Keywords

1 Introduction

In this chapter a theory that describes the assets that help to protect health is presented. Assets, and their opposite – the conditions which create vulnerabilities to ill health – are located in the lifeworlds of ordinary human experience and the health benefits and disbenefits which accumulate over the lifecourse (Kelly 2006). The lifeworld and lifecourse together are the bridge between social structure and individual human biology. Together they constitute the focal point where society and biology intersect and interact. The lifeworld and lifecourse are the mechanisms through which the social determinants of health produce biological outcomes in individuals. This is the vital link in the causal chain from the social to the biological and from society to individuals. Assets and vulnerabilities are the crucial mediating or intervening variables between the wider determinants of health and the human body and it is those intervening variables that produce individual differences in health (Lazarsfeld 1966; p. 157).

The theory begins with a consideration of the interaction between human ­behaviour and the structural forces which determine health. These structural forces are called vectors (Kelly et al. 2009). Four vectors of causation are described; ­population, society, organisation and environment. The theory developed in this chapter builds on the work done by members of the public health team at NICE to support the WHO Commission on the Social Determinants of Health (CSDH) as well as NICE’s experience of developing public health guidance (Kelly et al. 2007, 2009; Blas et al. 2008).

2 Vectors of Causation

2.1 The Population Vector

The first vector is the population vector. This consists of factors which impact on the health of populations as a whole, at national, regional and supra national levels. These factors arise because of the direct actions of organizations like the European Union (EU), nation states, global and national financial and banking systems, corporations and businesses, regional governments, some civil society organisations, donor organisations, and health systems. The actions of these bodies and organisations produce: (1) economic structures and processes, productive arrangements and concomitant markets which generate wealth and structural inequalities within and between societies and between individuals; (2) the legal and regulatory frameworks which either value health or do not, protect the rights to health or do not and provide for labour, women and children’s protection, or do not; and (3) the mechanisms to monitor and evaluate the health of populations (Blas et al. 2008). There is considerable evidence demonstrating that these actors and their actions have profound effects on health of individuals and within and between societies (CSDH 2008).

The sequelae of the ways these actors and their actions work within this vector have been described in detail in connection with the WHO Commission on the Social Determinants of Health (CSDH 2008). For example the negative as well as positive outcomes of the economic process of globalisation have been delimited very precisely (Labonte et al. 2007). The ways in which legal frameworks can protect women from political and economic marginalisation is another (Sen et al. 2007). The potential power of sound data collection systems, as the means of holding governments to account is yet another (Kelly et al. 2007). This evidence offers a starting point for understanding the causal mechanisms especially of the patterning of health at population level. The population vector is both the framework and the economic processes within which the overall patterns of health arise. At ­governmental level, the degree to which states are fragile or corrupt, are accountable through the rule of law and the democratic process, are fundamental to the way the framework and process support or negate health. It may be thought of as an interlocking system of laws, regulation, markets and politics (Blas et al. 2008; Bonnefoy et al. 2007).

To a very significant degree the ways in which this vector impacts on health for good or ill is a matter of political will and determination or of neglect (CSDH 2008). In other words organisations like corporations and governments act deliberately in what they do and their behaviour arises directly from human agency and intent. These actors in the population vector are goal oriented because men and women set the organisations up and run them in particular ways to achieve certain ends – corporations to make profits, donor organisations to provide relief, governments to govern and so on. Although of course they will always only be partially successful in their goals, and all of them are subject to the vagaries of unintended consequences, system dysfunctions and goal displacement, there is never the less deliberate human intent behind the goals and actions (Merton 1940, 1957). This is somewhat different to the next vector, society, where the same degree of deliberate goal orientation is much less obvious. It is also important because therefore solutions also lie within the power of human agency to do things differently and in ways that can promote rather than damage health if the will exists (Kelly et al. 2007).

2.2 The Societal Vector

The second vector is the societal vector. It is conceptually distinct from the ­population level vector. Society is probably one of the most used but least well understood concepts in the social sciences. It is best described as that group of social forces which arise as a consequence of human behaviour in all its forms, which in turn impinge, constrain, and organise human affairs in ways which for the most part are not a direct result of intentional human agency or intention (Giddens 1979, 1982, 1984). Society arises spontaneously from the billions and billions of human actions that take place every single second of every single minute. Politicians and governments always seek to control society, with varying degrees of success, and the regulations and legal frameworks described above in the population vector are manifestations of this. But societies are difficult to control because they have a reality sui generis independent of individual will (Hume 1748/2007; Smith 1776; Durkheim 1897/1952).

Society is made up of various elements, some of which will be touched on here. The building block of society is the dyadic interaction between two people (Simmel 1950; Homans 1951; Parsons 1951; Garfinkel 1967). Interaction can take many forms of course. But every human encounter tends towards one or other of two ideal types of human interaction – authority or power (Weber 1947). In the first ideal type person A is perceived by person B to have some legitimate reason to interact with them and to seek to ask them to do something. The process is reciprocal in that both have expectations of the other which are regarded as legitimate and both benefit from the interaction (Homans 1951). The prototype of such an interaction might be a simple purchase in a shop. The shop keeper or shop assistant expects the customer, to ask them for something and if the shopkeeper has it, for a legitimate transaction to ensue in which goods are exchanged for money. This type of interaction does not only occur in financial transactions or commercial arrangements. So a spouse asking their partner to make love, or in the work situation a line manager asking a colleague to perform a particular work related task, or a doctor asking a patient to remove an item of clothing in order to conduct a medical examination, all represent examples of the ideal type. The key idea is that the interaction is based on some notion (different in each of these cases) of the legitimate authority of one person over the other. The shop keeper, the partner, the work subordinate and the patient understand that the customer, the wife, the manager and the doctor all have a legitimate right to ask them to do what they are asking (May and Kelly 1982). It is important to note that the meaning attaching to the interaction, the legitimacy, is situation and role specific. So if the interaction and requests occurred in other circumstances, or perhaps the roles were reversed, then the legitimacy evaporates and interaction tends to break down (Garfinkel 1967).

The alternative ideal type is when the person who is asked or told do something, does not want to do it because they do not recognise the right of the person doing the asking to do so. They resist. In order get their way, the person doing the asking uses power or force. So someone going into a shop demanding the contents of the till, someone wanting sex from someone else who does not, someone bullying a work colleague or someone telling another to remove clothing when the other does not want to, are ideal type examples. If the powerful are to get their way, they will have to use force or coercion or the threat of it to do so. The relationship is not reciprocal, because only one party benefits. The demand being made is not legitimate and is not desired by the other party. So this relationship is one of power not authority.

Of course human interaction seldom fits neatly into these ideal types and is best seen as a spectrum between the two pure types of authority and power. Indeed much social life is made up of negotiating meaning and the consequent boundaries of legitimacy in human interaction and whether an action is about power or authority, or what mixture of each. It is out of this interplay at individual, group and organisational levels that society arises as a complex web of meaning, negotiation and social relations. It all gets more complex as we move from dyads to triads and then to larger groups (Simmel 1950), but the social forms which arise from human interaction all develop out of the basic dyadic structure.

In the context of this chapter, power relations are of particular interest. To a very significant degree the shape of society reflects struggles for power and competition for resources and alternatively the degree to which social relations are governed by legitimate authority. This definition of power includes actions which are outside of any formal political process and include such things as teenage gangs struggling for territory, and elitist social groups attempting to maintain exclusiveness by elaborate social rituals, language and dress codes. Sometimes power is played out as violent aggression, sometimes as legally sanctioned oppression and violence, sometimes as the micro politics of the office or institution. The structures of power and domination from the most benign to the most malevolent are intrinsic to the human condition and from the perspective of public health the effects, especially of the negative experience of power, domination, aggression and force, and the more benevolent forms of social control, have direct impacts on health (Kelly 2001).

Power plays out formally as politics in the population vector, but if we restrict the analysis to formal political systems, the important social structural consequences of power relations, viz. patterns of inequality, will be missed. Power struggles and the consequent patterns of social differences occur notwithstanding the intentionality of the actors involved. Formal controls of the economy belong in the first – population – vector, but the consequent social differences of the outcomes of economic power struggles belong to the second – social – vector. The social vector therefore includes social differences of all kinds. The important axes of social difference are class, gender, religion, caste, tribe, place of residence, and status (Weber 1948). Social systems may be conceptualised as existing on a spectrum from those which are very homogeneous to those which are much more heterogeneous. Sociologists used to argue that the process of modernisation was one in which as societies became more advanced they also became more complex and more heterogeneous (Durkheim 1933). This feature is true at a very macro level, but it is also true that even the simplest societies exhibited a division of labour based on age, physical prowess, and gender and so on (Lenski and Lenski 1971; Megarry 1995). Social differences and their consequences may be simple or they may be complex, but they are a real feature of social systems with very real effects on society’s members.

Social difference, in whatever great variety of forms it may take, is a universal characteristic of human social systems. These differences have important consequences including health consequences because they determine access to and possession of assets and exposure to vulnerability. Social difference determines access to resources and therefore life chances (Weber 1948). And access to resources is fundamental to being able to cope with the travails of life. Resources in the sense used here can refer to money, social support, social capital, skills, psychological resilience and market position. None of these factors are distributed equally or randomly in the population. They are differentially distributed according to social difference and are the outcome of power struggles.

Social systems generate cultures (Archer 1996). Culture is where meaning is created, formalised and preserved. So culture is as intrinsic a part of society as the struggle for power and dominance. All human systems develop cultures which are more or less complex and consistent sets of beliefs, norms, ideas, religions, ideologies and so on. Societies have means of expressing these in verbal, written and musical forms. A critical aspect of culture is the judgements made by powerful gatekeepers about good culture and poor culture, usually defined as taste (Bourdieu 1977, 1986). These judgments tend to reinforce definitions of who is a full member of the culture and who is not and are powerful resources for generating meaning linked to power. Societies develop varieties of ways of regulating cultural expression, religious and political ideas. To be distinctively human is to live in a cultural universe. To experience and share the membership of particular cultural groupings is essentially human and cultural groupings are in turn defined with reference the sharing of particular cultural artefacts, understandings and meanings. Culture is inescapable. It is impossible to opt out. We are born into an existing cultural milieu and through socialisation will be immersed in it.

From a public health point of view culture acts as a mediator of meanings associated with health, justice and fairness. People make sense of the worlds around them, including the changes they witness in their body as a consequence of disease. They assess illness and disease around them. They use cultural meanings to make sense of what they see. As they suffer the consequences of power and oppression or as they enjoy the fruits of their wealth, they will draw on cultural ideas to make sense of what is happening to them and to others.

2.3 The Organization Vector

The third vector is organizational. The architecture of human life is the organisations and institutions in which almost all human conduct takes place. Institutions and organisations include hospitals, employing organisations, large and small, in the private and public sectors, schools, universities, clubs, societies, professional associations and religious groups. It also includes some aspects of civil society, in the form of social groups and social movements. Obviously certain nation state organisations like civil services, the military and the police, are institutions and organisations and appear at this level as well as the state level, as do local government and municipal bureaucracies of various types. This list is not in any sense exhaustive. What is important is that the structures and functions of these organisations mediate as well as have direct health consequences on individuals.

The study of such organisations has been grist to the mill of sociology and industrial psychology for many years (Etzioni 1961, 1964; Burns and Stalker 1961; Buchanan and Huczynski 1985) and we know a good deal about the way such organisations work. The degree to which they are fit for purpose is a mixture of the task they are supposed to perform and the structures within, and the degree to which organisations are based on principles of flexibility or rigidity and external relationships. Organisations and professions involved in the delivery of health care are a particular subset of organisations. They are interesting for a number of reasons. They tend to be large. They tend to be expensive. They tend to be powerful, and all of us rely on them especially at times of extreme stress and anxiety, when we ourselves or our loved ones are ill or dying. In modern societies they are an incredibly significant cultural symbol too.

Such organisations have a significant role in delivering health protection, disease prevention and health promotion. They provide relief from pain and suffering. The impact on quality of life through the management of chronic illness is potentially and actually profound. Modern drug therapy means that many conditions which were once either fatal or were highly debilitating are no longer so, and instead the person with the condition can live a full and active life. The drugs which control epilepsy, diabetes and angina, are cases in point. There are also drug interventions which significantly reduce risk of certain diseases like heart attack and stroke – statins and antihypertensives are good examples. There is the surgery which usually significantly improves quality of life like knee and hip replacements, cataract surgery. Even minor correctives to vision, using spectacles has enormous benefits on the quality of life. All of these interventions and many others account for about 40% of health improvement (Bunker 2001). This is probably an underestimate of the potential benefits which the system could deliver if inefficiencies and dysfunctions could be eliminated, if the service reached out effectively to those most in need and if the take up and use of services were completely equitable.

2.4 Environment Vector

The fourth vector is the environment. The environment consists of everything from microviriology to global warming. The fact is humans inhabit a physical universe which is ubiquitously stressful or at any rate ubiquitously full of germs, viruses, radiation, dust, noise, heat, ultra violet light, asbestos and many other potentially harmful physical things, And as if that were not enough, humans take risks, for the fun of it sometimes, or more mundane reasons. The result is a steady stream of mortality and morbidity from a variety of environmental causes.

The material world provides a constant source of pathogens and passages between the pathogens and the body. Some of these pathogens and toxins are unavoidable, or risk goes unrecognised. It is a reasonable assumption that there are hundreds, if not thousands, of things in our personal environment which as yet we do not know are dangerous. There are also newly mutating viruses a few of which may wreak havoc of epidemic or pandemic proportions. On the other hand much that threatens us in this environmental vector comes out of, or is a response to, direct human actions intended or otherwise and is potentially avoidable. So some environmental dangers like radiation, prions, drug resistant viruses, climate change, the residue of many industrial processes, are the result of present or past human conduct. There is, in other words, a relationship, an interaction, between many elements in the environmental vector and human actions which speeds the agent from its point of origin to the host of the disease.

3 Lifecourse and Lifeworld

Public health requires a mechanism which bridges the social/population/organisation/environment vectors and human biology. That mechanism is to be found in the conjunction of the lifecourse and the lifeworld (Kelly 2006; Kelly et al. 2009). The epidemiology and sociology of the lifecourse are very straightforward. Through numerous studies of birth and other cohorts (Kuh et al. 2003) and a consideration of the associations between insults and benefits in utero (Barker and Martyn 1992) and subsequent patterns in later life (Graham and Power 2004; Hertzman et al. 2001; Irwin et al. 2007), it is possible to show that from the moment of conception to the moment of death the human organism is subject to positive and negative forces originating in all four of the public health vectors. These accumulate during the lifetime to produce the health state of an individual at any one time. Sometimes earlier negative impacts will be cancelled out by later benefits and also previous benefits may be wiped out by some subsequent negative impact. However, mostly current health is a cumulative outcome of factors which impinge on the individual over their lifetime. The lifecourse sees health state at any given point in life as a cumulative health profit and loss account. The lifecourse attends to the fact that along life’s pathway, there are often critical moments when particular directions are taken which will have short and long term costs and benefits (Graham and Power 2004). Sometimes the pathway choice is largely driven by social circumstances; sometimes it is a real choice. But consequences there will be. So the type of job entered may be entirely driven by local labour markets, decisions to start to smoke by peer pressure, whether to use a condom on first intercourse, or not, by the state of alcoholic intoxication at the time and even the decision to add salt to food by cultural habit. But each of these actions has potential short and long term health consequences. It is important also to note that the trajectory through the lifecourse is not uniform, nor strictly speaking chronological, because the velocity and shape of the lifecourse trajectory of a boy born to white middle class parents in say Guildford, a rich and affluent city, and that of a girl born to Bangladeshi parents in Tower Hamlets, a poor part of inner city London, will most assuredly be different. The accumulated health benefits and insults and the critical decision points and opportunities will also mean they may follow quite different paths.

The lifeworld is the personal experience of the lifecourse. It is a private psychological subjective space where conscious cognitive processes operate. It is where thinking takes place and where perceptions of internal and external sense experience are lodged. It is where the human makes sense of the social and physical world around them. It is also the place where mind, by mediating external sense experience interacts with others external to self (Schutz 1964, 1967, 1970; Mead 1934). It is where the world of pain and suffering is experienced, where feelings of disadvantage are noted (Kelly 1996, 2001, 2006). It is where the physical world is interpreted as malevolent or benign. In this sense, the lifeworld is also a physical space where interaction takes place, not just symbolic interaction (in the mind) but the real physical interaction between people and the self. It is the place where the insults and benefits of the lifecourse are both experienced and are mediated.

Lifeworlds consist of internal representation of external and internal sense experiences (Hume 1748/2007). External interaction critically depends on having an inner sense of self. It also depends on that self making the assumption, that others who come into their lifeworld, and with whom they interact, perceive and see the world, and more or less make sense of it, in much the same way that the perceiving self does (Schutz 1964, 1967). Such an assumption can never be proven, and this has been a considerable source of anxiety for some philosophers who have ­concluded therefore that it is impossible to prove the existence of the external world at all (Berkeley 1713/1996). However, empirical confirmation that others see and interpret the world in much the same way as the self does, comes from two sources. First the future and external others’ behaviour tends to be reasonably predictable. Things on a day to day basis, on the whole, tend to turn out pretty much like the past of which we already have had experience. In that past others mostly behaved as if they saw things in the same way as self. Second the causal attributions which self makes tend to be confirmed by the way others see and understand and explain the reasons for events (Hume 1748/2007). Lifeworlds tend to consist of unexceptional confirmation that even though we know that things do change, mostly we live in a predictable world and that permits life to flow along without it needing too much philosophical speculation (Descartes 1997; Hume 1748/2007).

Of course things do change and people’s lifeworlds are sometimes subject to seismic shocks, some of which may be predicable, some of which may not, and life does change all the time. However, it is the predictability that is of particular interest here. The predictability resides in the fact that lifeworlds although subjectively unique are also shared and have a shared predictability. That sharing is cultural and coping in the lifeworld is the keynote to understanding vulnerability and assets. Lifeworlds work because people routinely solve the problem of intersubjectivity, i.e. anticipating well enough roughly what others are thinking and feeling in order to interact with them. This is because even though each cognitive lifeworld is unique, it exists in a cultural and social milieu in which experiences and meaning are shared. Shared backgrounds, patterns of socialisation, and indeed the recurrent patterning of social life at the social level, mean that there are large amounts in localised lifeworlds that are similar. So families, workmates, friendship groups, the primary attachments of social life, have the characteristic, not of producing exact copies of each other’s lifeworlds, but rather of lifeworlds where a great deal overlaps. Of course as people move through space and time their lifeworlds change and the potential malleability is large. But the coalescence of lifeworlds, the development of shared patterns of meaning and cultural assumptions produces a predictable patterning of everyday life and of interrelationships between different but overlapping lifeworlds. The patterning of disease at population level is a consequence of this. So because lifeworlds are shared among individuals who share social position, and who experience similar consequences of the social, population, environmental and organisational vectors, and their patterns of behaviour have high degrees of similarity, the individual disease pathways acquire a population level dimension.

Lifeworlds are the locus of experience, of pain and suffering, of discrimination and disadvantage, the place where the vagaries and the good fortunes of life as they are visited upon us and take their toll across the life course, have their direct effects. The social, environmental, organisational and population vectors produce individual level diseases through the lifeworld. Individual disease pathways manifest themselves and operate via the lifeworld of the individual. There are individual biological differences between individuals on account of genetics, nutritional ­status, previous disease exposure, indeed the accumulated benefits and insults of unique passages through the lifecourse. There are also differences in the assets with which people cope with their lifeworlds and along with individual biological differences, this produces individual health differences.

4 Coping in the Lifeworld

So far this essay has operated predominantly within what Antonovsky called a pathogenic approach (Antonovsky 1985, 1987). That is the assumption is made that bad outcomes have preceding bad or pathogenic origins or causes. Antonovsky famously observed that all of medicine and almost all of the social sciences have this orientation whether the purpose is to explain human disease or social pathology. Antonovsky’s work in introducing salutogenesis as the opposite to pathogenesis was truly a paradigm shift in the social and medical sciences, at least conceptually. In very simple terms he insisted that in the health sciences in particular, but also the social sciences, the search for the origins of health should be at least as important as the search for the origins of disease. This he called the salutogenic or origin of health-approach. His original insight came via two different observations. The first was of his early studies of health inequalities. He noted, in empirical investigations of American blue collar workers that although their rate of mortality was higher than white collar workers, when the greatly enhanced risks intrinsic to blue collar occupations, their poorer housing conditions and their greater poverty in old age were considered, the surprising thing was that their rates of premature death were not very much higher than they actually were. He reasoned that there must be protective factors at work which mediated the noxious effects of their lives. His second insight came from studying survivors of the holocaust. He was interested in people who had been imprisoned in Nazi concentration camps, survived and gone on to settle into ordinary and productive lives in post war Israel. The conventional (pathogenic) approach was to see the consequences of the appalling experiences of the concentrations camps as producing pathology in the form of subsequent severe psychiatric morbidity. The reality was rather different. While some concentration camp survivors were undoubtedly psychologically unwell as a consequence of their experiences, the majority were not. This was not to say that they were unscarred by their experiences but they had coped with them and returned to a new and ordinary life. Once again Antonovsky concluded that there must be some protective factor at work. He argued that both the American blue collar workers and the concentration camp survivors exhibited a similar underlying psychological resource which provided the key to their protection from noxious social conditions or produced equanimity in the face of extraordinary human suffering. He called this, the sense of coherence (SOC).

Antonovsky’s work recalls an earlier literature on coping, adaptation and survival (Dubos 1980). What was proposed was an underlying ontology in which the human is seen as living in world which is intrinsically threatening, dangerous, risky, noxious and stressful but with which they cope (Lazarus 1976, 1980, 1985, 2001; Lazarus and Folkman 1984a, b; Lazarus and Launier 1978). The reality of the human condition produced by the four vectors and mediated through the lifeworld is precisely this. The stresses and stimuli are chronic, originating in the vectors, only interrupted by more or less occasional periods of acutely high levels of even more extremely stressful stimuli. In this regard, humans are all subject to stresses all of the time because ordinary human life is a life of routine aggravation and difficulty. From time to time these are overlaid by major life events like illness, death of loved ones, divorce and war. There are in this view of things, relatively few periods of calm and peace in the human condition. The lifeworlds of most people most of the time are routinely difficult.

However, in spite of the ubiquitous nature of problems, most people more or less get through, and some deal with these things better than others. Some seem to have more assets with which to cope. To return to Antonovsky’s hypothesis, there must be something intrinsic to some people’s lifeworlds which produces a greater ability to cope. Antonovsky sought to find the answer in the idea of sense of coherence which fundamentally he conceptualised as a psychological trait. But this is only part of the explanation. It is more helpful to think of these assets not as psychological traits but as skill based transactions between persons and their environment.

There are four assets or groups of coping skills which help to clarify the way people survive their own lifeworlds. These are technical, interpersonal, intrasubjective and intersubjective. These are the four different types of skills or assets with which we master the lifeworld in varying degrees and therefore mediate the stressors originating in the vectors.

The technical level is about the technical tool based skills which people use to deal with situations and people, things and the environment. Humans have evolved the ability to fashion and to use tools. Tools take many forms, and include the use of language to shape thought as the most basic tool of all. Our access to tools, and our ability to use them skilfully, including in particular occupational and professional configurations, not only determines our place in the labour market, but also in the wider world and within our own lifeworlds. Skills are the basis in evolutionary terms of survival; this is because they are the basis of being able to handle and deal with everyday life.

Many years ago Max Weber the German sociologist pointed out that the possession of skills for use in the labour market was a powerful determinant of life chances, by which he meant access to, or the means to exert power over others (Weber 1948). This is still fundamentally true – although extending Weber’s ideas to skills to deal with everyday life, means we include not just professional market skills and qualifications but the ability to manage encounters with bureaucracy, handling money, to the technical skills which determine the ability to use devices and machines. This includes everything from using the internet, mobile phone, motor car, as well as reading writing and communicating. These tools allow for mastery of the lifeworld, and the ability to negotiate meaning and interaction. They are the principal mediator of life chances in the face of powerful others. They are, in other words, fundamental assets which allow persons to exercise control over the vagaries of their lives and in turn act as mediators against the ­negative forces which impinge on the person’s lifeworld.

The second key component of managing the lifeworld, the second asset, is interpersonal. This is about managing relationships with others. The basis of human society is interaction. Human interaction is made up of two elements. The first is actual physical interaction, either face to face, or through some electronic means like a telephone – which happens in real time. The second is symbolic interaction. This means that as, we physically interact with others, or as we anticipate or reflect upon interacting with others, we are also rehearsing symbolically in our minds what the other person is thinking and will themselves do next in response to what we do and say. We put ourselves figuratively in the shoes of the person with whom we are interacting. This ability to more or less accurately take the role of the other is the core component of what makes interaction work. Our management of relations with others and our ability to successfully interact provides us with a fundamental means of being able to control our lifeworlds (Mead 1934).

Life is made up of routine skirmishes as well as smooth transactions with bureaucracies, retailers, local councils, tradesmen, neighbours, workmates, relatives and friends. Most people have the interactive skills to take the rough with the smooth although a few do not (May and Kelly 1992). Although some of these interactions may be deeply unsatisfactory, we can at least extricate ourselves from them and move on to other arenas, where we can escape the hassle and deal with other more satisfactory aspects of our lives. But for some people their lifeworld consists of chronically difficult ways of interacting with others, be they neighbours, in the domestic environment, work, community and officialdom of various sorts. These interactions are characterised by struggles for the claim to be taken seriously as a human being (in relationships governed by legitimacy and authority). These claims are denied by others acting in ways which seek to exert power over them. In other words some individuals spend much more of their time having others define what and who they are, rather than being self directed. So at this micro level the ability to control the lifeworld is undermined.

The next assets are called intra subjective – inside the subject. At the heart of our lifeworld is the emotional or intra subjective epicentre. This is the world of raw ­feeling and emotion, of sensibilities and sensitiveness, of fear and hatred, of love and empathy, of all those psychological states of which the human is capable. It is also the cognitive and calculating seat of thinking and feeling. Modern psychology classifies these things in a variety of ways and of course psychoanalytic approaches offer degrees of insight into the origins of these feelings. The task here is not to arbitrate between the various approaches that may be brought to bear to explain these aspects nor indeed consider the great philosophical debates from Descartes and Berkeley onwards, which have sought to reflect on these concerns. The point is rather more simple. It is to acknowledge that the human is a thinking being, that is sensitive to its external environment and stimuli in it and, is capable of ­manipulating sensations and ideas into highly complex patterns of reasoning and understanding. As well as being a reasoning calculating agent with a ­continuous sense of itself existing through time and space, it is also a highly volatile emotional creature capable of feelings of great passion and emotion.

Most germane to the question at issue here is that those emotions and feelings can be decidedly painful and indeed distressing to the point of psychological ­morbidity. As Antonovsky observed, some people seem a lot more resilient than others to the stressful external stimuli which assail the human. So too some seem better able to withstand inner turmoil and distress. It might be thought of as varying degrees of an inner toughness or psychological resilience. We might bring into play Antonovsky’s sense of coherence, or some of the many other scales of psycho­logical resilience and coping which abound in the literature. Whatever of these mechanisms turns out in the next generation of empirical investigation to be the better explanation remains to be seen. But the inescapable fact is that the individual feels psychological distress. That psychological distress is itself linked to somatic changes in the human body. The link between the emotional state of the person and underlying biology is real, although all the precise pathways remain to be fully elucidated. In a model which focuses on assets, what we have here at the heart of the lifeworld is either a relatively robust set of mechanisms that mediate stressors, or a relative vulnerability offering at least a part explanation of the link between the social and the biological mediated via the psyche. This is not the whole story and will apply in some but by no means all, causes of morbidity. On the other hand working towards the kinds of mechanisms that can help to ­produce psychological resilience at the heart of the lifeworld, through formal techniques like cognitive behavioural therapy, or working towards greater self efficacy, offer very promising approaches.

The final asset is called the intersubjective, a term deliberately borrowed from phenomenological philosophy. In that context intersubjectivity refers to shared meanings between subjects, between human actors. Interaction depends on intersubjectivity. The basic assumption, as noted above, on which most human actors work is that they assume that other people see and understand the world in more or less the same way that they do. In real time during interaction shared meanings are not only assumed, but tend to emerge and change through processes of negotiation and testing during the interaction. Shared meaning is important because it provides the way humans make sense of the world. As humans we are constantly engaged in a process, usually at quite a low level, of providing psychologically satisfying accounts of our own actions, the actions of others around us, and in general of other events in the world. One of the most difficult and shocking things for us to have to deal with is where the accounts of the world we carefully rehearse and then test in interaction are undermined by the actions of others or by other external events. Reappraisal is called for as we then repair our sense of who and what we are and our place in the scheme of things. The ability to provide satisfactory accounts is at the heart of being able to cope with things great and small. The inability to do so leads to an overwhelming sense of dread and failure and psychologically terrifying experiences.

5 Conclusion: Assets to Control the Lifeworld

The lifeworld is the bridge between the social, psychological and the biological. Lifeworlds are psychological, social and physical environments which are the locus of experience and the arenas of shared experience. The lifeworld is the cauldron of vulnerability and risk and as well as the bastion of resilience, resources and protection. If we are to help individuals and communities to build their assets from the inside in a way that is essentially bottom up, the place to begin is with the four aspects of the lifeworld where the critical skills of coping, the assets, are located.

So first it involves building skills, (the technical level). These skills should be all embracing, from those which are necessary in changing labour markets, to those which facilitate management of mundane everyday life. This is so very important, not least because many communities at the sharp end of deindustrialisation, poor urban planning, chronic unemployment, crime, drugs and deeply engrained intergenerational social and health problems, have been stripped of their skill base. They have been disempowered. The response of the various well meaning agencies of support in social services and local authority services has frequently been to reinforce the dependency of such communities, by for example emphasising claimants rights, rather than fostering their skill base. The skill base begins in preschool education and continues in the school curriculum. But it applies more widely to a vast array of disciplined activities.

At the interpersonal level, assets will only be built if community members value each other as well as themselves. There are not infrequently strong social networks and some social capital to build on to develop the interpersonal skill base. But at the same time zero tolerance to individuals and families who wantonly disregard the interests of others, zero tolerance to casual violence and aggression in teenage gangs and assistance to the police to deal with the organised crime which preys upon such communities and sells them contraband tobacco and illicit drugs, is first base for the development of such skills. Trusting interpersonal relationships depend on a culture in which individuals feel safe and not under siege, and where tolerance does not mean ignoring or turning a blind eye to the fall out of drug misuse and vandalism and other forms of petty and more serious crime.

At the intrasubjective level the assets are built on the deployment of psychological resilience and self efficacy. These are not quite two sides of the same coin but are comparable as the core of psychological inner strength. The resilience plays out of comparable processes to Antonovsky’s conception of sense of coherence. This is probably best conceptualised in terms of Lazarus’ model of the stress coping paradigm. Here the cognitive processes involved in the holding things together in the face of stressors and adversity involve making an assessment of the nature of the threat from the external stimuli. The assessment that then needs to occur is whether the stressor is benign, irrelevant or even positive. It also involves determining whether the stressor is harmful that is it could lead to threat harm or loss. If the stressor is appraised as any of these, the next assessment is to determine what can be done about it. There are four lines of action viz. seeking information, taking some kind of action, doing nothing or worrying. It is possible to develop these ideas as a basic way of handling stressful circumstances and developing resilience. The self efficacy approach involves cultivating the view that the individual is basically on top of things and will be able to deal with them. There are a number of strategies all very well rehearsed by psychologists which outline the basic elements.

Finally, the intersubjective assets are about the sense that things are meaningful and make sense. It is perhaps the most difficult of all as it requires the skill to see the bigger picture and to see how one stands in relation to the whole. It is significantly linked to a perception that the social structure is predictable and reasonably fair. It is about a conception that the world is largely predictable, secure and continuous. The idea that Antonovsky had, that of sense of coherence, actually comes close to it. Intersubjectivity in its original phenomenological sense meant the cognitive process whereby meaning is generated between subjects – people – and is shared. In the sense used here it emphasises the importance not just of shared meanings or understandings between people, but is about the way of arriving at shared meanings which help make sense of a chaotic external reality and allow us to make sense of things in ways which ameliorate some of the deeply distressing and potentially destabilising external stimuli and internal stimuli. This has been a theme which perhaps the sociologist Emile Durkheim gets closest to in his conception of anomie (Durkheim 1897/1952, 1933). For Durkheim the anomic society was one which a plethora of competing values and norms, expectations and understanding vies for attention and destabilises familiar anchor points. He concluded that the transition from traditional to modern societies made this process more likely. Post modernist writers have picked up the same vein of multiplicities of competing values, ways of living and so on. Durkheim argued for the importance of strong civil society including associations, professions and the like as the bedrock of protection from the vicissitudes of a changing society. This has a very contemporary resonance in concepts like social capital. It is the small scale community organisations through to institutions which can be relied on like police, doctors, teachers, that produce the stability which makes navigation through the perils of modern life easier and more meaningful. So the asset base here in order to help to reinforce strong and resilient intersubjectivity is the basic building block at community level.

Assets can therefore be grouped into these four areas. They are potentially available to everybody, but they are only available to some and some people deploy them more skilfully. Like so many phenomena which originate in social behaviour they both arise out of the thinking acting human consciousness and then create the very environment which impacts on the behaviour in the first place. At least though in some degree, such assets are learnable through socialisation and education. And while they will never be universal, institutions and organisations from schools, medical services, social care, as well as almost all the public and private bureaucracies which provide support to people, can act in ways which nurture these skills rather than deny them, or worse offer rights based solutions which can never be realised in practice, since they are political aspirations, not rights at all. These assets, or vulnerabilities are important not only of course because they can be nurtured and even more easily destroyed and eroded, but because they are the intervening variables which mediate between the major vectors of causation of disease and individual health outcomes.