Interview by Tom Peterson

Gary Gunderson serves as Vice President for Faith and Health at Wake Forest Baptist Medical Center. He is known for more than two decades of creative work in the field of faith and public health initially at The Carter Center and Emory School of Public Health. In Memphis his ideas found ground through 530 congregational partners showing hard evidence of significant improved outcomes including mortality, cost and dramatically lower hospitalization. He is a frequent speaker and author of several books, including Religion and the Health of the Public, with James Cochrane; Leading Causes of Life, with Larry Pray; Boundary Leaders; and Deeply Woven Roots. He serves as secretary of Stakeholder Health and blogs regularly at garygunderson.net.

How did the idea of Leading Causes of Life come about?

Now, I’m a non-technical non-healthcare trained person who’s been immersed in years of discussions about what congregations and faith have to do with public health. The interest in faith was always governed by some program that was actually motivated by some leading cause of death—a smoking program, an obesity program, and so on.

My first book, Deeply Woven Roots, was a response to that. If you want to work with congregations, you have to understand that structures of faith (like churches or denominations). You have to slow down and understand their DNA and social strengths. They’re usually more complicated than a nonprofit.

I had been frustrated for some time about the limitations of the discussion—this cause of death, that cause of death. I began to wonder if there were an opposite.

This came to a head when I was asked to speak to an infant mortality conference in Milwaukee in 1998. Dr. David Williams spoke before me. He spoke about how to talk about race and health. He described the pathological connection so well, I felt there was nothing else to say. But he also created a moral sense of urgency: how do you actually respond as a person of faith in the context of the toxicology, this wicked stew? I knew he was talking about infant mortality. But you could just as well have been talking about any of the other leading causes of death. I went to the microphone and said that the urgent intellectual work no longer lies in understanding the leading cause of death; it’s to understand the leading causes of life.

What are the five causes?

Connection

Connection is the way we humans are linked to each other. There’s no such thing as a single human. It’s the way we find our lives in complex relationships, most of which don’t have names they’re so complex. It’s beyond the simple nuclear family. It’s how we are part of lives in complicated ways, in complex relationship webs. Our brains are organized for this social complexity. We can recognize instantly 25,000 different faces. So our most fundamental wiring is capable of social complexity far beyond what we have language to describe.

The edge of biochemical science is finding more and more evidence of the fantastic ways we’re linked to each other in a way that it’s impossible to find a solitary autonomous human.

This is every kind of connection: our birth family; the intimate connections along our life journey; the connections of faith, culture, neighborhood; and the relationships of work and those we find ourselves in times of radical crisis.

All five leading causes enable each other. Together, they create a vital relationship that allows us to adapt. They enable what Nathan Wolfe would call adaptive novelty. We’re able to find new answers to new opportunities and challenges. Jonas Salk had an insight in survival of the wisest: very few of our human capacities and responses are hard wired. Most of our ways of adapting are in culture. So the causes of life give us the capacity to go beyond the reactive hard wiring that shape other animals.

Our brains are built for complex social relationships. That’s how we find food, water, and defend ourselves against large wooly mammoths. It’s been in only a short period of human history that we’ve been able to develop technologies and social innovations that allowed us to thrive.

So, we are able to find our life through connections.

Coherence

Coherence is the deep-gut level feeling that life makes sense. The concept owes much to the work of Aaron Antonovski, a sociologist who studied relationship between stress, health and wellbeing. Humans are able to survive and thrive if we think life makes any sense at all. The boundary between pre-human and human begins when we began making images, like painting herds of buffalo on cave walls. They were clearly imagining their place in the world, thinking about the meaning of life.

This is why religion, faith, art and most of our language go far beyond simply functional communication of instrumental tasks. People are moved and find our lives through narrative to understand how we live and what our lives are for.

Agency

I was in South Africa while I was thinking through the leading causes. I was reluctant to talk about it in this context of the catastrophe of HIV/AIDS because it sounded too positive, too cheerful. But the Africans grabbed it, saying it’s a very African idea. That’s where I learned the language of agency—in the radical disconnection of apartheid, the shattering of families from HIV/AIDS, and the incoherence of apartheid using religion against people. Even in that setting people made choices to move, to do. They worked, healed, resisted. Those are all expressions of agency.

Agency is the human capacity to choose and do, to move towards life. The medical method is to identify a pathology and defeat it. What’s actually going on in any human is more complex than that. These causes of life were innate to humans before we were writing down anything. They are the essence of the human capacity to thrive.

We’re just giving some language to something that’s already there. That’s five words more than medicine usually notices. Sometimes agency is the only cause of life you have to work with. Life may be incoherent; you may be disconnected. But you still can get up in the morning and move. It’s a fundamental capacity to choose to move toward life. It’s not resisting death, it’s an expression of a seeking of life. It’s a positive choosing.

Generativity

The fourth cause is generativity. It’s the quality of knowing our relationship to those who have come before us and those after us who will benefit from our life. It’s concern for those beyond our family. It speaks to the multigenerational web of life and to the obvious biological fact that someone generated me. Awareness of this multigenerational flow of life makes us make different choices and gives us a sense of gratitude, momentum, responsibility and accountability.

This is the most grownup of the five causes. This is why older adults sacrifice their own future on behalf of their own children or institutions they love or communities that have given them life. Carl Jung said that the first half of one’s life appropriately focuses on primal family responsibilities. The second half is for larger social life.

In generativity, grownups make investments, give themselves to more than their own biological spawn. It’s common for us to give our life to something greater that isn’t just biologically necessary, for example, those who give their lives in military service. Highly vulnerable communities that struggle with different kinds of violence are often alive at all because of grandmothers and uncles who themselves find their life in making themselves vulnerable to that larger neighborhood. The human species simply wouldn’t survive if we’d not found our lives in, and given our lives to, the work of generativity.

Dr. Joyce Eissien tells the story of interviewing older women about what they felt should be the priorities of health. Their number one concern was teenage pregnancy. Asked why this was a priority, one of the grandmothers answered, “You help these young girls and I’ll sleep better. Don’t worry about me.”

In practical terms, many of us work for institutions that were not created in our lifespan and that we hope will live beyond us. Community assets, such as churches, have longer lives than any of their members. The life of the community depends on the social structures that outlive any of us.

Hope

The easiest and best-documented cause is hope. In leading causes of life terms it’s expectation. Not just any expectation, but risky expectation. Anticipation. It’s the future and possibilities you see clearly enough that you can take risks to make it happen. In medicine, it’s well documented that mere optimism has a huge influence on the course of disease or recovery from injury.

It’s so powerful that when we test drugs we go to extreme lengths to hide the test from the people precisely because hope and it’s opposite, fear, are often more powerful than biology or chemistry. Our research apparatus has to keep hope and fear out of the equation so they don’t mess up the results.

I don’t mean mere optimism. These ideas are sure not “happy talk,” as cowriting with Larry pray made sure. This hope is grounded in the connections that give us life. It reflects the deep coherence; it both informs our agency and is informed by the collective agency where we find our life. It’s a hope for what I value deeply in life, so it’s generational. My mother died hopeful, because she knew that the things that mattered most to her would live.

For other mammals most even complex behaviors reflect memory. For humans, hope functions like a memory of the future. The future is so powerful it’s as if we remember it; it shapes our actions like memory. For example the greatest predictor of lifespan is how long you think you’re going to live.

Can you give an example of how using the leading causes of life can help us understand a real-life situation?

The more social the question, the more the leading causes of life help. Inside the health world, the more chronic the condition, the more you have to have to know about the causes of life to deal with the condition. In Memphis, when we started the Congregational Health Network, working with black churches, there was a huge burden of pathology to deal with, toxins in the soil, bad education, violence, joblessness, the constant insults of race.

The language of leading causes of life resonated deeply in the black churches because they wanted to know what they had to work with. They could trust a partner who knew there was more going on in the black church than death. Why would you relate to someone who thought that you were only in a trajectory of death? What we saw in Memphis was a complex social system organized around the leading causes of life. They were alive.

I told them that the hospital knew only about disease. But the data said that the African American males who reported that they merely attended church had a life expectancy 14 years longer than those who reported that they don’t have a faith community. That has extreme effect. It has to do with connection, coherence, agency, generativity and hope.

On the other hand, you may be trying to engage the complex social pathology of your community as a city planner, hospital administrator or businessperson. It’s useful for anyone trying to figure out how to deal with the social phenomenon of their city to have language and a logic to help see the life that’s already there. That’s really all you have to work with. In all of your interventions—whether you’re a physician working with a family with diabetes or the mayor—all you have to work with is the life that’s already there.

The first question should be: Where in this situation is the life we have to work with? This has to be asked simultaneously with what’s the problem? You can’t respond to the problem unless you have some sense of what to you have to work with.

Can you describe one of these complex places where you’ve seen the causes of life at work?

Think about Africa, with HIV/AIDS when there were 20 million aids orphans. You don’t see these numbers anymore. It’s been an unprecedented human catastrophe. In the early days, UNICEF went to survey African villages to find out what programs they needed to develop to work with these AIDS orphans. Almost everywhere they went they discovered that outside the village, a women’s group had created something to take care of about 100 orphans. No one knew if these orphans were infectious, so they were treated like lepers and not allowed into the village. They were not the women’s blood children. It turned out these groups were actually doing a pretty good job.

So it turned the question around for UNICEF to: what already exists in the village, where you wouldn’t expect it? In fact, there was life in the village capable to recognizing the extraordinary power of relationships. There was no word for the relationship between those children and those women. But their brain had no trouble figuring it out. There’s no coherence; no one understood it. It was an unspeakable religious phenomenon. And the women had an enormous sense of agency. They bought food, water, and the kids had agency. They didn’t give up on the next generation.

Where there was no hope, they created it. That’s how the causes of life work: you begin with the cause you can find and you nurture it. And through that focus the other causes become evident. Sometimes it’s simply raw agency. Hope came out of it. Of that generation of 20 million AIDS orphans, most of them turned out okay. Most kids raised in the toughest neighborhoods of Americans cities turn out okay. The leading causes of life language helps explain this.

How do these leading causes work on a more intimate level?

Look at your own lifespan. If you’re in a time of personal transition—such as going through a divorce or beginning a new relationship—the causes of life help open your imagination about choices you can make that would align with a life that’s trying to happen in you. You can reflect on the connections most vital in your life and move toward them. You can reflect on the things that look like death and move away from them. Even when you’re looking on this as a personal life evaluation, it’s profoundly social. It’s good for us as individuals to see how we’re connected and generating other life.

Life is not something we get, have and hold. Rather, life flows through us like a river flows through a channel. Happy people are the ones who have found their lives and given it to others. Any therapist will tell you that obsession with ones own wellbeing doesn’t make you happy. The social nature of leading causes of life is corrective of our current obsession with self.

Our culture is full of marketing that endlessly tells you what you need to improve your life. It exalts the subject of your own self—to sell you something. But that’s a false promise. Leading causes of life is not an alternative, it’s a radically different way of naming reality that’s more aligned with our best human thinkers and the people you’d most want to be like. You can use this theory about individuals but it’s not designed for that. It’s really about a human standing in the face of humans I care about: what do I do? The answer is to nurture the life of that which you love.

So the leading causes of life makes sense at different scales?

Yes, it works at every social scale. You can think of planet-level connections. We know we’re connected with people in parts of the world we’ve never heard of. Those connections can be toxic or associated with life. You can care about the whole world, and many who do are filled with a fear. But as we think about problems we can solve, it helps to think in terms of connections, for example, the millions of nonprofits. Connection is a wonderfully vital human reality right now.

Photo: Gary Gunderson in Independence Hall.