Health and the built environment – shared problems and shared spaces

Inspired by some of your comments on last week’s post about architecture and anti-depressants, this week I want to pass along another interesting nugget I stumbled across in my research about the role architecture plays in health.

Designing Healthy Communities is a project aimed at rethinking the role that the “built environment” has on key public health problems: not only depression but also heart disease, asthma and cancer. Dr. Richard Jackson, a leading physician who helped establish the California Birth Defects Monitoring Program and led 15 years of work at the Center for Disease Control on environmental causes of disease, argues that the way we design our environments has important consequences for our health.

Suburban sprawl, for example, prevents us from being able to easily walk or bike to the places we need to go; our dependence on cars to get around makes us more sedentary, which increases our risks for heart disease and other illnesses, and adds pollutants and toxins into the air we breathe, contributing to our development of chronic diseases like asthma and cancer. Because of this, cities like Denver are designing new live/work areas (like this one in Belmar) that make it easy for inhabitants to get around on foot or bike.

On the other hand, not having enough open areas in dense urban spaces prevents children from being able to play safely, away from moving vehicles – also encouraging sedentary lifestyles during key developmental stages – and minimizes access to fresh produce by not providing spaces for people to grow their own fruits, vegetables, and herbs. Preserving spaces for community gardens, as they have been doing in New York City, is one way to improve people’s access to these products.

Philosophically, this project is interesting for several reasons. First of all, it suggests once again that health is not something that we can isolate to a single cause. Certainly cancerous cells are a cause of cancer – but so might be where and how you live. But more  importantly, this project is a powerful reminder that health and disease quite simply cannot be tackled at an individual level. Finding solutions and cures to chronic diseases like heart disease, cancer, and asthma will not happen if we continue to focus on individual bodies as the “site” of illness or health. The causes of disease and their remedies will only become clear if we zoom out our focus on the problem to include not only the person but our environment as a whole, including the environment that we design and build to sustain and support our living.

This makes health a collective issue. Collective issues are tricky. They require cooperation, collaboration, dare I even say – consensus.

Many of us are accustomed to thinking of health as something we can pursue, choose, and foster individually. Academics in particular (including philosophers like Foucault and Deleuze and Guattari) have struggled long and hard to critique the normative and exclusionary definitions of health that tend to problematize individual differences. Western approaches to health, although they do promote a general norm that applies indifferently to all, encourage us to think of health as something that we can achieve through individual effort – if we just have the right exercise regimen, eat the right foods, take the right pills, or take ourselves to the right doctor for the right tests and treatments.

It is important to retain space for individual differences, preferences, and choice in defining and pursuing health. But much is at stake in this parsing out of where and to whom health belongs. We cannot solve the kinds of chronic and widespread problems we are facing if we do not also think about health as something that we choose and pursue together. We share our living environments and we (often unequally) share the effects that these have on our bodies. We can only promote health if we are willing to rethink some of the ways we have chosen to organize our lives together.

Why don’t we start by thinking about what kinds of living arrangements make for both healthy individuals and healthy communities?

(Note: there is a four-hour film series on Designing Healthy Communities that will be showing on PBS this spring; it’s also posted on the website. Check it out!)

Is it all in the brain? Depression and Relationality

If you have read my about page, you’ll know by now that I am currently doing research for my dissertation, which is on the “substance of health.” I want to learn more about the features of living bodies that are relevant to defining health, and how we can allow them to constrain our definitions of health in ways that help us more effectively promote health through medical practice and public policy.  This sounds pretty abstract to your average reader, even to fellow philosophers, so my advisor suggested I scan the news for anecdotes and issues that will help me frame and explain the theoretical issues I am trying to write about.

So, every day as part of my research, I spend a few minutes scanning various medical news sites. Most of them are generally what I would call mainstream Western (‘allopathic’) medical institutions – the NIH website, U.S. governmental news about medical advances and studies, the New York Times and the BBC Health sections. I’ll be honest; personal experience, as well as research into other kinds of ‘non-allopathic’ medicines, have convinced me that mainstream Western medicine has some theoretical weaknesses in terms of how it construes the human body’s structure and function. That’s what interests me in this topic. Although I’m mostly interesting in highlighting these weaknesses, it’s illuminating to make comparisons with other ways of thinking about health and bodies. So I also like to spend a little time looking at medical news from a more holistic perspective. One source for such news is Dr. Andrew Weil, who runs a Center for Integrative Medicine at the University of Arizona. He also has a blog for promoting holistic health.

Yesterday I came across this video on his blog, in which Dr. Weil talks about the “modern contributors to depression”:

If you take a moment to watch it (it’s very short), you’ll see that he mostly discusses social factors – in particular, social isolation brought about by changes in architecture and the modes of life encouraged by modern “conveniences.” Basically, a cause of depression might be that you are just too physically removed from other human beings to create and sustain meaningful relationships with them.

I found this interesting. I’m no expert on depression, so I did a quick search to see if the mainstream approach to depression acknowledges something like social isolation as a cause, or how both social isolation and depression might be causally linked to the physical arrangements of our lives.

Judging from the National Institute of Mental Health, the Mayo Clinic, and the New York Times Health Guide Overview‘s literature on (major) depression, depression is understood to be a brain disorder. A variety of factors can be involved, including genetic differences and inherited traits, hormones, chemicals in the brain called neurotransmitters, life trauma or stressful events. Needles to say, architecture and modern conveniences didn’t make the cut. The only one of these three sources to mention social factors – in this case. social isolation associated with the elderly – was actually the New York Times Guide (which appears to be a medically reviewed and surprisingly thorough source of information), although the NIMH does point out that both “environmental” and “psychological” causes may be in play, in addition to biological and genetic causes.

I just have to ask: Why conclude, then, that depression is a disorder of the brain, if all of these factors are at play? I really don’t get it.

If the causality can be as varied and as multi-faceted as psychology, environment, genes, life events, stress, and even social isolation (not to mention architecture, if we grant Dr. Weil’s point), why focus solely on the brain as the location of the problem? (I’m guessing this is because there has been some success treating depression through psychopharmaceuticals that aim at changing the chemistry of the brain. Yet psychotherapy is the other generally accepted therapy for depression. Does it also change the brain? Or does it only target the mind? Perhaps these are simply two ways to think of what controls our organism – on a material model, the brain, on a more humanistic model, the mind.)

Elizabeth Wilson, a professor of Women’s Studies at Emory University who holds a Ph.D. in pyschology, has written some really interesting work on neuroscience and biology. This week I have been reading an essay she wrote called “Organic Empathy: Feminism, Psychopharmaceuticals and the Embodiment of Depression” (in this interesting anthology of work on “material feminism”, which I am also writing about). She highlights some data that might disrupt the theory that depression is a disease of the brain: namely, that anti-depressants affect a lot more of the body than just the brain.

She points out that all of the new (SSRI and SNRI) anti-depressant medications are administered orally. This means that, despite widespread attention on their effects on the brain, before ever reaching the brain, they are processed in the body through the GI  (gastrointestinal) tract. The gut is also rich with nerves, and digestive difficulties (including lack of appetite and overeating) are commonly thought to be among the symptoms of depression. Not only this, but the pathway from gut to the brain is indirect and circuitous. One might even say ubiquitous. To get to the brain, as Wilson describes it, a drug like this passes through the mucus in the gut, into the bloodstream, through the liver where some of it is enzymatically removed, and then into general fluid circulation in the body, in  and between cells and organs, including not only the brain, but also the liver, the kidney, the viscera, the skin, and the fat. Why, then, she says, “might we not wonder about antidepressant effects at these other sites” (380)?

I think this is a fascinating question, but she goes much further. She points out that the brain is not isolated and autonomous, as it is often imagined to be. Despite common descriptions of the blood-brain barrier as something that isolates the brain from the rest of the body, pharmaceutical research actually shows that this barrier functions as a system of communication between the brain and other organs and body systems. The synthesis of serotonin in the brain, the process which is transformed by new antidepressants, is a process that happens in “ongoing commerce” with the gut and the rest of the circulatory system described above. Depression, then, ought to be thought of as a disordered relation among organs (385) rather than a disease of the brain.

Her main goal in the article is to show that talk therapy (psychotherapy) and psychopharmacy (antidepressant meds) ought not to be thought of as opposed  routes of treatment, as they often are, because they are both interventions into “patterns of relationality” (psychotherapy  uses transference to reestablish damaged psychic capacities for connection) (389). They both attempt to change the way a patient, or parts of a patient’s body, relates to other body parts, people, the environment, etc.

This idea of depression being related to relationality fits well with Dr. Weil’s video. Because of the physical and spatial structures that shape our lives, we don’t relate enough, or in the ways we need to. This fascinates me. Thinking of depression in this way also helps harmonize contradictory claims  from more conventional medical sources  that a) the brain is the problem in depression and b) environment, biology, genetics, stress, life trauma, and even social isolation are the problems in depression.

Rather than focusing solely on the brain (or it’s idealized partner in crime, the mind), why  not think about relationality as a model for what goes wrong in depression? Why not think about the brain and the body in their environment, in their connections, in their relations?

Human beings have complex capacities for connections, internal and external. In health, these connections are active and thriving. We might construe depression as problems of connection and relationality –  not only (as Wilson argues) the relationships between the brain and the rest of the body and its organs and systems, but also the body and its environment. The person and his or her interpersonal relationships. The embodied person in his or her architectural, structural, institutional, cultural social milieu.

Wouldn’t this open up more complex ways of not only understanding what might cause depression, but also how we might treat it?

Treating the Cause, Not the Illness –

I recently came across this article, published last summer in the New York Times, about a program, Health Leads, that seeks to promote health by helping medical practitioners attend to the underlying social causes of illness:

Treating the Cause, Not the Illness –

The author states, “The health care system remains senselessly disconnected from the ‘social determinants of health.’ In this regard, the United States has fallen behind the rest of the world. If a politician in India announced a public health plan that neglected malnutrition, he would be ridiculed. Here, leaders make this kind of omission all the time. Almost all of the debate about the 2010 Affordable Care Act was consumed with questions about health care access and quality. But if we really want to improve the health of millions of people, we have to address the conditions that make them sick.”

What an intriguing idea: the conditions of health or lack of health.
Among the conditions addressed by this program: lack of nutritionally adequate food, insufficient heating in the winter, dilapidated housing, toxic housing materials, lack of transportation to medical facilities or grocery stores, language barriers. Volunteers help doctors “prescribe” ways to obtain more and better food, get the heat turned on, find transportation to a health provider or a store, get access to legal help to push a landlord to clean up a dangerous housing situation, find a translator.

The basic premise of this article is that lack of health has social causes. We cannot effectively promote health without attention to these causes, which typically extend beyond the reach – the expertise, time, and resources – of medical practitioners.

The solution suggested by Health Leads, an organization staffed by qualified volunteers that integrates into existing health clinics, not coincidentally, is social in nature. To solve socially caused health problems, we need a health care system that is more integrated, addresses the social aspects of medicine, and relies on a network of social groups to help bring about the basic conditions required to promote healthy lives. This is a remarkable framework for health care, because it contextualizes the ill individual in a social world that contributes to the possibilities of health or lack thereof. The causes of illness cannot be isolated within the body of the individual. Neither can health. In both cases, the individual body exists within a varied, extended web that includes social and economic circumstances and their material effects.

Sociality. A fundamental, underlying structural element of health?