Aspects of Prevention and Hygiogenesis/Salutogenesis
Based on an examination of diabetes type 1 and 2, pathogenetic and salutogenic principles are explored. This yields perspectives on the significance of education and self-education in primary prevention and accompanying psychotherapeutic treatment.
Diabetes mellitus type 1 and 2
Primary prevention is concerned not only with the factors that may trigger an illness, but also with the way health is achieved. Thus it unites pathogenetic and salutogenic research.
Pathogenesis of diabetes mellitus type 1
In rare cases diabetes mellitus type 1 begins in the initial months of life. Its incidence rises continuously during childhood, reaching a plateau between the 5th and 7th years of life and then rising again sharply towards puberty. It reaches its peak at puberty with the second growth spurt. In girls, the highest incidence rate and the onset of puberty both appear 1 to 2 years earlier than in boys, so that the chief incidence is seen from the 12th/13th into the 14th year and then falls back to one half of this by the end of adolescence, becoming comparable to the incidence rate in early childhood once more. One has the impression that the onset of diabetes accompanies the entire period of childhood and adolescent development. On this background, type 1 diabetes reveals a pronounced developmental—i.e. incarnational—association.
If it is possible to contract this illness as early as the 1st or 2nd year of life, a destiny-related factor must be assumed. In spite of intensive research, it has not been possible to demonstrate conclusively the existence of hereditary aspects. Avid pathogenetic research continues but has rarely detected familial clustering. The children themselves bring a karmic—i.e. destiny-related—disposition to it as their own personal problem. Corresponding antibodies can be detected even in the vulnerable phase of very early childhood (as we now know, many years before manifestation of the disease), showing that the disease process is progressing, unnoticed, at a very early date. This suggests that it is strongly influenced by upbringing. In this context, research is focusing on the role played by environment and life style in the manifestation of type 1 diabetes.
Interestingly, research in this area has made hardly any significant progress in over 10 years. Still, it is known that environmental influences play a critical contributing role in the causation of type 1 diabetes. A survey article published in 1991 in the Deutsche Apothekerzeitung refers to a WHO study to be conducted in 58 countries over 10 years; thus its results can be expected this year or next. Current textbooks (e.g. Berger 2000) emphasize the strong environmental association of this disease as well as its pronounced impact on today's society in health policy and socioeconomic terms. It would be impossible to overstate the seriousness of the increase in this disease picture throughout the world. Up to the middle of the 20th century—into the fifties—juvenile diabetes was a rare disease (the best-known example being Finland). Since then there has been a steady rise: By the 1980s Finland had reached the highest world incidence at 40/100,000 children, which means 7 children per 1,000 births. The figures for Germany as well, though relatively low in comparison, must now be raised from 11 (1995) to 15/100,000, and an exponential increase is expected.
Thus in terms both of economy and of health policy, the most interesting question is: Concretely which influences are involved in the genesis of diabetes mellitus type 1 and how can its rising tendency be stopped? The most critical issues are clearly the environment, the upbringing and education of children, the question of primary prevention though structuring the living environment, as well as avoidance of psychological stressors such as unmanageable stress and trauma. Another factor under discussion is the chronic immunological overtaxing to which we are subjected. We need to investigate how such autoimmune processes can be triggered.
Pathogenesis of type 2 diabetes
In type 2 diabetes the pathogenesis is of a completely different nature. Here an unmistakable genetic factor is found—a highly significant concordance in monozygous twins of 60 - 100%, which is much more significant than the other disease pictures with a genetic component. It also clearly plays a greater role than the environmental and other risk factors discussed above. After all, the majority of people in our Western civilization suffer from overweight and lack of movement, yet the majority of these do not contract diabetes.
Thus it is the genetic factor that plays the key role in type 2 diabetes. But how do the genes receive a predisposition to diabetes? In the foregoing contributions to this issue, several authors have drawn attention to a quality of thinking that is technical, intellectual and lacking in inner warmth. In type 2 diabetics one can observe that feeling-imbued personal reflection does not come easily and no longer plays a leading role in their thinking.
Historically, the quality of thought we are describing developed over the last 200 years. In the year 1800 the industrial revolution began with the invention of the steam engine for the mechanical production of cotton. It was here for the first time that this type of thinking—cool, sober, objective, automatic— entered into practical application with mechanical innovations that had a huge and lasting cultural impact. Since then, it has been seven generations until our times.
The reproductive organs by which the genetic material is passed on harbor creative, flexible life processes: In men, sperm formation is observed throughout life. In women, however, the ova that mature throughout life until the time of menopause were all present in primordial form before birth. This provides them with a certain degree of protection from external influences, although all life processes are ultimately subject to the environment and changeable. From this point of view, the female constitution is always behind the pace of genetic change; it is the conservative pole, preserving what derives from earlier times. In the male constitution, the hereditary material connects more strongly with the "here and now."
When we consider that mandatory schooling for all children was gradually introduced in the 19th century, and that in the 20th century it also became the norm in Eastern Europe and deep into Russia, we are looking at an enormous social change. This development is accompanied by a penetrating intellectualization process over the course of generations. It was this process that Rudolf Steiner had in mind when he founded the first Waldorf School after the First World War. In this connection he spoke of the urgent need for a change in thinking—for health reasons.
Since then research has revealed that human hereditary material is susceptible to environmental influence, that it is in fact an open system reacting not only to external environmental influences, but also demonstrably to psychological, psychosocial and spiritual influences—in other words, to qualities of thinking. It is a highly sensitive and complex reactive system. Thus Steiner's indications appear in quite a different light today. For this reason salutogenic research has been developing increasingly fruitful approaches since the end of the 20th century and the beginning of the 21st. The insight is growing that health represents a highly complex interplay of numerous factors, a condition of labile equilibrium that merits being studied and nurtured.
The Berger textbook describes the connection between hyperglycemia and vascular damage as follows (Berger 2000, p. 264): "The pathogenesis (of diabetic microangiopathy) has a glucose-toxic, metabolic basis. Due to anatomic peculiarities in the vascular supply of these three tissues (retina of the eye, renal glomerula and nerve tissue), as a result of a biochemically-metabolically induced endothelial lesion with a secondary permeability increase and thickening of the basal membrane of vessels, it becomes possible for hemodynamic alterations with multifocal ischemia and hypoxia to manifest in a particularly early and deleterious manner."
Thus this process takes places by way of the blood, through the vascular supply of these three specific tissues. The numerous AGE (advanced glycation end product) proteins that have been detected are now judged to represent ineffective attempts on the part of the organism to heal itself by overcoming the unphysiological and (to the cells) lethal hyperglycemia.
In his contribution to this series, Friedwart Husemann has provided a spiritual-scientific description of the "physiological diabetic constitution" that is always latent in the metabolism of the portal vein blood. Extrapolating from this, one can conclude that in the three vascular regions particularly endangered by diabetic sequelae, a kind of imitation of the liver - portal vein metabolism takes place. The rhythmic system merges definitively into the metabolic system in these places: The rhythms stop, and in this extremely peripheral metabolism, metabolic activity affects blood respiration as if this were portal vein blood. Thus a multiplicity of pathogenic proteins, lipoproteins and enzymatic peculiarities lead to a kind of liver cell metabolism at the wrong place.
The better I am able to identity with the world and with myself, the more I am a "person" in its original sense of "per-sonare" (to sound through) and can penetrate and control my organs, the healthier I am. This penetration fails when metabolism occurs at the wrong place; then a barrier is formed, membrane thickens and substances are deposited because they no longer reach the place of their natural functions. This progression leads to a practical paralysis of the will, which is so characteristic of type 2 diabetes: vigorous, energetic, goal-oriented action yields to a certain listlessness, to fatigue and low drive. Yet the energy is not gone; it has been held within as if the will, no longer able to connect and identify itself through healthy metabolic organs, were withdrawn and shunted into feeling. This is why one often observes increased emotionality and sometimes lack of self-control, a vacillation between depression and aggression, because will and feeling have been pressed so closely together.
One of Rudolf Steiner's descriptions of the concept of feeling is "will that has been held back in the soul." When we speak today of motivation and mean an action that is not yet executed, a readiness to act, then it is this will-embued feeling that enthuses and excites us inwardly to the point where the inner movement can be actually turned into an outer deed. The type 2 diabetic may have quite enough motivation, but cannot so easily direct it into a clearly controlled action. The faculty of thinking, due to its abstractness, its speed or its lack of warmth, has grown distant from feeling; feeling gets bogged down in the will, so to speak. The will has been pathologically held back by the impaired metabolism and thinking struggles to maintain the connection.
Consequently, the therapeutic endeavor will be to create new order in the metabolism-based will by way of the thinking—e.g., through artistic practice, curative eurythmy, art therapies (see preceding presentations) or substances. The goal will be to enable the will to direct itself outwards again and for the feeling to re-connect more strongly with the thinking and motivate actions in the right way, without the patient's being emotionally driven or losing control.
In the textbook referred to above, the pathomechanism of glucose toxicity is vividly described in regard to diabetic microangiopathy. The striking phenomenon of "glucose memory" is noted: even when the metabolism is optimally regulated and no excess glucose at all can be detected in peripheral regions, still the faulty metabolism—the metabolic activity of the AGEs—continues. This is attributed to a retained memory of glucose toxicity. This may well be a reasonable hypothesis, but from the anthroposophical point of view one must wonder where the glucose gets its toxicity if it flows to the periphery at normal levels. If the glucose toxicity has been shown to be present through all the years of hyperglycemia, one must wonder if the glucose has not become toxic because this sugar is not really grasped by the I-organization (for the anthroposophical background to this, see Rudolf Steiner's Theosophy). Hence the cause must be sought on the spiritual level and cannot be solely explained by the concentration of glucose.
As a working hypothesis, we may thus assume that the I-function is able to permeate the glucose with warmth and to accompany the warmth processes in the entire sugar digestion process of the organism. The taste of "sweet" is the sense-perceptible archetype of a taste in which I feel one with myself and the world. Thus the I is already present in the very first experience of taste, the physical assimilation of sugar. When a person is no longer able to enjoy sugar, really this feeling that is evoked by sweetness; when there is no place for the grateful feeling of release in the taste of sweetness—this is already the beginning, psychogenically, of the diabetogenic metabolic condition. When sugar is taken up into the unconsciously active etheric body (fluid organization of formative forces), the question is how this process can be accompanied in a health-supporting way. Quality-of-life studies essentially always focus on satisfaction. They are measures of satisfaction. According to Steiner the only lasting way of nurturing the etheric body and supporting its regenerative, self-healing power is "to cultivate the feeling of satisfaction." If we do not succeed in maintaining a basic level of satsifaction with life through all its ups and downs, a continuum of a certain inner and outer peace or at least the willingness to keep making fresh attempts at it, this already has a diabetogenic action on the etheric body.
Absorption of sugar no longer takes place properly in cellular respiration, and healthy permeation with warmth abates. Substances can no longer be channeled to the right place in relation to the external world or for healthy organ building. An excessive self-orientation develops, accompanied by the backing up of the will into the feeling life as described above. In moral terms, this could be described as an excessively ego-oriented gesture; for the lack of warmth towards the world is also experienced on the soul level. Warmth is the functional vehicle of the entire human organism. If sugar is no longer permeated with warmth on all effective levels—physical, etheric and astral—it then has a toxic action. In this sense diabetes mellitus is an absolutely central disorder of warmth regulation and activation, a disorder that confronts the human I with itself.
The vital role of consciousness, of attention, in this process is vividly brought out in the contributions of Michael Jecht and Dörte Hilgard. The message of this disease—and this applies, differently weighted, to each type—seems to be: "Learn to do some of what your I unconsciously performs in your organism; learn anew to value your I, its task for your body and the world. Learn to permeate all you do with warmth; learn to be present; learn presence of mind, presence of spirit."
Nature (Heredity) and Nurture (Education)
After seven generations of increasing intellectual overtaxing and growing cold in our thinking, we witness this disease assuming massive proportions in the highly industrialized countries of the world, possibly abetted by our habitual stress, which functions as the great adapter to outer circumstances. As present-day human beings we adapt too readily, or not consciously enough, to outward conditions and therefore our hearts are not fully engaged; ever less warmth is available for the moment at hand—to fill it, to grasp it, to be creative with it. Diabetes appears today as an endemic disease; thus prevention means a change in life style, a radical change in our relationship to ourselves, our work and the world. Salutogenesis offers us several quite fundamental indications and prepares health dispositions for the incarnations to come.
A. Antonovsky (1977) describes the sense of coherence as follows: I am coherent—connected in warmth, in relationship and, yes, in coherence—when the things of the world are comprehensible to me, when things are meaningful to me. Things tell me something, they signify something to me and, finally, I find them manageable. These three traits characterize the healthy psyche. When I understand the world, when I understand and am able to find meaning in myself, when I can deal with my antipathies towards myself and the world in such a way that even the ugly has meaning for me, motivating me to positive action, and when I can also find the courage and strength to do it: then I am coherent with myself and the world.
This challenges the core competencies of the I: The I has initiative; it is capable of interest; it can enter into itself and the world; it can direct its attention. It is that agency within us that can manifest only intentionally, warming our thinking, feeling and willing. It is the very source of coherence. Thinking without participation of the I will never lead to understanding of the world, no more than feeling and will without real authenticity, I-presence. Thus primary prevention must be based on promoting the human I and its understanding of itself; only in this way is it possible.
What task does a chronic disease have? From the pathology one can learn to get an intimation of the task, for the task is the therapy, so to speak. In the pathology I can 'read' what ails me and together with the physician and therapist I can try to come to terms with it. This is the proper task of physicians: to follow the pathogenetic model, supplying what is missing, compensating and regulating imbalances. What the physician needs beyond this as background is the intention and the ability to be the teacher, the mediator of a comprehensive understanding of health. Strictly speaking, the salutogenic approach sees each disease as containing a piece of health as well. In this light, illness becomes an inner, moral issue, the task being to recognize what still needs to be dealt with and to take it on. It becomes a grace of God grace, a gift of fate and, paradoxically, the way to healing. In his lectures for young doctors and medical students, Rudolf Steiner notes that they should learn to love the illness, since the healing is already contained within it. Or, as he says in his lectures for priests and doctors, God Father sends illness for karmic compensation. Illness is always a healing, divinely sent harmonizer of destiny.
Such statements are still beyond present-day notions of psychogenic moral influence. It is a completely different level, the spiritual plane, that is addressed here. In the physician's work, there are always three planes to be distinguished and attended to. On the planes of soma and psyche, particularly focusing on the pathological process, what is "wrong with me" is always experienced as painful and also as shameful: "Why do I have to go through this now?" Or, "What did I do?" "How did this happen?" And, "Who is to blame?" One is always inclined initially to look for the guilty party and to moralize, but then to work to make it better. This is the human plane, the plane of the evolving soul, the plane on which we are continually faced with new lessons. There is, however, another plane—the plane on which one seeks the deeper meaning and searches for the wisdom in destiny. In the light of repeated earth lives, an entire incarnation of suffering becomes recognizable as a healing crisis which one can accept with deep affirmation. The illness of diabetes has such an aspect.
Rudolf Steiner addresses the theme of salutogenesis as primary prevention in early childhood education as follows: "As long as the child is an imitating religious being, it does no good at all if I admonish the child..." (Anthroposophische Pädagogik, p. 34/35). Here the critical salutogenic principle, i.e. the strongest source of resistance that the human being possesses, becomes his religious relationship to God, to other human beings and to the world. The deep reverence that can touch us when we observe the phenomena of nature is also a religious relationship.
This proves to be the strongest power of resistance in extremities such as holocaust, prison, prolonged famine and all types of stress. The small child still possesses this capacity constitutionally: the child exhibits devotion to all that surrounds it by imitating it in a way analogous to religious devotion. This capacity fades towards the ninth year of life. The younger one is, the more one finds everything worthy of imitation because one comes from the spiritual world with the attitude that things on earth as they are in the spiritual worlds, namely good. It takes about 9 years before one has weaned oneself of this attitude. Then one begins to judge for oneself what is good and worthy of imitation. As long as the child remains an imitative religious being, it is no use at all for me to admonish the child.
To heed words, the soul must be emancipated to some degree from its environment and ready to make a mental representation of what is said. Words alone are not helpful with a child. But everything that we do in front of the child and with the child is helpful. In this case the child perceives the inner, moral aspect of the action. Just as the color-blind person looking at a colored surface sees only shades of gray but not the colors, so the adult sees people's gestures, their looks, their facial expressions, the speed, slowness or jerkiness of their movements. He sees only the physical aspect but no longer perceives the moral within it. The child still perceives the moral aspect, albeit subconsciously. In their total devotion to the world, children "see" the thoughts and feelings of those around them, only not fully consciously. This principle—if taken seriously— would be the core of primary prevention in the first developmental stage up to the change of teeth: to meet the child with an identification that is religious. For the adult, this means living a life as permeated with meaning as possible and modeling it to the child, as if to say: This too is a world where God and human dignity have a place; look towards it with joy! According to Rudolf Steiner, the most important power to stimulate healthy formation of the human organs, the metabolic organs, is the joy and the "bright faces" of those who teach and raise us.
In Menschenerkenntnis und Unterrichtsgestaltung, p. 68/69, Rudolf Steiner finds occasion to speak directly of diabetes: "In everything the teacher does with the child, he must ask himself if he understands what he is doing himself. Why in heaven's name does this student have to do fractions with me at this moment? Or, why do I have to torment her now with walking a spiral in eurythmy? Perhaps we would do better to have a talk. Why am I doing this? There is nothing teachers will not accomplish if they stand in the right relation to their teaching, i.e. if they keep setting themselves the task of attempting meditatively, now and then, to answer even briefly the question, What are you actually giving to this human being by teaching him history, geography, etc.—gaining clarity about what one is actually doing. Let us take a few examples to illustrate this. The eurythmy teacher, for example, knows that in doing eurythmy he is releasing the child's spirit, while the teacher of reading knows that she is embodying, incarnating the spiritual. If she always keeps this clearly in mind, she will in a sense see,If when she reads wrongly or teaches the child something boring, that the child is inclining more and more towards a metabolic ailment; the teacher senses that she is producing a future diabetic (type 2 is meant). Then the teacher becomes aware of the real responsibility involved. If you continually occupy the child with too much boring reading material, you produce diabetics. That is not intellectual overtaxing—there is nothing finer for a human being than to know a great deal—the only question is: How is it transmitted? If I am united with my conscience (as the totality of my self-won knowledge) in coherence, in warmth and in love, it is a wonderful thing if it contains much knowledge. But if it is a massive load of indigestible information to which the teacher was unable to build up any relation for me, that is spiritually comparable to an organic deposition. It is cold ballast—unwarmed, unordered and in the wrong place. In other words, intellectual subject matter above all must not be boring, or else it is diabetogenic and also leads to the various forms of what is called a bad conscience.
"We need a pedagogy that is based on insight into the human being, insight into the child. And in turn such a real pedagogy based on insight into man will be present in that age when Ph.D. dissertations are accepted with titles such as: "A case of diabetes in a 40-year-old man traced back to the injurious effects of play in his 3rd-4th year." At that time one will recognize what it means that the entire human being consists of body, soul and spirit and that in the child, body, soul and spirit are still a unity. Spirit and soul later become free of the body, and then there is a threefoldness. Then they are so to speak pushed apart in the adult as spirit, soul and body, and only the body retains what entered it during the period of childhood development as a germ for later life. Now it is a peculiar fact that in the soul, we experience the consequences (which have entered into the unconscious) quite early; physically, in the body, we experience them seven to eight times later. If you bring up a child in a heart-felt manner, giving the soul its due in the 4th/5th year of life so that the child has taken it up and her inner world is under its influence, then this will really become apparent in 8th year of life, for example. People still take care not to teach something in the 4th or 5th year of life that does not have a wholesome effect in the 8th/9th year. But this is the soul effect. The bodily effect—because the body is emancipating itself—reveals itself more slowly, seven to eight times more slowly. In soul development, the fruits of an influence from the 5th year will be apparent already in the 8th; but in the body they become apparent after 35 years, after a period that is seven times longer." (Anthroposophische Pädagogik und ihre Voraussetzungen, GA 309, p. 38).
Thus pathological symptoms caused by improper play begin to appear starting in the 35th-40th year. And what is improper play? Mechanical toys, for example, where the entire activity takes place in cars and in electric trains and the child's activity is to control them. This already presents us with the picture of a metabolism that is separating from the child. These are no longer toys that are moved by hand, they move themselves. In other words, feeling and will are squeezed into each other and a separation takes place from the object, which is steered from without. This is a diabetogenic type of play. First on the soul level and then, once schooling has made its contribution and development continues along this path, one can only imagine—particularly in our computer age—how rapidly this endemic disease is now progressing on the physical level too.
What would proper play be in the first seven-year period, while the child is still a religious imitator? The child's imagination—her own will, her own creativity—always need to supply something that the object does not offer. In other words, the little child recognizes: "I am needed the whole way along. Everything is unfinished; I need to finish something everywhere. I am needed." That is creative play.
Primary prevention means asking ourselves the fundamental question what healthy development would look like at the different stages of life. How can all subjects at school be used in such a way as to best Howsupport the child's sense-based relationship to the world in this first seven-year period, so that the child can develop joy in existence and identification? In terms of spiritual science, the primary origin of metabolic diseases—the entire range of them, everything that manifests as acquired metabolic illness in the second half of life—lies in irreligiousness in the first seven-year period. It is no accident that the Last Supper of the Christian church is linked to metabolic processes. The critical thing for a child in the first seven-year period is that the world permit communion, that it be digestible; and this happens through imitation, through the senses, through the development of joy, through interpersonal connection and contact with authentic adult human beings.
After this phase of life all organs are functional; they have attained their form and from now on the development of the soul stands in the foreground. In order to develop healthily in life, the soul needs a human being who loves the tender, essential core of the I in complete trust and full of expectancy. "Children, do you love your teacher?" To Rudolf Steiner this question was the test for whether a teacher could remain with a class or not. He knew that the period between the ages of 7 and 14 is when one must succeed in finding coherence with oneself; one must succeed in finding this kernel of love. If not, the capacity for love that awakens fully at puberty becomes mere sexuality. The morally central being of the I must be awakened, otherwise the body emancipates itself and the young person is subject to the lure of power and eroticism – the dual dangers of a failed education in the second seven-year period.
But how is this to be accomplished? It is only possible if a relationship develops with the teacher that is based on love, so that the teacher is able to set boundaries and explain and punish in a way that the students can accept. Then the student senses underneath, "This is for my best, the teacher really wishes the best, he just doesn't say it." Thus as long as one is not developmentally ready for the leadership of one's own I, one needs a sort of "substitute I." During this period the teacher is, in the best sense, a kind of guide for whom one feels love and enthusiasm and under whose shelter one can learn self-reliance of soul.
The third competence to be developed is personal autonomy: After puberty, learning takes place through understanding—through one's own independent insight. This means there is a difficult balance to be found between one's own self, identification with oneself—which has already been found on the feeling level—and what one found earlier in the first seven-year period: a religious connection to the world. This is the task of the third seven-year period. It establishes a basic orientation towards self-education in later life, by which type 2 diabetes can be prevented or, in the case of an ongoing disease process, the prognosis can be improved.
The healthy human being—the embodiment of all human dignity—is manifested in a religious relationship to the world and to fellow human beings, founded on a good will that is supported by a healthy metabolism. Out of a loving relationship to the world, to one's own becoming, to the world's development and to other people, there arises an autonomous, free relationship to the world around one and to oneself. In this way one's own place in this world can grow to embrace so much that it creates its own meaning. And when primary prevention is conceived in this way, it can offer a contribution to our understanding and to the therapy of diabetes mellitus.
Dr. Michaela Glöckler
Medizinische Sektion der
Freien Hochschule für Geisteswissenschaft am Goetheanum
• Antonovsky, A. (1997): Salutogenese. Zur Entmystifizierung der Gesundheit. Tübingen, dgvt-Verlag (Deutsche Gesellschaft für Verhaltenstherapie).
• Berger, M. H. (2000): Diabetes mellitus. München, Jena, Urban&Fischer
• Steiner, R. (1981): Anthroposophische Pädagogik und ihre Voraussetzungen. p. 34/35
• Ibid., p. 38
• Steiner, R. Menschenerkenntnis und Unterrichtsgestaltung. Dornach 1986. p. 68/69.
• Steiner, R. Theosophie. Einführung in übersinnliche Welterkenntnis und Menschenbestimmung, Dornach 2002.
• Steiner, R. Die Erziehung des Kindes vom Gesichtspunkte der Geisteswissenschaft, Dornach 1992.
Heart-felt thanks go to my pediatric colleague Dörte Hilgard for editing this lecture.