Overview and Introduction to Salutogenic Framing

Dr. Burns argues that for too long, society has viewed wellbeing through a pathogenic lens, which defines health merely as the “absence of illness or infirmity” [06:36]. In this view, public health is often likened to a person rescuing drowning people from a river, rather than going upstream to understand why they are falling in at all [08:22].

His alternative, the salutogenic framing, centers on creating wellness [07:21]. Key aspects of this perspective include:

• Navigating the “River” of Life: Instead of trying to avoid life’s problems entirely, we must learn to “navigate” through them [09:15]. This requires the ability to adapt, self-manage, and respond to environmental events [09:45].

• The Importance of Control and Purpose: Dr. Burns highlights that many individuals struggling with poor health outcomes—often labeled with “bad” behaviors like substance abuse—are actually reacting to a lack of agency, control, and purpose in their lives [16:45], [41:47].

• Sense of Coherence: Drawing on sociologist Aaron Antonovsky, he introduces the “sense of coherence”—the ability to perceive one’s environment and internal state as structured, predictable, and explainable [25:05]. A lack of this, often stemming from early life trauma or inconsistent parenting, can lead to chronic stress and negative biological/developmental consequences [25:55].

• Co-production and Empowerment: The solution lies in moving away from a system that “does things to people” based on bureaucratic targets, toward a model that asks citizens what they need to live a good life, builds trust, and empowers them to lead their own solutions [54:23], [55:42].

Summary of Key Themes

• Inequality and “Deaths of Despair”: Dr. Burns explores how inequality, rather than simple dietary or lifestyle choices, drives poor health outcomes in Scotland and beyond [11:27]. He links this to social fragmentation, economic instability, and “deaths of despair” (drugs, alcohol, and suicide), mirroring trends seen in other parts of the UK and the US [19:45], [21:20].

• The Science of Compassion: He details the biological impact of childhood adversity, explaining how inconsistent care alters brain development—specifically affecting executive function (prefrontal cortex) and stress response regulation (cortisol/glucocorticoid receptors) [31:31], [35:07].

• Transformative Interventions: Through various examples (e.g., the Broadway experiment with homeless individuals, the transformation of an estate in Cornwall), he demonstrates that providing support, mentoring, and autonomy—rather than just medical treatment or punitive measures—can lead to profound, sustainable improvements in health and wellbeing [48:14], [50:05].

The lecture concludes with a call to action for frontline staff and leaders to “do the right thing” for people, take risks, and foster a system that supports, rather than alienates, citizens [01:02:40], [01:23:15].

Video Referenced: Public Lecture Society, Community, Health and Wellbeing - Sir Harry Burns

The sociologist Aaron Antonovsky asked it. Working in the 1970s with survivors of profound trauma, he noticed something that the pathogenic frame — the standard medical focus on disease and its causes — could not explain. Some people, exposed to conditions that would predictably break most people, did not break. They remained functional, engaged, even healthy. What did they have that others did not?

His answer was the Sense of Coherence — a person’s capacity to experience their world as comprehensible, manageable, and meaningful. Comprehensible: the world makes sense to me, even when it is hard. Manageable: I have the resources to cope with what I face. Meaningful: it is worth the effort to engage with my life.

He called the framework that flows from this insight salutogenesis — health creation rather than disease prevention. The difference is not a matter of emphasis. It is a fundamentally different question. A pathogenic system asks: what is wrong, and how do we stop it from getting worse? A salutogenic system asks: what creates health, and how do we build more of it?

That question, asked of the challenge of artificial intelligence and its impact on work and the social contract, changes everything about how we respond.

The Social Contract and Its Foundations

The American social contract — the implicit agreement between citizens, employers, and democratic institutions about the terms of economic life — was never written down in one place. But its essential architecture is legible: work hard, develop skills, contribute to your organization and your community, and in return you will have income, security, identity, and a place in the social order. Your expertise will be valued. Your contribution will be recognized. The rules you learned will continue to apply.

This contract was always imperfect. It excluded too many people for too long. It concentrated its rewards inequitably. It broke down in specific communities and for specific populations in ways that produced decades of unaddressed damage. But for a significant portion of the American workforce, it was real enough to organize a life around. People built careers, families, communities, and civic identities on the foundation of its basic promise.

Artificial intelligence is breaking that contract. Not gradually, at the margins, in ways that allow for managed adaptation. It is breaking it at the center, at speed, in the sectors where the knowledge economy concentrated its most educated and credentialed workers. The legal researchers, the financial analysts, the software developers, the healthcare administrators, the professional services workers who built their lives on the premise that cognitive expertise was the secure foundation — these are the workers discovering, in real time, that the rules have changed. That the skills they spent decades developing are being automated. That the contribution they made is being replaced by a system that does not require their participation.

The standard policy response to this disruption has been organized almost entirely around the income dimension. Wage insurance, retraining programs, expanded unemployment benefits, universal basic income — these are the tools in the toolkit, and they address a real problem. When displacement occurs, income replacement matters enormously. It is necessary.

But it is not sufficient. And the salutogenic framework tells us precisely why.

The Triple Coherence Attack

AI displacement does not only remove income. It simultaneously attacks all three dimensions of the Sense of Coherence — and that is what makes it categorically different from prior economic disruptions, and categorically more dangerous to the foundations of democratic life.

Consider comprehensibility first. The social contract made the world legible. You knew what the rules were, what success required, what you needed to build to secure your place. Thirty years of investment in expertise produced a comprehensible relationship between effort and outcome. AI displacement breaks that relationship without explanation, without warning, and without providing a new framework to replace it. The rules changed and nobody told you. The skills you built on the assumption that cognitive expertise was durable turned out to be the precise target of the disruption. The world has become, in Antonovsky’s precise clinical sense, incoherent. It no longer makes sense in the way it used to make sense.

Consider manageability. The resources that made a working life manageable were not only financial. They were the professional identity built over decades of practice. The workplace community — the colleagues, the relationships, the sense of belonging to something larger than oneself. The daily structure of contribution and recognition that gave life its rhythm. The institutional knowledge and the tacit expertise that made a person feel competent and capable in their domain. AI displacement removes these resources simultaneously. It does not just reduce income. It eliminates the scaffolding of a manageable life.

Consider meaningfulness. Perhaps the deepest wound is to the sense that the investment of a lifetime has been worth it — that the effort to build expertise, to develop judgment, to contribute to an organization and a profession and a community, has produced something of lasting value. AI displacement attacks that sense directly. It says, in the most concrete possible terms, that the cognitive work you did can be replicated and improved upon by a system that requires none of what you spent decades developing. The meaningfulness of professional life depends on the sense that your contribution is irreplaceable, at least in some dimension. That sense is precisely what AI displacement removes.

This is what the clinical literature calls, in the context of individual patients, a coherence crisis. When it happens to one person, it produces anxiety, depression, identity disruption, and in severe cases, the kind of suicidal ideation that brings a 40-year-old engineer to a psychiatrist’s consulting room, brought by his wife because he has stopped functioning. When it happens to millions of workers simultaneously — as it is happening now, and as it will accelerate — it produces something that has a name in the historical record. It produces the social conditions that precede democratic breakdown.

Why Income Is Not Enough

The policy community is not unaware that something beyond income is at stake. Every serious analyst of AI displacement acknowledges the challenge of meaning and identity in passing. But passing acknowledgment is not the same as building it into the architecture of the response.

The standard policy toolkit addresses the income dimension with increasing sophistication: short-time compensation, wage insurance, portable benefits, sector-based retraining, an automation tax, a Public Wealth Fund, even a 32-hour workweek to distribute the productivity gains as time rather than money. These are real tools and they matter. But they share a common assumption: that if the income floor is maintained, the other dimensions of what work provides — identity, community, meaning, civic agency — will take care of themselves.

They will not. Antonovsky’s research was unambiguous on this point. The Sense of Coherence is not a byproduct of income security. It is built from specific experiences, over time, in specific institutional and relational contexts. It requires that a person’s world make sense to them in ways that go beyond financial stability. It requires that they have genuine agency over the conditions of their lives. It requires that their contribution be recognized as meaningful by the communities and institutions around them.

An income floor maintains the material conditions for a manageable life. It does not rebuild the comprehensibility, the relational resources, or the meaningfulness that displacement removes. A displaced worker receiving wage insurance and a retraining voucher has more financial security than one without. But they are still living in a world that has become incoherent — still navigating the loss of professional identity, still experiencing the disintegration of workplace community, still confronting the question of whether the expertise they built has any lasting value.

That is the gap in the current response. And it is not a small gap. It is the gap between a policy that prevents financial catastrophe and a policy that supports human flourishing. Between a safety net and a social contract. Between disease prevention and health creation.

What a Salutogenic Response Looks Like

A salutogenic response to AI displacement asks different questions than the standard policy toolkit. Not only: how do we replace the income that displacement removes? But: how do we rebuild the conditions under which workers can make sense of their world, manage what it asks of them, and find it worth the effort to engage?

Those questions have policy implications that go beyond the income floor.

On comprehensibility: workers need accurate, accessible, democratically legible information about what is happening to them and why. Not the techno-utopian narrative that erases the disruption, and not the apocalyptic narrative that makes the future seem beyond influence. The comprehensibility that supports health is built on honest engagement with real conditions. The Citizen Briefs that Moonshot Press has developed for the People’s Council are an attempt to provide exactly this — not advocacy, but structured comprehension. Here is what is happening. Here is why it makes sense that you feel this way. Here are the policy tools available to respond to it. Here are the questions you should be asking your elected representatives.

On manageability: the resources that make a working life manageable need to be rebuilt deliberately, not assumed. Professional retraining, when it is done well, does not only replace credentials. It connects displaced workers to a new occupational community — new colleagues, new professional identity, a new context for contribution and recognition. The care economy proposals in the current policy toolkit are, at their most ambitious, precisely this: not just a sector with labor demand, but a professional community in which displaced workers can rebuild a sense of competence, connection, and contribution. Time banking — the creation of community exchange systems in which hours of service earn tradeable credits — is another institutional response to the manageability dimension. It builds economic infrastructure for the non-wage dimensions of work: the contribution, the recognition, the network of mutual obligation that makes daily life feel navigable.

On meaningfulness: the deepest salutogenic challenge is rebuilding the sense that human contribution matters in a world where AI systems can perform an expanding range of cognitive tasks. This is not primarily a policy problem. It is a cultural and institutional one. It requires deliberate investment in the contexts in which human contribution is irreplaceable — care, community, democratic participation, creative work, the relational dimensions of education and healthcare and civic life. The care economy investment that is recommended in the AI transition policy toolkit is, from a salutogenic perspective, not simply a workforce absorption strategy. It is an investment in the sectors of human life where meaningfulness is most directly produced and most urgently needed.

The Democratic Stakes

The salutogenic framework has one more implication that goes beyond individual wellbeing and workforce policy. It is an implication about democracy itself.

Antonovsky’s research established something that has been confirmed many times since in the public health literature: that the conditions for health are not only individual. They are social and institutional. A person’s Sense of Coherence depends not only on their internal resources but on the degree to which the institutions around them — the workplace, the community, the political system — are themselves coherent. A person living in an institution that is comprehensible, manageable, and meaningful is more likely to be healthy than a person living in an institution that is opaque, unresponsive, and purposeless.

Democratic institutions are, at their best, salutogenic. They provide comprehensibility — citizens understand how decisions are made and how they can influence them. They provide manageability — citizens have genuine tools for participating in the governance of the conditions of their lives. And they provide meaningfulness — civic participation connects individual citizens to something larger than themselves, to the common project of self-governance.

AI displacement is attacking democratic coherence on all three dimensions simultaneously. The policy process for responding to it is opaque — dominated by the companies building the technology, by the investors funding their expansion, and by the advisory councils populated by the same executives whose financial interests are served by rapid deployment with minimal constraint. The tools available to ordinary citizens for influencing that process are inadequate to the scale of the challenge. And the narrative surrounding AI — oscillating between techno-utopian abundance and apocalyptic doom — offers citizens almost nothing in the way of genuine democratic agency.

The salutogenic proposition, applied to democracy, is this: citizens are not passive recipients of disruption. They are sovereign. They hold authority over the conditions of their own lives. And they are entitled to democratic institutions that are comprehensible enough to navigate, that provide genuine tools for participation, and that connect their individual lives to the meaningful project of self-governance.

That is the standard against which the current response to AI displacement should be measured. Not only: does it maintain the income floor? But: does it rebuild the conditions under which citizens can remain whole — comprehensible to themselves, capable of managing what the transition asks of them, and genuinely convinced that democratic participation in shaping that transition is worth the effort?

That is what the salutogenic framework demands. It is a higher standard than the one we are currently meeting. It is also the only standard adequate to what is at stake.

“The care of human life and happiness, and not their destruction, is the first and only legitimate object of good government.” — Thomas Jefferson

Shimon Waldfogel, MD is the Founder and Publisher of Moonshot Press, President of the Institute for Salutogenesis, and Director of Project 2026. He practiced geriatric psychiatry for approximately thirty years before transitioning to civic entrepreneurship. He is based in Blue Bell, Pennsylvania.

Moonshot Press · Institute for Salutogenesis · Thrive in Montco PA moonshot.press · thriveinmontco.substack.com · mysaluto.org

For over a century, medicine has been driven by a single question: What makes people sick? This question has led to remarkable advances—vaccines, antibiotics, surgical techniques that would seem like miracles to our ancestors. But it’s also left us with a blind spot.

What if we also asked: What makes people healthy?

This isn’t just wordplay. It’s a fundamental shift in perspective—one that opens up entirely new possibilities for how we approach wellbeing. This shift has a name: salutogenesis.

The Birth of a New Question

The term “salutogenesis” comes from the Latin salus (health) and the Greek genesis (origin). It literally means “the origins of health.” The concept was developed by medical sociologist Aaron Antonovsky in the 1970s, and it emerged from a striking observation.

Antonovsky was studying women who had survived Nazi concentration camps. As expected, many survivors showed lasting psychological trauma. But what caught his attention was something else entirely: a significant number of these women were thriving. Despite enduring unimaginable horror, they had somehow maintained their mental and physical health.

This puzzled him. How was this possible?

Rather than asking what broke down in those who struggled (the traditional medical approach), Antonovsky asked what enabled some people to stay well despite overwhelming adversity. This question led him to develop the salutogenic model—a framework for understanding what moves people toward health and flourishing.

The River of Life

Antonovsky used a powerful metaphor to illustrate the difference between the traditional approach and salutogenesis. Imagine life as a river.

The traditional medical model positions doctors as lifeguards standing downstream, ready to pull drowning people from the water. They intervene when things go wrong—treating illness, managing disease, responding to crises. This is essential work, but it’s reactive.

The salutogenic approach asks different questions: What determines how well people can swim? What makes the water calmer in some stretches? Can we teach people to navigate the currents? Can we improve conditions upstream?

The river metaphor acknowledges something important: we’re all in the water. No one stands safely on the shore. Life inevitably brings challenges, stressors, and hardships. The question isn’t whether we’ll face difficulty—it’s whether we have what we need to keep swimming.

The Sense of Coherence

At the heart of salutogenesis is a concept Antonovsky called the Sense of Coherence (SOC). This isn’t a personality trait you either have or don’t have. It’s more like an orientation toward life—a deep, enduring confidence that:

1. Life is comprehensible. The world makes sense. Even when difficult things happen, they aren’t random chaos. You can understand, at least to some degree, what’s happening and why. This doesn’t mean everything is predictable—just that events can be placed within some coherent framework.

2. Life is manageable. You have (or can access) the resources needed to meet life’s demands. These resources might be your own skills and strengths, or they might come from others—family, friends, community, institutions. The key is believing that challenges can be addressed.

3. Life is meaningful. Your existence matters. The demands of life are worth investing in. There are things you care about, purposes worth pursuing, reasons to engage rather than withdraw.

Of these three components, Antonovsky considered meaningfulness the most important. Without a sense that life is worth the effort, people are unlikely to seek understanding or mobilize resources when challenges arise.

People with a strong Sense of Coherence don’t necessarily have easier lives. But they tend to navigate difficulties more effectively. They perceive stressors as challenges rather than threats, identify and use available resources, and recover more readily from setbacks.

Resources for Thriving

If the Sense of Coherence is the orientation that helps us navigate life’s waters, what shapes that orientation? Antonovsky identified what he called Generalized Resistance Resources (GRRs)—the factors that help us manage stress and move toward health.

These resources are remarkably diverse:

• Material resources: Financial security, housing, access to healthcare

• Knowledge and intelligence: Education, skills, the ability to learn and adapt

• Social support: Relationships, community connections, a sense of belonging

• Cultural stability: Shared values, traditions, a sense of identity

• Coping strategies: Problem-solving skills, emotional regulation, flexibility

• Physical factors: Good nutrition, exercise, adequate rest

What matters isn’t just having these resources, but the life experiences that come from engaging with them. When we repeatedly face challenges and find that we can understand what’s happening, marshal appropriate resources, and find meaning in the struggle, our Sense of Coherence strengthens.

This begins in childhood. Children who grow up in environments where life is consistent (comprehensible), where they’re given responsibility matched to their abilities (manageable), and where they’re valued and included (meaningful) tend to develop stronger orientations toward coherence.

But this isn’t deterministic. While early experiences matter, the Sense of Coherence can be strengthened throughout life through positive experiences and supportive environments.

A Systems Perspective

The salutogenic paradigm recognizes that health isn’t just an individual matter. We exist within interconnected systems—families, communities, institutions, cultures, ecosystems. Our wellbeing is shaped by forces at every level.

This means that promoting health requires thinking beyond individual behavior change. Yes, personal choices matter. But so do neighborhood design, workplace policies, social services, economic conditions, and cultural values. A systems approach asks how we can create environments that naturally support flourishing—that help more people develop the resources and orientation to thrive.

This perspective also bridges disciplines. Understanding what creates health requires insights from medicine, psychology, sociology, economics, urban planning, education, and beyond. No single field has all the answers. Salutogenesis provides a framework for integrating these perspectives toward a common goal.

Beyond Fixing What’s Broken

Perhaps the most profound implication of salutogenesis is this: health isn’t merely the absence of disease.

The traditional model positions health as a baseline that illness diminishes. Treatment aims to return people to that baseline—to fix what’s broken. But salutogenesis suggests that health exists on a continuum. Even without disease, there are degrees of vitality, of flourishing, of optimal wellbeing.

This shifts our aspirations. We’re not just trying to avoid sickness. We’re asking what it means to truly thrive—and what conditions make that possible.

This doesn’t mean abandoning the disease-focused approach. When people are sick, they need treatment. But it does mean expanding our vision to include health promotion, not just disease prevention. It means designing systems that help people flourish, not just survive.

Why This Matters Now

We face challenges today that the traditional medical model wasn’t built to address. Chronic diseases, mental health struggles, loneliness, burnout—these aren’t problems that can simply be fixed with a prescription. They require understanding the conditions of our lives and how those conditions support or undermine our wellbeing.

At the same time, we’ve accumulated tremendous knowledge about what helps people thrive. We understand more than ever about the social determinants of health, the importance of meaning and connection, the power of community, the foundations of resilience. What we often lack is an integrating framework—a coherent way to think about all these factors together.

The salutogenic paradigm offers that framework. It provides a theoretical foundation for understanding health promotion, a practical orientation for designing interventions, and a hopeful vision for what’s possible when we focus not just on avoiding harm but on creating the conditions for human flourishing.

In future posts, we’ll explore specific applications of the salutogenic paradigm—from individual practices that strengthen the Sense of Coherence to community and policy approaches that create health-promoting environments. We’ll examine the research evidence, share practical tools, and consider what it would mean to build a truly salutogenic society.

The Institute for Salutogenesis exists to advance this paradigm—through research, education, and advocacy. We believe that asking “what creates health?” has the power to transform how we approach wellbeing at every level.

A salutogenic focused approach to health and wellbeing is based on the concept that good health is not just the absence of illness, but the presence of positive physical, mental, and social wellbeing. This approach emphasizes strategies to promote health and wellbeing, rather than simply managing illness and disease. In other words, what allows the individual, confronting the many stressors of life, to maintain wellbeing and flourish.

The salutogenesis concept has been adopted in many sectors and organizations, including National Institutes of Health, NASA, some departments within medical schools in the US and International public  health organizations.  Recognizing its increasing relevance, the word salutogenesis has recently been added to The Merriam-Webster dictionary. 

“Salutogenesis“ an approach to human health that examines the factors contributing to the promotion and maintenance of physical and mental well-being rather than disease with particular emphasis on the coping mechanisms of individuals which help preserve health despite stressful conditions.”

Summary of Characteristics of Antonovsky’s Salutogenic Orientation: 

• Rejects the dichotomous classification of healthy and diseased in favor of a multidimensional health/disease continuum.

• Focuses on the total story of a human being, including their sickness, rather than solely the etiology of a disease.

• Asks what factors are involved in maintaining or improving one's location on the health continuum, rather than focusing on stressors.

• Recognizes that stressors are omnipresent, and the consequences of stressors can be salutary if the stressor is successfully resolved.

• Seeks to find all sources of negative entropy that can facilitate active adaptation of the organism to the environment.

• Looks at deviant cases found in traditional medical inquiry to gain a deeper understanding of health.

• Recognizes the role of social determinants of health in determining individual outcomes and expands potential interventions to include those directed at the individual, community, and broader cultural and political levels.

• Provides a richer understanding and suggests strategies to engage with challenges brought about by changes in economic, social, and cultural conditions.

• Facilitates communication and collaboration between health sciences and professions.

• Translates research findings into an individual-based action plan and focuses on the sense of coherence in understanding stressors, managing them and find them meaningful.

(Based on Antonovsky, 1987, pp.12-13) From Design for Human and Planetary Health - A Holistic/Integral Approach to Complexity and Sustainability - PhD Thesis Introduction -Daniel C. Wahl - 2006

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