions on the ground, in schools, in mental health facilities, age-supportive communities, etc. are soldiers of the institutional war waged upon oppressive and outdated systems. Public health ties itself to the betterment of humanity. Progress on such a scale may require interventions along the entirety of the scale.
Link, B. G., Phelan, J. (1995). Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior, 35, 80-94.
Lopez, A. D., & Murray, C. C. (1998). The global burden of disease. Nat Med, 4(11), 1241-1243.
McLeroy, K. R. et al. (1988). An Ecological Perspective on Health Promotion Programs. Health Education Quarterly, 15(4).
Saveanu, R. V., & Nemeroff, C. B. (2012). Etiology of depression: genetic and environmental factors. Psychiatric Clinics of North America, 35(1), 51-71.