Humanity's responses to the Covid-19 pandemic has been variable and often chaotic. This presentation attempts to use 'Sense of coherence' and 'Ikigai' as 2 lenses to gain a holistic perspective of the varied human responses to the pandemic crisis of 2020. Comprehension or understanding, Manageability or coping-behavior, and Meaningfulness are the three components of Sense of Coherence (SOC), first proposed by Antonovsky. Ikigai is a Japanese concept of one's 'Purpose of Life', which has been modified by a life-coach from the West. Using SOC and Ikigai, we can try to get a holistic understanding of the varied responses of humanity across the globe.

1. Using Two Lenses
(Sense of Coherence & Ikigai)
for Holistic Understanding of
Humanity’s Responses to the
Pandemic
Dr KR Sethuraman.
Senior Professor and Medical Dean,
AIMST University, Malaysia

2. “Nothing Is As It Seems, Nor Is It
Otherwise.” – A Zen Saying.
• The truth we perceive may not represent the Real truth.
• We perceive our version of truth within the brittle framework
of language*, logic, symbolic thought and personal beliefs &
values.
* Mokusatsu, a Japanese word could be translated as “no comment”
or “withholding comments” was translated as “let’s ignore the final
warning” as response to the call for Japanese surrender in W-War-2
– The first atomic bomb was dropped on Hiroshima 10 days later.
– A translation error that killed >70,000 people instantaneously and
>100,000 as a result of the destruction and radiation.
Indeed, Nothing Is As It Seems, Nor Is It Otherwise!!!
• Please have an open and receptive mind for this presentation
* Ref: https://www.pangeanic.com/knowledge_center/the-worst-translation-mistake-in-history/#

3. Today’s Agenda
• Introduce concepts of Sense of Coherence (SOC) and Ikigai
(Japanese word for ‘reason to live’)
• Consider the varied and often contradictory responses of Humanity
to the Pandemic-2020
• Use SOC and Ikigai as two Lenses, try to understand the basis for
such human behaviours
• Consider the proactive action by Doctors, Public Health
campaigners and the rulers to provide effective relief to the
affected
– My article of June-2020 related to this topic for free download:
https://www.ajmhsrcmp.org/images/journal/Vol3_Issue1/SethuramanKR_AJMHS_2020
_Vol3_Issue1_ReviewArticle_COVID19.pdf (Asian Journal of Medicine & Health Sciences)

4. What is a Crisis Scenario?
• “The meaning of a crisis lies not in the situation but in the
interaction between the situation and the ability of the person to
successfully cope with it”. – WI Thomas (1863-1947)
• Like most crises, the Pandemic-2020 too has five components
(Roberts et al, 2005)
– a hazardous event viz., the emergence of a mutant corona virus SARS-
CoV-2 or Covid-19
– a vulnerable state of Human beings, viz., the absence of protective
antibodies to combat the virus
– a precipitating factor, which is uncertain and is still being debated
– an active crisis situation, which is based on people’s perception of
danger
– the resolution of the crisis, which in the case of CVP-2020 may take
several months more to achieve.

5. Sense of Coherence
– Aaron Antonovsky
• Based on study of the survivors of Nazi atrocities, Antonovsky
proposed Sense of Coherence (SoC) as the basis of ‘wellness’
• A strong SoC helped that individual to cope better with
stressors (such as the CV-Pandemic-2020)
• He enunciated that SoC had three components:
i) Comprehensibility: “do I truly understand my situation and
the reasons for my stress?”
ii) Manageability: “do I have the resources to cope with it?”
iii) Meaningfulness: “do I feel it is worth my time and effort to
manage it?”

6. Sense of
Sense of Coherence: 3 components…
“My world is
understandable”
“My world is
manageable”
“My world has
meaning”
Coping
24/06/2020 6Salutogenesis in Family Medicine

7. I – Comprehension or Understanding
• Emotional or ‘visceral’ reactions of people to a crisis greatly
influence their ‘cerebral’ understanding of the crisis and a
rational approach to cope with the challenges
• In relation to the global crisis of CVP, it has been a "gut"
versus "brain" battle (right from Nov-2019 in Wuhan, China)
• Public health experts predict very challenging times ahead &
at least a few years of living with the "New Normal"
• If we think in rational and cerebral way, we would accept this
and adopt the new-normal behaviour to be safe
• However, wishful thinking, resistance or denial make people
ignore these instructions and put themselves at risk

8. Misunderstanding is
Common!
In DLE,
Only
5% SLE
In SLE,
DLE in
20%
A Textbook of Medicine:
1- Skin diseases: Only 5 % of
Discoid Lupus goes on to Systemic
Lupus; REASSURE the patients of
DLE
2- Auto-immune diseases: 20% of
SLE start with DLE; therefore,
WARN all the DLE cases to watch
for Systemic Lupus
A medical example from 2004

9. II – Manageability
• Antonovsky said that the sense of coherence enabled one to
focus on adapting to the crisis and remain well even in a
stressful milieu; in contrast, lack of coherence lead to
Maladaptive coping behaviour that put them at risk
• He proposed that to manage the challenge effectively, one
required General resistance resources (GRRs) and Specific
resistance resources (SRRs)
• Therefore, to face the pandemic and remain well, adequate
and effective resources are available to the people to meet
the challenges of CVP-2020;
if not, the people will choose other means of coping with the
crisis

10. General Resistance Resources (GRR)
to cope with the challenges
• GRR includes material & non-material resources
• Antonovsky classified GRR into 3 types:
(1) Adaptability at a personal level, viz., biochemical, physical,
psychological and socio-cultural aspects of the individual
(elderly & those with comorbidity are vulnerable to CVP)
(2) Deep & Meaningful bonding with others, such as family
members and friends
(frontline workers in CVP need Love and Support; Not HATE)
(3) Committed support system and effective links between
the person, his/her community and the supporting agencies
(If only our migrant labour force had been looked after well…)

11. Specific Resistance Resources (SRR)
• Antonovsky stressed on the importance of SRR
• SRRs are effective in specific circumstances causing the crisis,
e.g, in case of the CVP-2020, the SRR would be:
i. a vaccine, PPE etc, to prevent the Covid-19 infection
ii. specific medications to mitigate/treat the disease
iii. critical care facility to manage severe cases
iv. monetary and other support like transport etc.
• Availability of and accepting the use of GRRs and SRRs enable
the people to actively face the crisis and to remain well even
under the stressful situation

12. PANDEMIC
WELLNESS
Vulnerability vs Resistance to Stress
GRR & SRR
Lack of SOC/GRR/SRR
24/06/2020 12Salutogenesis in Family Medicine

13. III – Meaningfulness
• An acceptance that the additional demands created by the
challenge are worth my money, time and effort to resist it;
also embracing curiosity and a sense of adventure
– “it is an once in a life time crisis that will stay in our minds for
decades”
• Meaningfulness is highly personalized as every individual has
a unique set of personal beliefs and values.
• Every one perceives all that happens around him/her through
these filters.
• Biases may promote adaptive (eg, “constructive paranoia” or
“prepare for the worst & hope for the best”) or maladaptive
(eg, avoidance, denial, fatalistic negativism etc) behaviour

14. Some of the Coping Strategies in the context of
CVP-2020: Adaptive & Maladaptive
• Anticipatory problem solving: the individual is proactive to prepare for
all eventualities in a rational “cerebral” way
• Accepting Responsibility: the individual takes responsibility in boldly
facing up to the challenges – e.g., cycling home long distances
• Dependence on social support: such people depend on relief-providers
• Confrontation: one meets the crisis head-on and persists until achieving
the goal in a constructive way or a destructive way
• Denial: a false belief that nothing has really happened and that people
always exaggerate – (VIPs ignoring all the safety precautions)
• Escape or Avoidance: belief that they do not have to follow any advice
as the crisis will vanish soon (misplaced faith in superstitions)
• Lack of Self-control: Those, who exhibit their anxieties through social
media and contribute to the infodemic & panic
(https://www.verywellmind.com/social-network-use-and-social-anxiety-disorder-4117143)

15. Humour as a Coping : When life gives you a
pandemic, it is okay to laugh about it
God gets a police-ticket for
‘touching Adam’ !
NEW NORM: Security
staff Checks the
Temperature of
Doctor and Nurse !

16. How Personal Biases affect Human Responses to
CVP-2020 – some examples
• Depending on the individual beliefs, people may ascribe the
CVP crisis to
– astrology (malevolent planetary positioning),
– astronomy (the recent sighting of a comet coming towards the Earth),
– karma theory (Mother Nature responding to the avaricious
exploitation of the natural resources) etc.
• Their personal belief system makes them suggest cause-and-
effect relationship to mere coincidental occurrences listed
above.
– More on Self-fulfilling prophecy at
https://en.wikipedia.org/wiki/Self-fulfilling_prophecy

17. Media Hype Promotes Myths and “Infodemics”
• Because Guru is leaving Ketu’s alliance and entering Capricorn
on March 30, we will all be free from the effects of the Covid-
19 from 30th March, said Ashish Mehta, an astrologer.
• Acharya Sandeep Bhargava, predicted that the pandemic will
end this year globally by May 11.
• Upendra Shastri claimed that things will have a positive turn
from May onwards.
– Read more at: https://www.deccanherald.com/national/when-will-coronavirus-
end-in-india-and-across-globe-astrologers-prediction-815370.html
• Reality Check in mid- June!!!

18. Use of Unproven Remedies as ‘Cures’ – A
Maladaptive Behaviour
• Numerous unproven strategies and downright irrational
methods, which people are using in various parts of the globe
for prevention, diagnosis, treatment of COVID-19 are listed in
Wikipedia (https://en.wikipedia.org/wiki/List_of_unproven_methods_against_COVID-19)
• Some examples from 130+ references from all over the Globe:
• Drinking camel urine - advocated in the Middle East
• Drinking cow urine & applying cow dung on the body in India
• Sri Lankan herbal drink as a viral-cure remedy
• An "anti-coronavirus mattress” was advertised in India
• People who find any of these as being meaningful, fall prey to
the charlatans and fly-by-night operators

19. Another
Covid-19
Anxiety!
Doctor, Now I use the following 21 things to prevent a
Covid-19 attack:
Yoga + Walk + Lemon Water + Turmeric powder +
chayvanprash + Kachha Garlic + Kachha Ginger +
Almond + Anzeer + Khurmani + Kali mirch + Laung +
Gargles of hot saline + Drinking hot water + Tulsi Batti +
Giloi batti + Neem Batti + Arsenic Albs Homeopethic
Medicine + Allopathic drugs NAC + HCQ + Ivermectine.
Doctor. Any latest thing that I need to add to this?
KRS

20. Domestic Violence/Child abuse as Maladaptive
and Abhorrent Coping Behaviour
Globally, there has been an increase in domestic violence and
child abuse.
• Social tensions, which predispose to violent behaviour, seem
to arise from
– dominant and vulnerable members confined at home 24/7
– reduced access to resources (GRR and SRR),
– disruption of normal lifestyle,
– stress of losing job,
– financial insecurity and
– being physically isolated from various support systems
Ashley Abramson. How COVID-19 may increase domestic violence and child abuse.
URL: https://www.apa.org/topics/covid-19/domestic-violence-child-abuse

21. Coping by the Poor without Basic Needs for Life
• The lockdown in India to delay the spread of the virus resulted in the poor and the
marginalised without access to basic needs
• Some of them dug the city dumps for
– discarded food that they could eat and
– other discarded items of value (including used face masks and gloves) that they could sell in a
flea market
– Not covered in Indian media but shown on Germany’s DW TV
• Angry reactions from many Indians at the “foreign TV” for this expose’ and blaming
the poor for recycling used masks;
no one tracked the vendors who were reselling used stuff at jacked up prices in black-
market!

22. GRR = steps 1 & 2 of Maslow’s Hierarchy of Needs
= GRR

23. Components of Meaningfulness to an Individual
• Purpose (why should I)
– Goals
– Future fulfillment
• Values (is it worth it?)
– Justify course of action
– Moral decision making
• Efficacy (is it of use?)
– It will make a
difference
• Self worth (can I/we?)
– Skills
– Belonging to groups
you value
People found it more meaningful to accept the restrictions if they were
for self-protection rather than to protect others (Selfishness > Altruism)
Zettler et al (2020). Individual differences in accepting personal restrictions to fight the COVID-19 pandemic: Results from a
Danish adult sample. DOI: 10.31234/osf.io/pkm2a

24. To understand such “abnormal” and
often hazardous responses, we need to look at
the concept of ikigai …

25. Ikigai, a Japanese Concept
Reason for Living (or Purpose of Life)
is the Basis of Feeling Well
• The Japanese word derives from iki, meaning life and
gai, meaning value.
• Ikigai signifies “a reason for being, encompassing a sense of
purpose, a life of meaning & joy and a feeling of well-being.

26. Ikigai, a Japanese Concept – Modified by a Life-Coach*
* Winn, Marc. Ikigai Venn Diagram. What’s Your Ikigai?, The View Inside Me, May
14, 2014, http://theviewinside.me/what-is-your-ikigai/.
The sudden Loss of
Jobs and Livelihood
has rendered Millions
of workers with a Loss
of Sense of Coherence
and wellbeing.
Sociologists were
missing in most of the
“crisis teams” leading
to several unexpected
outcomes…

27. Ikigai Explains Life vs Livelihood Dilemma
• Lakhs of migrant workers, who have lost their livelihood were
stranded without any mode of transport to return home.
• Perceiving starvation to be a far greater threat than the
pandemic, they marched in thousands to their native villages;
quite a few have lost their lives on the way...
• Later, the Govt yielded to organise special trains and buses
• No doubt, several of them might carry the killer virus to the
villages all across India.
• Time will show its impact in terms of mortality and morbidity
in villages (WHO – April 2020)
India_ Migrant workers' plight prompts UN call for ‘domestic solidarity’ in coronavirus
battle. UN News 2020. URL: https://news.un.org/en/story/2020/04/1060922

28. What can Medical Professionals do to help their
worried patients?
• Adopt Roberts' Seven-Stage Crisis Intervention Model to
COVID-19 Pandemic:
• Step 1 – Rapidly Establish Rapport
• Step 2 – Assess Psychosocial & health risks
• Step 3 – Identify Major Problems or Crisis Precipitants
• Step 4 – Deal with Feelings & Emotions appropriately
• Step 5 – Generate and Explore Alternative solutions
• Step 6 – Suggest an Action Plan that the patient can
understand and find it meaningful & manageable to follow
• Step 7 - Follow-Up: being ‘always there for the patient’ helps
assuage fear and panic

29. Public Health Campaigns Need to Balance
Cognition and Emotion
i) The campaign leaders must acknowledge the ambivalence of the people: they
are extremely anxious and yet, many of them resist rational advice.
ii) Early in the crisis, the public may feel that the officials are overreacting; later,
when the crisis is full blown, the same public may feel that the officials
showed apathy. The campaign must repeatedly and emphatically inform the
people.
iii) The campaign must be proactive and get the people prepared for the
subsequent actions, such as personal hygiene, social distancing, wearing of
protective gear, volunteering to donate convalescent plasma, etc.
iv) The leaders must acknowledge the public fear and other reactions such as
denial, stigma, embarrassment, depression etc., to make it easier for the
people change their mind set without feeling undue guilt or remorse.
v) The campaign should be careful in wording the messages. It should not be
guilt inducing or intrusive. Such a direct approach can trigger defensive denial
instead of determination and action.
vi) The messages should avoid false optimism and instead promote solidarity,
resilience and adaptability to cope with the New-Normal.
Ref: Sandman PM, Lanard J. Strange COVID-19 bedfellows: gnawing anxiety and under-reaction.
https://www.cidrap.umn.edu/news-perspective/2020/03/commentary-strange-covid-19-bedfellows-gnawing-anxiety-and-under-reaction

30. What Rulers can Do to Proactively Mitigate the
Sufferings in Pandemic
• Preamble: in 2040, historian may record this: Absence of
sociologists and invisible/inactive social welfare agencies
affected proactive planning of relief for the poor and
vulnerable; the migrant labourers, without basic needs like
food & shelter, had to make drastic life & death decisions
• Public Health views are very important for reducing morbidity
and mortality; saving Lives Matter
• However, saving Livelihood is equally important
• It is possible to be proactive in taking care of both if all the
key players and stake-holders take a holistic view of the crisis
• Who ever can contribute to the people’s understanding and
acceptance of the New Norms should be included in the Team
for planning crisis management and mitigation efforts

31. Thank You All!