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SW. ST. MP

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1342 ANGELO A. ALONZO

frequently with dangerous consequences for him as a personand for the species in general [4. p. 3491.

Here, Dubos presents us with three ideas of interestto the present discussion.

First, the concept of health is a mirage, as DubosThe Mirage of Health suggests, because of the emerg-ing and changing nature of our environments. Whileevaluative criteria are relative and emergent, we arestill evaluatively concerned with how effectively theindividual functions in his environments of chance orchoice even though a static and stable healthful stateis not possible over the long term.

Second, distress, disease and death are a naturalpart of mans environment. As a consequence of ourconstantly changing environments periods of adapt-ion and maladaption are to be expected. Theseperiods of adaption or health are conditioned by theaspirations and values governing our environmentsand by highly individual requirements and subjective

experiences [4].Third, Dubos refers to both adaption at an individ-

ual and general species level. While some individualsmay abstractly view their adaptive skills as reflectingthe success or failure of harm sapiens it is morereasonable to argue that most individuals view theirday-to-day social situations or environments as theprimary focus of their adaptive efforts. However,variations abound with a minority focusing on thehuman condition as a macro-ecological and per-sonal concern. While Dubos is a member of thisminority, most of us are nearsighted in this regardand a situational approach may prove useful in

grounding the conception of health as a relationshipfor both professionals and laymen.

SOCIAL SITUATIONS AND ADAPTION

If we take seriously the emergent nature of alldimensions of the environment, including man, it iseasily understood why health is a mirage. Yet, weaspire to have health, and cling tenaciously to adapt-ions we have struck despite their possible long-termnonadaptive consequences. Whether we view oursocial situations or environments as immediate orglobal, the individual finds that it is within social

situations that biophysical, psychologic, sociologic,physical and cultural realities and influences intersectand interact. The socially defined situation is a neces-sary condition of human conduct [S] and individualsarc continually constructing and confrontingcmcrgent. engrossing and negotiable situations thatarc socially. physically, psychologically and culturallybounded. Holzner suggests that society appears asa multitude of timed and spaced situations whichdctine the living environments of individuals who are,also. distributed in space and time [6, p. 801.

Conceiving of individuals as situationally distrib-utcd in time and space allows us to consider eachindividual as possessing a set of situations or asituation set where he can be expected to be foundenacting social roles [7]. When one considers thesituational intersection and interaction of environ-mental factors, the adaptiveness of man is bothextraordinary and fragile. We are capable of over-coming seemingly insurmountable physical and emo-

tional consequences of physical trauma. yet we can besocially and psychologically disabled by a sebaceouscyst.

While individuals may have difficulty or experienceproblems in adaption to a single situation or acrossmultiple situations. a broader interpretation of health

as adaption, suggests that the cause or causes of aproblem could be social, psychological. biophysicalor cultural or a combination thereof. Difficultiescould be social in the sense that the individualexperiences alienation from a situation; physicalwhen he cannot tolerate temperature extremes: orcultural when the individual is unable to achieveculturally prescribed physical attractiveness, wealthor religious conviction. In addition. factors relatingto socioeconomic status. political, economic, legaland religious ideology, racial and ethnic prejudice.gender and age discrimination and, of course.medical beliefs and practices. have profound

influences on the nature of social situations and ouradaption to them.

If we consider the possible complexity of socialsituations and the potential for maladaption inherentin each situation, one can appreciate that we areexceptional social psychological actors with the ca-pacity to create, sustain and transform our socialsituations to minimize, if not overcome, maladaption.However, we and our family and friends are not alonein our efforts at adaption. Irrespective of the pre-vailing political and economic ideologies, societygenerally assumes certain responsibilities for publichealth and safety ranging from sewage and air trafficsystems to the promotions of healthy family environ-ments to reduce spouse and child abuse. Nonetheless,efforts to promote societal adaption are not alwaysconsistent; e.g. the promotion of anti-smoking pro-grams may benefit the individual smoker and societyin general, but may harm tobacco growing regions ofa country.

In addition. Dubos argues that we complicate ourbiological adaption by creating human and socialurges and striving that have nothing to do withspecies survival [8, p. 611. McKeown nicely sum-marizes our dilemma when he states that: Our habitscommonly begin as pleasures of which we have noneed and end as necessities in which we have no

pleasure [9, p. 1241. At a more inclusive ecologicallevel Dubos. McKeown and others [3. IO-121 arguethat ill health, social ma/adaption and other patholo-gies, are a product of our own behavior, i.e. themanifest and latent consequence of our social. medi-cal. economic and political organization and culturalquest for general progress. Thus. adaption and, there-fore, health are a relationship to ones social situ-ations that must be continually addressed, with deter-minants of successful or unsuccessful adaptionranging from the individuals psychosocial and bio-physical characteristics to sociocultural reality.

WHO CAN PROMOTE HEALTH

Stone offers a conception of health consistent withour discussion thus far when he states that a moderndefinition of health.. recognizes it as an un-measurable state of a complex, continuously adaptingorganism. Within limits. we can identify changes in

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Health as situational adaption 1343

health that can be associated with the terms better orworse [13, p, 91. The promotion of health thusentails the enhancement of adaption. Yet the complexnature of mans response to his situations may ac-count for many of the difficulties we experience indeveloping methods of prevention and intervention.When we consider the nature of the interactionbetween environmental factors and social, politicaland economic ideologies and their potential impacton physical. social or psychological adaption, it isevident that no single profession is capable ofeffective prevention and intervention.

Though the problems of health and adaption arecomplex, some are still confident that contemporarymedicine can rise to the occasion and solve ourproblems by the application of science and tech-nology. However, medicine is not without its criticswho argue that: medicine is too preoccupied with theprovision of services rather than analyzing factors

conducive to health or adaption [2]; medicine doesnot solve or cure physical and psychological prob-lems, but primarily provides crutches [I I] and half-way technologies [4]; medicine tends to view diseaseas an entity upon which to declare war seeking tosuppress it, crush it with drugs, burn it with lasers andcut it out with surgical tools [2]; medicine cannothandle problems of an advanced society: disordersrelated to stress, to environmental hazzards, to workor to the self-indulgent life styles fostered by powerfulcommercial and social interests [3]; and, generally,medicine focuses too narrowly on fixing a passive,diseased body [151.

HOLISM

An obvious alternative to the medical perspectiveis holism. in which all of the factors noted above thataffect adaption are considered in preventing andovercoming problems in adaption. Holism stressesthe interconnectedness of man and his environmentsand is thus oriented toward overcoming the reduc-tionist emphasis in contemporary medicine [161.While the narrow reductionism of medicine maycontribute to patient dissatisfaction. unmet social andpsychological needs. and an inefficient use of re-sources. holism also has its critics. Guttmacher [3]

notes the following problems: holism has the poten-tial to medicalize life. and to create a therapeutic statewhere social stratification and identity are based onones status as patient or healer: holism does notadequately consider economic and social or-ganization as the cause of individual problems;holism shifts responsibility for health care to theindividual and thus allows those interested in cuttingcosts of social welfare benefits and the medical caresystem to do so without altering their basic struc-tures: the acceptance and impact of holistic conceptsand practices will vary by socioeconomic status. withthe healthiest and the wealthiest being most benefited;and. lastly;. because holism will operate within the

same pohttcal and economic context as contemporarymedicine. it is open to many of the same criticisms ascontemporary medicine.

While holism is consistent with an adaption andecologic approach to health. there is the major prob-lem of medicalization wherein health is viewed as anSS\, ?I ,-,I

end in itself and life is dominated by medical pro-scription and prescription [3]. At one extreme, wehave an all encompassing potentially obtrussive holis-tic approach to health and adaption, which gives usthe fundamental breadth to appreciate ourselves asintrinsically both producer and product of our envi-ronments. At the other, we have a narrowly focused,reductionist approach to health, which is a reflectionof our political, economic. scientific and social ideol-ogies, but does not view itself as responsible for, oreffective in, intervening in the environments of theindividual, or in society to effect a change in healthstatus. Our ideologies regarding the individual, es-pecially laissez faire individualism. would not allowsuch wholesale environmental intervention as wouldbe necessary to affect improved adaption. In Fuchs[I llterms, do we wish a zoo or a jungle regardingthe question of who is responsible for our health andhow much constraint is necessary to protect the

individual from himself.

A SITUATIONAL APPROACH

While we cannot resolve the ideological issues andtheir consequences, we can suggest an approach tohealth that stresses the importance of the socialsituation and the social psychological actor in cre-ating, sustaining and changing his environments. Thesocial situation allows us to ground Dubos [8] andAllands [181 concern for adaption as a long-range,transgenerational process. The social psychologicalactor is oriented toward his everyday situation setand behavior therein. In focusing on the social situ-ation and the social psychological actor in his situ-ation set it is possible to suggest that initial efforts toimprove adaption, if such an evaluative notion ispossible, must begin by sensitizing the individual tothe holistic interconnectedness of their situations toone another and of the factors and dimensions oper-ative and interactive in each sitation of their situationset. More than just health education, individuals canbe made to appreciate the consequences of adaptionand maladaption if grounded within their own situ-ation set. Since life style accounts for the greatestproportion of health problems [9], and life styles areplayed out within social situations, it is reasonable for

the individual and professionals to make situationalassessments. However, in a pluralist society there isalways the problem of deciding what criteria is to beused in assessing anothers situational adaption.What profession has the theoretical and appliedknowledge, legitimacy and authority to intervene inour lives? Social work comes to mind and the recentwork of Coulton [19] suggest that an ecologicalsystems theory approach is feasible, but is the theoryadequately developed to be applied? Medicine cer-tainly has the authority, but not the interest or thephysician manpower. And, as noted above, the tech-nological imperative of specialization has severelylimited the scope of the medical mission.

The problem is to convince medicine and otherdisciplines to focus on and appreciate socially situ-ated man-environment transactions. to preserve theindividuals confidence in his own health while at thesame time assisting him, to encourage individualresponsibility for maintaining health. and to promote

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I344 ANGELO A. ALOE~ZO

an awareness of signs and symptoms that requiremedical attention [9]. Further, the interrelatednessand interdependence of behaviors and environmentsnecessitates the development of a strategic plan forintervention which balances individual and collectiverights and interests, specialization and general com-petence, intervention and nonconcern and pluralismand authoritarianism.

THE BIG PROBLEM

The largest, and by far the most difficult issues tomanage, are those that center around the macroeconomic, political, cultural and structural elementsin our societies. It is not effective to attempt tointervene in the individuals situation set if the eco-nomic interests that have produced hazardous work-ing conditions are intransigent to change. As theecologic orientation suggests, tinkering with onlyone part of the environment is an ineffective meansof achieving adaption and health. The task of under-standing our environments, developing techniquesfor intervention, intervening in our situations, andevaluating those interventions, is a complex anddifficult task which immediately appears un-manageable, but which is a challenging task. The taskmust begin by considering the social situation set ofthe individual, by sensitizing him to the most validand reliable assessment of the interconnectedness andinteractions between situations and behavior, and byproviding the individual with the resources to alterhis situation set. It must be remembered, however,that broader political, economic, cultural and struc-tural changes are also necessary for effective individ-ual adaption, because neither individual nor societaladaption can occur independently.

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