Luther King popularized the notion of the Beloved Community, a term
first coined in the early days of the twentieth century by philosopher-theologian
Josiah Royce.1 Dr King envisioned the Beloved Community as
a society based on justice, equal opportunity, and love of one's fellow
human beings. As explained by The King Center, the memorial institution
founded by Coretta Scott King to further the goals of Martin Luther
King's Beloved Community is a global vision in which all people can
share in the wealth of the earth. In the Beloved Community, poverty,
hunger and homelessness will not be tolerated because international
standards of human decency will not allow it. Racism and all forms
of discrimination, bigotry and prejudice will be replaced by an all-inclusive
spirit of sisterhood and brotherhood."1
The Beloved Community
and the National Health Care Crisis
to a variety of health problems, we have developed highly technological
solutions that, only a short time ago, seemed beyond our ability to
resolve. Artificial joints are routinely placed in our oldest patients;
our fastest-growing group of cardiac catheterization patients are in
their 80s; and last year, I referred two 90-year-old patients for aortic
valve replacement surgery. (Both patients did well postoperatively,
and one even returned to work part-time.)
fixes--often described as "medical miracles"--can, at our
discretion, become routine but are extremely expensive. We as a society
struggle with justifying this high cost. One possible solution to this
quandary is to allow medical care to constitute an ever-increasing percentage
of our gross national product. Another option is to improve our efficiency.
Both remedies have their place. First and foremost, however, just as
cardiac surgery is in many cases prerequisite for restoring healthy
function to a human body, the essential and fundamental components of
the Beloved Community--justice, equal opportunity, nonviolence, and
love of one's fellows--are prerequisites for building a healthy society.
explains how such concepts can help point us in new and exciting directions
that greatly inform the ongoing debate about the current crisis in our
health care industry.
1. Income and mortality rates among white men in the United States.
by permission of the publisher and author from: Wilkinson R. Unhealthy
societies: the afflictions of inequality. London: Routledge; 1996.5
Salutogenesis, the Study
medicine focuses on pathogenesis. Understanding the pathogenic mechanisms
leading to illness
allows us to make monumental advances in preventing and treating disease,
but an exclusive focus on pathogenesis may blind us to other, equally
important areas of study. Israeli researcher Aaron Antonovsky suggested
that we should focus on salutogenesis, the study of wellness and the
factors that promote good health.2 Thus, to better understand
wellness, this article discusses some powerful determinants of health--factors
that are rarely the focus of either our preventive or our therapeutic
Socioeconomic Status and
body of medical literature shows that most diseases have a gradient
of risk that parallels a person's position in the social hierarchy.3
The lower the rank, the higher the risk for morbidity and mortality.
This association holds for most chronic illnesses, including coronary
artery disease, hypertension, diabetes mellitus, and heart failure.
The association is weaker (but present nonetheless) for many types of
respiratory disease and cancers.
from the Multiple Risk Factor Intervention Trial (MRFIT) study on cardiovascular
mortality4 illustrates this gradient-of-risk effect (Figure
1).5 Some argue that the gradient is a result of differences
in access to health care. However, in the United Kingdom, where everyone
has access to the National Health Service, the gradient for cardiovascular
mortality is not only present but steep (Figure 2).6 Studies
of British civil servants living in the Whitehall section of London
showed that most of the excess mortality does not result from the risk
factors (smoking, hypertension, diabetes, and cholesterol) usually targeted
in our prevention efforts.6 Smoking and hypertension are
more common among people with the fewest economic resources. The Whitehall
investigators proposed that most of the excess mortality is the pathophysiologic
consequence of excessive psychosocial stress--stress such as that produced
by having relatively low income.6 Evidence supporting this
stress hypothesis can be found both in human and in animal studies.
Only a few of these studies are reviewed here.
Psychosocial Stress; East-West
study7-9 attempted to explain the differences of cardiovascular
risk in Swedish and Lithuanian men. In 1978, Lithuanian men had similar
rates of cardiovascular mortality as Swedish men but by 1994 had rates
of cardiovascular death four times higher. This phenomenon was attributed
to improved health in the Swedish population as well as generally deteriorated
health among the Lithuanian population. Conventional risk factors did
not explain the differences in population health between the two countries.
Kristenson et al7 found that the Lithuanian men reported
more social isolation, job-related strain, and depression than did the
Swedish men, a result suggesting that the increased rate of cardiovascular
death among the Lithuanian men was socially determined.
study, men from each country first had basal cortisol levels measured
and then were subjected to experimental stress consisting of mental
arithmetic testing, anger recall, and immersion of one hand in ice water.8
The cortisol response to stress was measured for each group (Figure
3)10 (see also references 8, 9, 11) and showed that both
the low- and high-income Swedish men had a normal stress response: Low
basal cortisol levels (before application of experimental stress) rose
and fell in response to stress.9 In contrast, the Lithuanian
men showed a highly abnormal stress response: The most prosperous Lithuanians
had low basal cortisol levels and a blunted stress response, whereas
the low-income Lithuanians had extremely high basal cortisol levels
and completely failed to mount a normal stress response.9
This study, if replicated, could thus show how presumed social stress
can have a devastating effect on normal physiologic functioning.
2. Relative risk of death from coronary heart disease according
to employment grade, and proportion of differences that can be
explained statistically by various risk factors. Note: "others"
= height, body mass, exercise, glucose tolerance.
by permission of the publisher, BJM Publishing Group, and author
from: Rose G, Marmot M. Social class and coronary heart disease.
Br Heart J 1981 Jan;45(1):13-9.6
of a normal stress response in these low-income Lithuanian men brings
to mind the learned helplessness that occurs in experimental animals
repeatedly subjected to uncontrollable, unpredictable stressors. This
learned helplessness response may help us understand depression in humans.
Psychosocial Stress; Animal
University neurobiologist-primatologist Robert Sapolsky, who has been
studying wild baboons in Kenya for more than 20 years, showed that basal
cortisol levels were higher in male subordinate baboons than in their
dominant male counterparts. The subordinate baboons also had lower levels
of high-density lipoprotein (HDL) cholesterol and a less-robust cardiovascular
response to infusion of epinephrine.12,13
experimentally altered the dominance patterns exhibited by captive macaque
monkeys, all of whom were fed an atherogenic diet.14 All
monkeys with altered status showed increased atherogenic plaque formation.
Compared with monkeys who remained subordinate, monkeys who began as
subordinate but became dominant by experimental design had a 44% increase
in atherogenic plaque formation.14 Compared with monkeys
who remained dominant, monkeys who began as dominant but became subordinate
had more than six times the amount of atherogenic plaque formation,
suggesting that social incongruity may in itself be stressful.14
Shively and coworkers also showed that without any manipulation of dominance
status, dominant monkeys had much less atherosclerosis than did subordinate
monkeys and that injection of acetylcholine caused abnormal coronary
vasoconstriction in subordinate monkeys but not in dominant monkeys.15
Social Cohesion and Mortality
Studies showed that socioeconomic status is a more powerful predictor
of health outcome than are the risk factors we currently ad
dress.6 The study of East-West mortality differences7-11
and the animal studies12-15 mentioned here suggest that lower
social rank and social disruption are not only stressful but are accompanied
by neurohormonal pathophysiology. To explore the factors contributing
to the health of a community, researchers have begun to study social
cohesion, ie, the extent to which members of a community form mutually
beneficial social ties.
of the relation between social cohesion and health outcome has shown
a close relation between civic trust and the rate of mortality from
all causes16 (Figure 4).17 The lower the level
of trust between individuals in a given US state, the higher the rate
of mortality from all causes. A similar relation exists between mortality
rates and participation in voluntary organizations. Life expectancy
is longest in US states whose populations participate the most in voluntary
societies may have no better predictor of health outcome than degree
of income equality. Once a country has progressed beyond the epidemiologic
transition point where chronic disease replaces infectious disease as
the leading cause of death, life expectancy correlates more with income
equality than with GNP. 5 In Greece, which has a lower GNP
than does the United States, life expectancy is longer than in the United
States.5 Life expectancy is highest in Sweden and Japan,
the countries with the greatest income equality.5
is seen also in US states. States with the greatest income equality
have the longest life expectancy as well as the fewest homicides.18
Perhaps income equality is such a powerful health determinant
largely because of our long evolutionary history of living in relatively
egalitarian social groupings.5 We do not appear to be well
suited physiologically for great differences in status. The stress of
having unequal status appears to be mediated psychologically. The least
prosperous group in the Whitehall Study, for example, although having
four times higher cardiovascular death risk than in the wealthiest group,
were not poor in any real material sense. They all lived in homes and
owned cars and television sets.6
3. Serum cortisol responses to a standardized stress test among
study populations in Vilnius, Lithuania, and Linköping, Sweden,
by income group. Low income: group with lowest 25% of income.
High income: group with highest 25% of income.
with permission from the publisher, editor, and author from Figure
2.10 in Brunner E, Marmot M. Social organization, stress, and
health, published in: Marmot M, Wilkinson RG, editors. Social
determinants of health. Oxford (England): Oxford University Press;
1999,10 and adapted from: Kristenson M. Possible causes
of the differences in coronary heart disease mortality between
Lithuania and Sweden: the LiVicordia Study [dissertation]. Linköping,
Sweden: Linköping University; 1998.11 (See also
references 8, 9.)
research on primates19 has suggested that primates who hunt
cooperatively (humans would be included in this category) are "hardwired"
for fairness. A recent study in humans shows that our pain center in
the anterior cingulate cortex is aroused when we feel socially excluded.20
Perhaps we become vulnerable to illness when our physiologic "hardwiring"
for fairness and inclusion is repeatedly contradicted by our social
experience. Fairness and inclusiveness are essential elements of the
Beloved Community Medicine
suggested that salutogenesis is a fruitful area for us to explore. Because
the studies cited here suggest that human health is largely determined
by social factors, understanding these factors and developing health-promoting
strategies seem necessary for addressing today's health care crisis.
How can Kawachi's insights on trust and civic participation16
be incorporated into our practice? Should we prescribe community service
and performance of good deeds as therapy ("mitzvah therapy")
the way some of us have begun prescribing physical activity? What would
be the effect of one million Northern California Kaiser Permanente members
doing weekly good deeds in their communities with our encouragement
and medical sanction? Can we form respectful partnerships with community
groups to help make this a reality?
linking income equality and health may be the most difficult of all
to acknowledge and assimilate. Can these data stimulate us to consider
how our purchasing, hiring, and investing decisions can help build the
local economies of the communities we serve? Can we adopt salary policies
that will be a national model for how a multitiered corporation can
reward all its employees fairly? Given that income inequality often
leads to abuses of rank, can we be a model corporation that consistently
treats all our staff and Health Plan members with dignity and respect?21,22
in population medicine requires us to broaden our perspective from preoccupation
with individual patients to awareness of entire populations. Salutogenesis
requires us to expand our awareness past community medicine to Beloved
Community medicine. Embracing these ideas will lead to creative initiatives
for addressing the social determinants of health and thus improving
health for everyone while limiting the use of expensive allopathic medication
and surgery. If we implement this new approach to medical practice,
perhaps we will fulfill Dr King's vision of the Beloved Community. In
Dr King's own words:
the end is reconciliation; the end is redemption; the end is the creation
of the Beloved Community. It is this type of spirit and this type of
love that can transform opposers into friends. It is this type of understanding
good will that will transform the deep gloom of the old age into the
exuberant gladness of new age. It is this love which will bring about
miracles in the hearts of men."1
Percentage responding: "Most people would try to take
advantage of you if they got the chance."
4. State-level correlation of mistrust with age-adjusted mortality
by permission of the publisher (Copyright American Public Health
Association) and author from: Kawachi I, Kennedy BP, Lochner K,
Prothrow-Stith D. Social capital, income inequality, and mortality.
Am J Pub Health 1997 Sep;87(9):1491-8.17
E Adler, PhD, University of California at San Francisco; Robert M Sapolsky,
PhD, Stanford University School of Medicine; S Leonard Syme, PhD, Professor
Emeritus, School of Public Health, University of California, Berkeley;
Deborah Rangel, MS, Kaiser Permanente Medical Center, Richmond, California;
and Vivien M Feyer, EdM, CAS, all reviewed the manuscript. I am grateful
to Dr Sapolsky for acquainting me with the work of Aaron Antonovsky
of the "well-being" movement.
King Center. The Beloved Community. Welcome to The Beloved Community
[Web page]. Available from: www.thekingcenter.org/prog/bc/index.html
(accessed October 13, 2003).
A. A sociological critique of the "well-being" movement.
Advances: The Journal of Mind-Body Health 1994 Summer;10(3):6-44.
NE, Boyce T, Chesney MA, et al. Socioeconomic status and health. The
challenge of the gradient. Am Psychol 1994 Jan;49(1):15-24.
GD, Neaton JD, Wentworth D, Stamler R, Stamler J. Socioeconomic differentials
in mortality risk among men screened for the Multiple Risk Factor
Intervention Trial: I. White men. Am J Public Health 1996 Apr;86(4):486-96.
G, Marmot MG. Social class and coronary heart disease. Br Heart J
R. Unhealthy societies: the afflictions of inequality. London:
M, Kucinskienë Z, Bergdahl B, Calkauskas H, Urmonas V, Orth-Gomer
K. Increased psychosocial strain in Lithuanian versus Swedish men:
the LiVicordia study. Psychosom Med 1998 May-Jun;60(3):277-82.
M, Orth-Gomer K, Kucinskeinë Z, et al. Attenuated cortisol response
to a standardized test in Lithuanian versus Swedish men: the LiVicordia
study. Int J Behav Med 1998;5(1):17-30.
M, Kucinskienë Z, Bergdahl B, Orth-Gomer K. Risk factors for
coronary heart disease in difference socioeconomic groups of Lithuanian
and Swedish men--the LiVircordia study. Scand J Public Health 2001
E, Marmot M. Social organization, stress, and health. In: Marmot M,
Wilkinson RG, editors. Social determinants of health. Oxford (England):
Oxford University Press; 1999. p 17-43.
M. Possible causes for the differences in coronary heart disease mortality
between Lithuania and Sweden: the LiVicordia Study [dissertation].
Linköping, Sweden: Linköping University; 1998.
RM, Mott GE. Social subordinance in wild baboons is associated with
suppressed high density lipoprotein-cholesterol concentrations: the
possible role of chronic social stress. Endocrinology 1987 Nov;121(5):1605-10.
RM, Share LJ. Rank-related differences in cardiovascular function
among wild baboons: role of sensitivity to glucocorticoids. Am J
of Primatology 1994;32:261-75.
CA, Clarkson TB. Social status and coronary artery atherosclerosis
in female monkeys. Arterioscler Thromb 1994 May;14(5):721-6.
JK, Shively CA, Clarkson TB. Determinants of coronary artery reactivity
in premenopausal female cynomolgus monkeys with diet-induced atherosclerosis.
Circulation 1994 Aug;90(2):983-7.
I. Social cohesion and health. In: Tarlov AR, St Peter RF, editors.
The society and population health reader. Volume II, A state and community
perspective. New York: New Press; 1999. p 57-74.
I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income
inequality, and mortality. Am J Pub Health 1997 Sep;87(9):1491-8.
I. Long live community: social capital as public health. The American
Prospect 1997 Nov 1-Dec 1;8(35). Available from: www.prospect.org/print-friendly/V8/35/kawachi-i.html
(accessed April 23, 2003).
SF, De Waal FB. Monkeys reject unequal pay. Nature 2003 Sep 18;425(6955):297-9.
NI, Lieberman MD, Williams KD. Does rejection hurt? An fMRI study
of social exclusion. Science 2003 Oct 10;302(5643):290-2.
RW. Somebodies and nobodies: overcoming the abuse of rank. Gabriola
Island (British Columbia): New Society Publishers; 2003.
R. The power of partnership; seven relationships that will change
your life. Novato, California: New World Library; 2002.
B Ritterman, MD
is Assistant Chief, Department of Medicine
at KP Richmond. E-mail: firstname.lastname@example.org;
or on the Web at:
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