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Shambhala Sun | November 2002

The Community Cure

"Social and cultural factors impact our health profoundly, both positively and negatively."

It always seems to come down to who you know. The people we grew up with, have in our lives now, and will grow old with have a huge effect on our well-being and even our risk of future disease. Community is where we assimilate family and cultural health beliefs, attitudes and behaviors. Community also encompasses neighborhoods and attendant social factors such as the degree of violent crime, unemployment and access to health-care services. All these components blend to impact our health profoundly, both positively and negatively.

Sometimes it's easy to see these social effects on a person's life. While attending a medical conference recently I stayed at the San Francisco Zen Center and was approached by a vaguely familiar smiling face. Aside from the shaven head, the reason I didn't recognize my old patient immediately was because he looked so happy. I had last seen him seven years before when I had driven him to the ER late at night in response to a bleak and desperate suicidal telephone call. Some of the key factors that contributed to his depression came from his social environment. In talking with him in San Francisco it struck me that, although he had accomplished a lot of personal psychological progress, some factors in his long-term recovery were strongly social as well. Once he was feeling a bit stronger, he had made the wise decision to become part of a Zen community that was both caring and supportive. Zen training is arduous and demands a certain psychological hardiness but also provides crucial feelings of belonging, purpose, spiritual solace, inspiration and an abundance of ready sympathetic ears.

Current research confirms for us that isolation, the antithesis of support, is a powerful risk factor for disease and early death. Although not commonly accounted for in routine medical practice, the effects of isolation have been addressed by compassionate and informed public figures: Mother Teresa commented that "loneliness is like the leprosy of the West," when she talked about the pain of isolation in modern society. Dr. Dean Ornish, an eminent spokesperson for lifestyle modification and wellness, concludes that social support is one of the most powerful health influences we know of.

But social impacts on health go beyond support and isolation. We get powerful health beliefs from our culture and these can have huge effects on our well-being. A recent study showed that elderly Chinese are more likely to die on what they view as "unlucky" numbered days. Another study showed that Jews are less likely to die just before or on religious holidays.

Culture also affects how we express disease and distress. As a clinician I know that within some cultures I really have to probe to find out how sick a patient really is, whereas within other cultures I can hear the distress as soon as I'm through the doors of the ER. If cross-cultural nuances are not appreciated, an important diagnosis may be missed initially, which can negatively affect treatment outcomes.

This "socialization of symptoms" applies equally to gender-- specifically how men and women express symptoms of the same disease. Women with heart attacks may present different symptoms than the classic chest pain that most men complain of. Older women especially may present as vaguely "not well" or with diffuse abdominal pain. Some overly stoic men may have undiagnosed heart attacks because they deny the chest pain and attribute their experience to gas.

Socioeconomic factors are also important. If you are born into poverty in North America you are more likely to smoke, exercise less, be overweight and eat poorly (so choose your incarnation well). These habits in turn give rise to the plethora of lifestyle-influenced diseases, including heart attacks, strokes, diabetes and some cancers. Folks living in poverty are also more likely to die a violent death, have restricted access to medical care, or experience clinical depression. Improving lifestyle habits will reduce some of the risk for chronic disease, regardless of socioeconomic status. However, without accessible public health, many marginalized people have little chance of changing their lifestyle. They are just focused on getting by day to day.

Personal interactions within a family of origin are probably the most enduring social factors in health. In that environment, one is exposed to multiple positive or negative developmental factors. Our parents and siblings are usually a source of love and support, but for those people whose family life unfortunately went seriously wrong in childhood, the fallout can be long lasting. Experiences of sexual abuse, physical abuse or neglect are risk factors for later depression, chronic pain and disability. These past factors can be explored and addressed, but it's uncommon for them to be identified as contributing factors to current medical conditions.

Work is a social environment in which many of us spend about one-third or more of our waking time. Twenty-five per cent of workers identify the workplace as a stressor due to conflicts, high demands or little control. If long-standing and severe, these factors may lead to psychiatric illness such as depression. Some preliminary research shows an association with heart disease in some particularly stressful jobs, but the flip side is also true: The positive aspects of work may contribute to an overall feeling of well-being. Involuntary unemployment is associated with depression and prolonged disability.

If we push the limits of our definition of social support we can include unseen beings. Some people feel incredibly supported by an invisible community of spirits, devas, ancestors or angels. They feel a tangible presence in their lives or feel connected to these spiritual entities, often by prayer or ritual. In essence they never feel alone. Research shows that folks with a regular spiritual practice tend to be happier and healthier, perhaps in part because of this sense of connectedness.

There is much more to wellness than nutrition and exercise. Value your friendships and family and stay connected to the positive aspects of your community. If you have heavy past emotional wounds, acknowledge their potential effects and look to heal or grow beyond their limits. We often need help to do this. If you are comfortable believing in unseen beings, ask for guidance and support. Examine your social environment critically. Is it nurturing or unhealthy? My Zen patient is a case in point. Make wise choices like him. Wendell Berry put it nicely when he said, "The smallest unit of health is a community."

Chris Stewart-Patterson, M.D., is assistant professor of medicine at the University of British Columbia and an emergency department physician at an inner city hospital in Vancouver.

The Community Cure, Chris Stewart-Patterson, M.D., Shambhala Sun, November 2002.

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