Dukkah -- Dis-ease and health

This is the third post in the series connecting aspects of Buddhism and public health. In the first two, I explored two of the dharma seals: impermanence and interconnectedness (although the second is frequently extrapolated to its most challenging application: non-self.) The third dharma seal is usually considered to be dukkah. Dukkah is frequently translated as suffering, but in a very broad sense. Another translation that may be more accurate is dis-ease, dis-comfort. The Dalai Lama posted on Facebook earlier this week this comment on dukkah:

"Every type of happiness and suffering can be divided into 2 main categories: mental and physical. Of the two, it is the mind that exerts the greatest influence on most of us. If we are not ill or deprived of basic necessities, if the body is content, we virtually ignore it. The mind, however, registers every event, no matter how small. Therefore we should focus our most serious efforts on bringing about mental peace."

If the body is not cared for, it will dominate our thoughts, of course. Too hungry and we can not concentrate; too tired and we can not make wise choices. No amount of mental peace will chance the body's needs.

However, as the Dalai Lama suggests, more often than not in our time and place, our dis-ease is caused by the mind. In this country (US) in this time (2000s), most people have more food than we need (although our access to healthy and whole food is much more limited), and need to engage in far less activity than our bodies need to get that food. Most (not all, but most) have adequate shelter and can clothe ourselves as is needed to protect our bodies from the elements. Most of the time, the stressors in our lives originate in our minds.

A mind-originating stress is not less valid than a body-based one. In fact, they are interconnected. Body-based dis-ease causes us to feel emotional and/or mental dis-ease, as I described already. Mind-based dis-ease causes physical symptoms and outcomes in the body. Chronic stress has been shown to have important outcomes: heart and blood pressure problems, less-healthy birth outcomes, blood sugar irregularity, etc. In fact, few if any body diseases lack a mental health component; almost all are impacted by stress. Also, when we are upset, we frequently crave the very things that are not good for us. For example, many people find stress directly impacts their appetite. We feel hungry, and crave foods that will make our bodies feel less good in the long run; or we feel disgusted by food and avoid eating when we need. The two are not readily separable. Since our bodies and minds are not separate beings, this should not be a surprise. However, we need to figure out if our hunger is for lack of food, for example, or from stress. The difference is not how important they are, but in how we address them.

When addressing dukkah, the Buddhist approach is most helpful in addressing the mental stresses. (Physical ones, of course, are more straight forward in terms of figuring out what to do. If food is needed, apply food. The challenge is in the circumstances that led to food not being available.) It is also a helpful approach in terms of figuring out if the source of the problem is the mind or the body.

In Buddhism, the belief is that mind-based dukkah is caused by a disconnect between what is real, and what we would like to be real. Therefore, the approach is to see, truly see, what is real. This is harder than it appears. The question is not what upsets you, but what is the situation -- from all angles. When we can see the situation this way, we will see the way to resolve our dis-ease as simply and clearly as solving a physical dis-ease.

To get to a place where we can see clearly enough to accomplish this feat, we need to quiet our minds: meditation. This is, essentially, the main reason that meditation has physical benefits -- because our minds and bodies are interconnected, and we need this clarity to resolve our mind-based dis-ease. Meditation can be done while sitting still with a quiet mind, or while walking or doing work with a quiet mind. Wash the dishes, just focusing on the dish in front of you. "I am washing this glass. Soap, water, warm, cool."

Dukkah is typically personal: what is out of sync between my expectations and my life? However, as public health messages are crafted by people, that disconnect can, and does, happen in our work. When our messages are not reaching people we have to ask ourselves the same kinds of questions. To see the context of the health behavior we want to impact clearly, we must start by listening and observing clearly, without expectations. Without that, we will not reach our audience. If we have not listened clearly, we can not expect to be heard.

Buddhism for public health, part 2

Nonpermanence

The Buddhist philosophy says that permanence is an illusion that we cling to, and that clinging to it causes us suffering. Either we are so focused on the future that we miss the now, or we try to make things stay the way they are. Both approaches to fixing this problem become suffering. Some Buddhists remind themselves of this principle by placing cut flowers on their altar or shrine. As the flowers rapidly change from young, to full-bloom, to waning, and desiccated, there is no denying the changes.

Living things are constantly changing. Cells grow and age, are replenished and replaced. Our systems are responding to constantly changing stimuli and context, and therefore are changing. All living things are always aging, growing, shrinking, getting stronger and weaker, moving through cycles, and passing through stages of existence.

As living things, we as individuals have ideas about our bodies that are based on past experiences. Ideas about our body types, our capabilities, what is normal for us, become part of our identity. Experience is of course a critical teacher. However, if we are not currently listening to our bodies, those ideas can quickly become mistaken. I still think of myself as a tree-climber, a monkeybar-swinger. As I am nearing 40 years of age, I must recognize that this no longer true for me. Many other changes are more critical to our health for us to notice. Digestive processes, reproductive systems, our heart and circulatory system, muscles and bones, are all in need of our awareness of changes as time passes.

As public health professionals, it is important for us to be aware of how audiences see themselves, which may be based on their past instead of their present. However, the physical world is not the only one that changes; the psychosocial landscape is also constantly in flux. As I sat training a new qualitative data collector, I realized this important way in which we need to remember nonpermanence in our work. When we collect data, the information we are collecting is true for the person we are listening to, at the time we are listening.

As we prepare to ask recent fathers about their prenatal and postnatal experiences with breastfeeding information and infant feeding, we must remember that what they tell us is true today. Two months ago, they may have said something different. Two weeks from today, they may tell another story. Today, this is his truth.

It is easy, as professionals, to feel that we know a population, a community, and how it perceives a topic. However, that answer is inherently yesterday's answer (or, more likely, last year's). The value of qualitative research is that we find what today's truth is. To communicate with our audiences in the present, we need that knowledge.

Buddhism for public health

What is Buddhism? A religion? A culture? A philosophy? In many ways it is all of these, but as Adrienne Howley describes best in "The Naked Buddha," at its heart it is a philosophy, an approach to life and a way of understanding what we perceive.

The basic message is that we all suffer, and that the way out of suffering is to adjust to how life is instead of how we would have it be. The many steps to achieving this escape from suffering involve specifically perceiving our selves, our surroundings, and each other clearly, honestly and without judgement. It sounds simple, but it is extremely difficult to do. Even just looking myself straight on without either excuses or judgements is a huge challenge. How do I begin to apply this embrace to my environment? My loved ones? Strangers?

So, the question might be Why bother?, or How could doing so have anything to do with public health? This is a complex and multi-level conversation, so I would like to try one piece at a time. Here is the first piece of this puzzle:

Interconnectedness: Within the Buddhist philosophy, we are all connected with each other. We are of this planet, subsist on this planet, and will return to this planet. On a microbial level, the planet is on and in us. We are on and in the planet.

As we look at non-human ecosystems (lakes, woods, deserts, oceans), we are learning that that which impacts one member of the ecosystem impacts the whole. Take out the jelly fish, and their competitors, their prey, their prey's competitors, and their predators are all immediately impacted. Soon, the entire ocean is different.

Ultimately, public health is the health of each of us as a community. When we neglect members of our ecosystem -- our community -- the impact is immediately upon us all. When we allow some people to be treated less, we are all lessened. Understanding this, communicating this message, can be a key to changing our public health messages from blaming or helplessness to mutual benefit.

We also all need each other. This means that promoting healthy individuals and individual choices needs to reconnect us. We are living in a disconnected environment, where people too often do not know their neighbors. Research shows that people need community, need each other; elderly people who are connected to others -- family, religious organizations, volunteer work -- are healthier than their disconnected peers. We need health promotion that builds upon and strengthens our communities.

So, as a starting place, we need to start thinking of ourselves not as separate individuals, but as unique expressions of a larger whole. When we do, we realize that others are not other. Connecting to each, we can support each other and be stronger for it.

Health Care For All

While it is an amazing thing that the Obama administration is taking on our health care system at this time, that a politician is willing to tackle such a daunting task, I have to ask why. Why would it be unpopular with people (voters) to make access to health care providers available to everyone? What are the real benefits and costs to the average person and to the community at large in providing everyone with health care access in the form of insurance?

First, while most people who have insurance assume they always will, this is not true. If you work for a small company, that company may find it too expensive to maintain access -- poof, your insurance is gone. An accident or illness can either take you out of the workforce unexpectedly, or can be reason for an insurer to discontinue services -- poof. You can lose your job (yes, even you), and -- poof. You can find yourself under-employed -- poof. You could easily find ourself among the uninsured. Many Americans spend some portion of their adult wage-earning years uninsured. If they are lucky, they won't need health care during that time. However, luck is not dependable.

Second, people who do not have health insurance are part of our community and still need health care. When people do not have a regular provider, someone to call when a health problem first arrises, they frequently go without care. After time, the problem usually gets worse for neglect, and eventually, the problem becomes an emergency. Emergency room care is more expensive, for both the individual and the community, financially and physically. Frequently problems that were easily treatable earlier become expensive, painful, traumatic experiences by the time they are seen in the ER. Other times they are fatal. Privacy is limited; continuity of care is even more limited; other infections are usually available to pick up while you visit. And all at an astronomical cost.

The one advantage in an emergency room is that you can't be turned away. Whether you can pay or not, whether you have coverage or not, you will get the care you need.

As a community, we all pay for this higher-cost care. We also all pay for the disability and decreased productivity that happens when diseases and injuries are allowed to get worse (for lack of other options).  Preventative care, early detection, regular check-ups, all cost far less than emergency care for late-stage diagnosis and treatment. If we vote only from self-interest, it is in our interest to make sure that everyone in our community (which is the nation if we are honest with ourselves) has access to health care.

Let's pay less by taking better care of each other from the start. 

H1N1 vaccine debate

I sympathize with the confusion the mixed messages from medical sources will cause. As a health communicator, I have worked and/or spoken with several people with a specialty in risk communication (such as the risk of a pandemic flu) and have weighed the debate thoroughly.

On the one hand you have people who are hesitant with new drugs generally. There is good reason for this. Every drug has side effects. New drugs, including vaccines, are not well tested in my estimation before going to market. This is especially true when there is a big push to get the drug available. (This was not true in the 80s with new AIDS drugs, and the political/public backlash about that has changed the process. However, increasing pressure from pharmaceutical companies and weakening of the FDA have also changed the bench-to-trench process for new drugs.) There is also discussion among some about what we are doing as a population to our immune systems by not exercising them. No one really knows the final answer on that one yet.

On the other hand, the next great pandemic is what the risk communication people consider to be the really scary threat to worry about. Far above terrorism or food-borne illness or natural disasters, they worry about the potential of a new virus in this global community we live in. They are happy that children are being taught to wash hands religiously, as that is one of the best defenses. If we could just get people to avoid going to work/school when they are sick, they say, we’d all be in a better place to handle such a crisis.

I don’t get us vaccinated against the flu normally (shocking to many of my colleagues) and won’t get us vaccinated against this particular flu either. Generally, flu vaccines are only going to be useful against +/- 30% of this season’s flu strains. (They are necessarily based on last seasons’ strains.) Most healthy people who are well nourished are well equipped to fight off the virus. The vaccine is intended to avoid unnecessary death, and for most of us that is not the threat. Mostly the virus represents a week or so of really unpleasant days and discomfort. For most of us. Not desirable, but not deadly.

All that said, you should make the best decision for your family and feel good that it is a good decision. With so little known about the long-term effects of getting vaccinated or not, both decisions are good and defensible.

why the kitchen table?

In so many cultures here in the U.S. and around the world, the kitchen table is where it all happens. When friends and family gather, this is the place where the real conversations happen. This is where people share their hopes, dreams, fears and failures. The kitchen table is where resolutions are made, and the terms social support and community have meaning.

What we eat; how, when, and with whom we eat; these are all there at the kitchen table. Our goals for our fitness and health, for our children and ourselves; our fears of failure and change; and the comfort and support to get us to the next level are all there, too. I've even heard a breastfeeding mother's chest eloquently described as the baby's kitchen, "warm, comfortable, and smells like food."

I am passionate about many of the things that happen here around the table: healthy, sustainable and non-toxic foods, for example; healthy body image and how we share that with our children; the conversations that lead to our choices around birthing and breastfeeding; that intimate support for all of life's changes and choices. Over a steaming mug or a slowly warming glass, a plate of food or the preparations of another meal, we share this part of our lives with the people we trust most. Maybe that is why our bodies are healthier when we share our meals.

The kitchen table is where health communication happens in people's lives, and that is where we need to be to support people in their choices. Pull up a chair; we've been waiting for you.