Presence as a Social Determinant of Health?
Public health research has shown that social isolation, loneliness, social support, and social capital are closely related to health. Yet I wonder whether there is another dimension that has received less attention: presence.
By presence, I do not mean simply being in the same physical space. I mean the experience of having someone there, of feeling seen and acknowledged, and of sensing that one is not completely alone. Even without words, touch, or practical help, the simple fact that someone is present may matter.
Some artists have explored this power of presence. In Marina Abramović’s The Artist Is Present, the artist and each participant simply sat facing one another. There was no conversation, no physical contact, and no practical support. Yet many participants appeared deeply moved. The work suggested that simply facing another person and being fully present can have a powerful emotional effect.
Christian Boltanski’s installations offer another form of presence. Through memory, absence, and traces of anonymous lives, his works make us feel the presence of people who are no longer physically there. Rirkrit Tiravanija’s relational works point to a different dimension. People gather, eat, and spend time together. In these works, sharing time and space becomes central.
These artistic practices suggest that presence is not a single phenomenon. It may appear as being seen, being remembered, being accompanied, sharing a room, sharing a meal, or simply spending time with others.
I have noticed something similar in home-based medical care. For some older adults living alone, the most meaningful part of a visit is not necessarily a prescription, a test, or medical advice. It is the fact that someone came, sat with them, and acknowledged their existence. That simple act can become a form of support.
This perspective raises an important question for social prescribing. We often assume that social prescribing works by increasing participation, activity, and access to community resources. But perhaps one of its more basic therapeutic mechanisms is creating moments in which people feel seen, accompanied, and present with others.
Presence may overlap with social support, belonging, recognition, and relational welfare. At the same time, it may deserve attention as a distinct dimension of social connection. Public health has developed many concepts to describe how social relationships influence health. The language of presence may help us notice something more immediate and embodied: the health significance of simply being there with another person.
Can presence itself influence health outcomes? This is a question I want to keep exploring.
健康の社会的決定要因としての「プレゼンス」
公衆衛生の研究では、社会的孤立、孤独、ソーシャルサポート、ソーシャルキャピタルが健康と深く関係していることが示されてきた。しかし私は、もう一つ見落とされがちな次元があるのではないかと感じている。それは「プレゼンス」である。
ここでいうプレゼンスとは、単に同じ空間にいることだけではない。誰かがそこにいてくれること。自分の存在が見られ、認められていると感じられること。言葉や具体的な支援がなくても、「私は一人ではない」と感じられるような関係性のことである。
一部のアーティストたちは、このようなプレゼンスの力を探究してきた。マリーナ・アブラモヴィッチの《The Artist Is Present》では、アーティストと参加者が向かい合って座るだけで、会話も身体的接触もなかった。それでも、多くの参加者は深く心を動かされたように見えた。そこには、何かを「してあげる」ことではなく、ただ向き合い、そこにいることの力があった。
クリスチャン・ボルタンスキーの作品は、記憶、不在、名もなき人々の痕跡を通して、すでにそこにはいない人々の存在を感じさせる。リクリット・ティラヴァーニャの作品では、人々が集まり、食事をし、同じ時間を過ごす。そこでは、特別な出来事よりも、共に場を共有することそのものが作品になる。
これらの芸術実践は、プレゼンスが一つの形だけではないことを示している。プレゼンスは、見られること、記憶されること、寄り添われること、同じ部屋にいること、同じ食事や同じ時間を分かち合うこととして現れるのかもしれない。
私は在宅医療の現場でも、これに似たことを感じてきた。一人暮らしの高齢者にとって、訪問のなかで最も意味を持つものは、必ずしも処方や検査、医学的助言ではないことがある。誰かが来て、そばに座り、自分の存在を認めてくれる。そのこと自体が、大きな支えになることがある。
この視点は、社会的処方についても重要な問いを投げかける。私たちはしばしば、社会的処方は人々の参加や活動を増やし、地域資源につなげることで効果を持つと考える。しかし、その背景にはもっと基本的なメカニズムがあるのかもしれない。つまり、人が「見られている」「伴われている」「誰かと共にいる」と感じられる瞬間をつくることである。
もちろん、プレゼンスはソーシャルサポート、所属感、承認、リレーショナル・ウェルフェアと重なり合う。しかし同時に、社会的つながりを考えるうえで、独自に注目する価値のある概念かもしれない。公衆衛生は、社会関係が健康に与える影響を説明するための多くの概念を発展させてきた。そこに「プレゼンス」という言葉を加えることで、私たちは、ただ誰かと共にいることの健康上の意味に目を向けることができる。
プレゼンスそのものは、健康アウトカムに影響を与えうるのだろうか。これは私がこれからも探究していきたい問いである。
Before Entering Someone’s Home
In my private life, I do not often visit other people’s homes.
Yet in my work, I frequently enter the homes of patients under my care.
Most of them are older adults.
Some live with family members, while others live alone, surrounded by a quiet form of solitude.
Some homes are carefully cleaned and arranged. Others are filled with the accumulation of daily life, sometimes almost to the point of becoming hoarded spaces.
Each time, I pause for a moment before entering.
I wonder whether they are doing well today.
Whether they have fallen.
Whether they have been eating.
Whether they are sitting in the same place as last time.
In many cases, their lives continue much as before.
I ask about changes since the previous visit, listen to their symptoms, check the medications they need, and complete the examination.
As work, the process often proceeds calmly and routinely.
And yet, at times, being inside another person’s home gives me a strangely surreal feeling.
In a hospital consultation room, the patient enters the space of medicine.
In home care, however, the physician enters the space of the patient’s life.
There is furniture, smell, photographs, bedding, a kitchen, a chair that has been used for many years.
Before anything is said, the space itself seems to reveal something about how that person has lived.
A home is not merely an address.
It contains history, background, silence, and the weight of a life.
I enter the home as a physician.
But sometimes, before being a physician, I feel like one human being briefly standing inside the interior of another person’s life.
The visit ends.
Medications are prescribed.
The medical record is written.
Still, even after I leave the house, something remains with me for a while: the dimness of a room, the presence of objects piled up over time, the image of a person sitting by the window.
Perhaps home care is not only about seeing illness.
Perhaps it is also about entering a place where someone has lived, pausing before the weight of that life, and noticing something that can only be seen there.
Distance and Connection
I study how loneliness and social isolation affect health. I also see social prescribing as part of this inquiry: a way to consider how people reconnect with others, communities, and meaning. Isolation is the absence or invisibility of social connections. Loneliness is how that distance is felt. Art does not simply solve loneliness. But it can give form to what is difficult to say, and open a space where another kind of connection becomes possible.
Is Health “Determined”?
Thinking about health from a life course perspective
In social epidemiology and behavioral science, there is a concept called the Life Course Perspective on Health. In simple terms, it means looking at health across the timeline of a person’s life.
When we think about health, we often focus on the present:
Do I have a disease now?
Are my test results normal?
What are my current lifestyle habits?
These are important questions. But our health is not shaped only by the present moment.
The environment before birth, childhood experiences, school life, family and friendships, work, income, housing, neighborhood, loneliness, and social support can all influence our body and mind over time.
This is the basic idea of the life course perspective: health is shaped gradually throughout life.
This idea is closely related to the concept of Social Determinants of Health, often abbreviated as SDH. SDH refers to social conditions that affect health, such as poverty, education, employment, housing, social isolation, discrimination, and access to healthcare.
However, I personally feel a little uncomfortable with the word “determinants.”
Of course, poverty, isolation, discrimination, unstable work, and poor housing can seriously harm health. Health should not be explained only by individual effort or lifestyle choices.
Still, the word “determinants” can sound too strong.
Social conditions influence health.
They can limit people’s choices.
They can create serious disadvantages.
But they do not completely determine a person’s health or life.
The life course scholar Paul H. Wise has warned against understanding early life experiences in an overly deterministic way. Early childhood matters, but people can still change, receive support, and recover during adolescence, adulthood, and later life.
In other words, health is not something that is fixed once and for all.
I prefer to understand SDH not as factors that “determine” health, but as social conditions that shape health.
Social conditions matter deeply.
But people cannot be explained only by those conditions.
Healthcare, welfare, education, community connections, family, friends, culture, and art may all have the power to gently change the course of a person’s life.
Health does not exist only inside the individual body.
At the same time, it is not simply decided by society.
Health is gradually shaped by the time we have lived, the environments we have experienced, the relationships we have had, and the support we may receive in the future.
That is why it is important not only to look at disease, but also to ask what kind of life a person has lived — and what kind of life may still be possible.
ライフコースの視点から考える
社会疫学や行動科学の分野には、Life Course Perspective on Health という考え方があります。日本語にすると、「健康を人生の時間軸から考える視点」と言えるかもしれません。
私たちは健康について考えるとき、つい「今、病気があるか」「今、検査値がどうか」「今、どんな生活習慣か」に注目しがちです。もちろん、それも大切です。しかし、人の健康は「今」だけで決まるものではありません。
生まれる前の環境、子どもの頃の生活、学校での経験、家族や友人との関係、仕事、経済状況、住んでいる地域、孤独や支えの有無。そうしたものが、長い時間をかけて、その人の身体や心に影響していきます。
このように、健康を人生全体の流れの中で考えるのが、ライフコースの視点です。
この考え方は、Social Determinants of Health, SDH と呼ばれる概念とも関係しています。日本語では「健康の社会的決定要因」と訳されます。貧困、教育、雇用、住環境、社会的孤立、差別、医療へのアクセスなど、健康に影響する社会的な条件を指す言葉です。
ただ、私はこの「決定要因」という言葉に、少し違和感があります。
もちろん、貧困や孤立、差別、不安定な仕事や住まいが健康に悪影響を与えることは間違いありません。健康を個人の努力だけで語ることはできません。
けれども、「決定」という言葉は少し強すぎるように感じます。
社会的な背景は、その人の健康に影響します。人生の選択肢を狭めることもあります。ときには、深刻な不利をもたらします。それでも、それがその人の健康や人生を完全に決めてしまうわけではありません。
ライフコース研究者の Paul H. Wise は、人生の早い時期の経験が大切であることを認めながらも、それをあまりに「決定論的」に考えることの危うさを指摘しています。幼少期の経験は重要ですが、その後の思春期、成人期、老年期にも、人は変化し、支えられ、回復する可能性があります。
つまり、健康は一度決まったら変えられないものではありません。
私は、SDHを「健康を決定するもの」としてではなく、健康を形づくる社会的な条件として理解したいと思っています。
社会的な条件は健康に大きく関わる。
けれども、人はその条件だけで説明できる存在ではない。
医療、福祉、教育、地域のつながり、家族や友人、文化やアートには、その人の人生の流れを少しずつ変えていく力があると思います。
健康とは、個人の身体の中だけで完結するものではありません。しかし同時に、社会によって一方的に決められるものでもありません。
健康は、その人が生きてきた時間、置かれた環境、人との関係、そしてこれから受ける支援の中で、少しずつ形づくられていくものです。
だからこそ、病気だけを見るのではなく、その人がどのような人生を歩んできたのか、そしてこれからどのように生きていけるのかに目を向けることが大切なのだと思います。
参考文献：
Wise PH. Framework as metaphor: the promise and peril of MCH life-course perspectives. Matern Child Health J. 2003;7(3):151-156.
Halfon N, Larson K, Lu M, Tullis E, Russ S. Lifecourse health development: past, present and future. Matern Child Health J. 2014;18(2):344-365.
Perspective is a journal where I share thoughts and reflections related to my current research, artistic practice, clinical work, and interests in public health.
Topics may include social isolation, health equity, social prescribing, everyday life and care, and the relationship between art and health. Through this page, I hope to move between research, practice, and personal reflection.
While some posts may touch on academic or professional topics, I aim to share them in an accessible and educational way.
Perspective は、現在取り組んでいる研究やアート制作、日々の臨床や公衆衛生への関心をもとに、考えたことや学んだことを記録していくジャーナルです。
社会的孤立、健康格差、社会的処方、日常生活とケア、アートと健康の関係など、自分が関心を持っているテーマについて、研究・実践・個人的な視点を行き来しながら書いていく予定です。
専門的な内容を扱うこともありますが、できるだけわかりやすく、教育的な形で共有していきたいと考えています。