A SALUTOGENIC VIEW OF HIVAIDS 14 May 2003

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A SALUTOGENIC VIEW OF HIV/AIDS14 May 2003

• The Very Rev. Drew A. Kovach, M.D., M.Div.
• Director of HIV Services
• Hawaii Permanente Medical Group, Inc.
• dkovach_at_hawaii.rr.com
• [phone]

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WHO I AM WHAT I DO

• 30 years a Family Practice Physician
• Medical School Faculty and Residency Director
• Solo Private practice primarily gay and lesbian
  medicine and HIV
• FP in a multi-specialty group specializing in HIV
  medicine
• 27 years an ordained priest
• A man taking care of people living with HIV for
  over 20 years with a multi-level view of health,
  wholeness and wellness

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CONCEPTS WHOLENESS WELLNESS

• Whole people
• Body
• Mind
• Spirit
• Whole lives
• Levels of Healing
• Life being livable and enjoyable not just being
  alive
• A good life

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We see the world not as it is,
but as we are.
H.M.
Tomlinson
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HIV/AIDS

• The most comprehensive chronic disease
• Impacts all aspects of a persons life
• Social
• Economic
• Physical
• Emotional
• Spiritual
• With an uncertain future

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HOLISTIC APPROACH

• Mind, Body, Spirit The trinity of man
• 3 Spheres
• Dis-ease, in any one affects the other two
• Managing whole people to make people whole

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"The willingness to take risks is our grasp of
faith." George Woodberry
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OBSERVATIONS

• Similar patients with HIV
• Same age
• Same duration of illness
• Same stage of disease
• Similar support systems
• Similar medications/side effects
• Very different quality of life

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OBSERVATIONS OF SURVIVORS

• Accepted reality of diagnosis but refused to see
  the condition as a death sentence at least not
  an imminent one
• Have a great deal they want to do unfinished
  business
• Tend to have a sense of meaning and purpose and
  finding a new meaning as a result of the disease

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OBSERVATIONS OF SURVIVORS

• Have a spiritual sense of feeling of something
  beyond the self
• Take personal responsibility for and believe they
  can influence their health
• Are assertive, have the ability to say NO and
  can withdraw from involvements and nurture
  themselves

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OBSERVATIONS OF SURVIVORS

• Acceptance of who they are and the lack the
  perception of disease as punishment

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"Most of the shadows of this life are caused by
standing in one's own sunshine." Ralph Waldo
Emerson
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REPRESENTATIONS OF HIV/AIDS

• As a catalyst for personal growth
• As a catalyst for spiritual growth
• As belonging
• As relief
• As strategy

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REPRESENTATIONS OF HIV/AIDS

• As confirmation of powerlessness
• As isolation
• As irreparable loss
• As punishment
• As contamination

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"You cannot do a kindness too soon, for you
never know how soon it will be too late. "
Ralph Waldo Emerson
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SURVIVOR THEMES

• Death imprint
• An indelible image of death that becomes lodged
  in the imagination, specific to the nature of the
  particular disease
• Survivor guilt
• The question Why did I survive while he, she or
  they died? Guilt stemming from the randomness
  of the situation, that fact that survival or
  death may be largely a matter of caprice, fate or
  luck

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SURVIVOR THEMES

• Psychic numbing
• The survivors diminished capacity to feel.
  While the numbing may be adaptive in the
  emotional overload of illness, it can also lead
  to long term adverse effects such as withdrawal,
  depression, despair and feeling numb or dead
  inside.

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SURVIVOR THEMES

• Suspicion of counterfeit nurturance
• Distrust of the genuineness of help or concern
  that is offered. Trust in a benign or benevolent
  world has been sorely tested. The reality of the
  illness overrides any comfort that things will
  be OK.
• Struggle for meaning
• Arises because of how massive death experiences
  grossly contradict many of the rules by which
  persons had previously guided their lives

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"We make a living by what we get. We make a life
by what we give" Winston Churchill
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VISIBLE CLUES OF TRANSFORMATION

• Empowerment based on self acceptance
• Willing ownership of the power and responsibility
  to shape the meaning of illness in our lives
• Shifting priorities from ones prior life
• Increased altruistic behavior and contribution to
  ones communities

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VISIBLE CLUES OF TRANSFORMATION

• Willingness to take action and tackle the work of
  the healing process
• Managing and leading your health care team
• Assessing individual needs and designing a
  tailored healing program
• Learning/practicing self-care activities and
  healing techniques
• Engaging in release work
• Focusing on self and clarifying mission and
  vision for the future
• Opening oneself to higher energies and power

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VISIBLE CLUES OF TRANSFORMATION

• Embracing the truth and contradiction of both
  light and shadow, of joy and sorrow
• Increased focus on now and the present

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"Everything you need you already have." Wayne
Dyer
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WHAT IS HEALTH?

• A natural given that is continuously threatened
  by a host of risk factors?
• Bacteria Viruses
• Injury
• Malignancy
• Stress
• Environmental factors
• Worn out organ systems

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HEALTH

• If we avoid the risk factors and change our
  behavior will we be healthy?
• Is health just the absence of disease?
• Can people be healthy in spite of injury and
  disease?

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MODELS OF HEALTH

• Pathogenesis
• the development of morbid conditions or of
  disease more specifically the cellular events
  and reactions and other pathologic mechanisms
  occurring in the development of disease.

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MODELS OF HEALTH

• Salutogenesis
• Latin salus health
• The origin of health
• Why people stay healthy
• Instead of why people get sick

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STATE OF HEALTH

• A complete state of physical, mental and social
  well-being and not merely the absence of disease
  or infirmity. (WHO, 1947)

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"The purpose of learning is growth, and our
minds, unlike our bodies, can continue growing
as we continue to live." Mortimer J. Adler
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Aaron Antonovsky A Salutogenic Perspective
Toward a New View of Health and Illness1979

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HEALTH APPROACHES

• Pathogenic Traditional and Predominant
• Seeks to explain why people get sick and why they
  enter a given disease category (Officially
  Diseased)
• Salutogenic Proposed antithesis
• Focuses on the origins of health and poses a
  radically different question Why are people
  healthy?

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ANTONOVSKYS SENSE OF COHERENCE

• Belief that life is comprehensible
• Belief that life is manageable
• Belief that life is meaningful

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WHY IS SALUTOGENIC DIFFERENT?

• Differences in Salutogenic Research
• Look at data differently
• What is in the data we look at?
• Ask different questions
• Why are these people well?
• Suggest alternative hypothesis
• Eating complex carbohydrates will yield greater
  endurance with to activity or hunger cravings
• Eating saturated fat will lead to a higher
  incidence of cancer

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FUNDAMENTAL DIFFERENCE

• We learn from disease cases, are they the
  majority?
• 10-15 of population clinically ill
• Homeostasis foundation of pathogenesis
• Heterostasis foundation of salutogenesis

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DO WE NEED PATHOLOGY?

• What do you think?
• I say absolutelybut we need both
• We must understand more than what leads to
  illness or disease if our objective is health
• Are these approaches in competition?
• Can and should we use both?

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WHO STAYS WELL WHY?
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"The greatest discovery of my generation is that
human beings can alter their lives by altering
their attitudes of mind." William James
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MIND AND BRAIN AS ONE?

• Neuroscience rests on the premise that a
  complete knowledge of the workings of the brain
  can provide a complete knowledge of human
  behaviors, thoughts and feelings both in sickness
  and in health.

Damasio et al. 2000 Nat. Neurosci.
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KEYS TO HEALTH

• A SALUTOGENIC
• APPROACH

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"Those who wish to sing always find a
song." Swedish proverb
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HARDINESS

• Control
• Persons belief that he or she is able to
  influence the course of events
• Commitment
• Persons curiosity about the sense and
  meaningfulness of life
• Challenge
• Persons expectation that it is normal
  beneficial for life to change

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COPING

• Everyone appraises situations in a different way
• Those appraisals are decisive if a particular
  situation is stressful or not
• Pathogenic appraisal
• Salutogenic appraisal

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SOCIAL SUPPORT

• Cared for
• Loved
• Esteemed
• Valued
• Belonging to a network of communication and
  mutual obligation

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RELIGION

• Concept of God
• Meaningfulness of life
• Sense of belonging
• Strengthening sense of coherence
• Being protected from harm
• Thorndikes Law of Effect

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OTHER FACTORS

• Happiness
• Humor
• Love

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"To live a creative life, we must lose our fear
of being wrong." Joseph Chilton Pearce
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PSYCHOLOGICAL STRENGTHS

• New directions for capacity building
• The prevention of damage to the quality of live
  of the individual
• The enhancement of the quality of life of the
  individual
• In their private and work lives

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SALUTOGENIC FORTIGENIC FUNCTIONING

• Sense of coherence
• Locus of control
• Self-efficacy
• Hardiness
• Potency
• Learned resourcefulness

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"You may have a fresh start any moment you
choose, for this thing that we call failure is
not the falling down, but the laying down."
Mary Pickford
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MAINTENANCE ENHANCEMENT OF PSYCHOLOGICAL HEALTH

• Constructive thinking
• Satisfaction with life
• Emotional intelligence
• Reality orientation
• Self-actualization
• Resilience
• Toughness

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MAINTENANCE ENHANCEMENT OF PSYCHOLOGICAL HEALTH

• Coping
• Social Support
• Dispositional optimism
• Personal causation
• Self-directedness
• Social interest
• Sense of humor

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THE PARABLE OF THE THREE STONECUTTERS
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When live loses its meaningit loses its soul
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MEANING OF ILLNESS

• Cultural context
• Comprehensibility
• What does it serve?
• Are you living with the disease or are you the
  disease?
• Do you lessen the pain or are you the pain?

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BENEFIT FINDING

• Some benefit of illness to find new meaning in
  life or to learn something?
• How do you express pain? Hot or cold reactive?
• How fast does time go for you?
• Sometimes the purpose of pain is to initiate
  prayer not always to praying to decrease pain

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THE STORY OF THE DESERT BIRDS
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WISDOM FROM CULTURE

• Pain and fear
• Pleasure and joy
• Light and shadow
• All are essential

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"No one is useless in this world who lightens
the burden of it to anyone else." Charles
Dickens
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NEW ILLNESS PARADIGM

• Flight or Fight
• Tend Befriend
• Forgive accept forgiveness

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GOOD MOOD

• Modulates stress
• Lessens pain
• Decreases side effects

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"One who hates another digs two
graves. Anonymous
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THE POWER OF WORDS

• O ke oleo no ke ola
• O ke oleo no ka maka
• Words give life
• Words give death

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"Forgiveness is the fragrance the violet sheds
on the heel that has crushed it." Mark Twain
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FORGIVENESS

• Easy to say
• Hard to do
• Forgive others
• Forgive ourselves

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ROCK VS. WATER LOGIC

• 1 rock 1 rock 2 rocks
• 1 water 1 water more water

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HAWAII

• HA Breath
• WAI Water
• I Spirit
• COME TO LIFE IN HAWAII

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LIFE

• Love gives life
• Life gives love
• Live fully in the minute through the joy and the
  pain

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LIFE

• Whatever you dream
• DARE TO DO IT
• Whatever it takes
• DO IT
• Just say yes
• AND ENJOY THE JOURNEY

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