Jonathon Tomlinson, GP and educator, the Lawson Practice, Hoxton

Published in JHH 18.3-Shifting the paradigm

Introduction

Agriculture is reaching the limits of what can be produced by applying chemicals to depleted ecosystems. Healthcare is reaching the limits of what can be gained by giving drugs to people living in depleted ecosystems. Agricultural and medical chemicals have been so successful at increasing yields and extending life that farmers and doctors have been able to ignore the ecosystems that give rise to biodiversity and good health. The catastrophic global loss of biodiversity combined with diminishing agricultural returns have provoked renewed interest in sustainable and regenerative farming. The presence of new infectious diseases and rising prevalence of long-term diseases despite ever more being spent on healthcare should prompt us to consider what healthcare can learn from agriculture about what we’ve done wrong and what we can do to fix it.

The late GP, academic and activist Dr Julian Tudor Hart, who spent most of his career working in the small Welsh town of Glyncorrwg, described himself as a Glyncorrwgologist:

‘I knew more, did more, and certainly wrote and spoke more about the health problems of Glyncorrwg, than any other doctor. So I became the world expert, a specialist in at least the initial recognition, and often the terminal management, of the entire potential range of health problems in that unique community. … What higher ambition could any doctor have?’
(Tudor Hart, 2010)

I am a Hoxtonologist. I have been a GP in Hoxton, east London for nearly 20 years and I feel the same way about the place I work and my role there. Knowing about the ecology – that is the relationships that contribute to the health of my patients – informs everything I do. Diagnosis and treatment of, for example, hypertension, diabetes or schizophrenia in Hoxton is informed by a knowledge of Hoxton ecology, which is unique and distinct from the ecology of Glyncorrwg or anywhere else.

Deep ecology and deep medicine

Deep ecology is a philosophy that views humans as an integral part of the natural world, sustained like all species by complex webs of interdependency. Deep medicine is a philosophy that views humans and their health in the same way, recognising connections not only with the natural world within us and around us but also with histories, communities, and cosmologies (Marya & Patel, 2021).

Re(wilding)

The sociologist Mildred Blaxter described diagnostic categories as a museum of past and present concepts of the nature of disease (Blaxter, 1978). The numbers of diagnostic categories increase every year, but very few, however old or however much they have ceased to be useful, are assigned to actual museums for us to study and learn from.

The same could be said of medical specialties which continue to expand and subspecialise as medical professionals carve out careers in which their power and authority rests on their dominance over the diagnosis and treatment of narrowly defined biological deviance. The medical gaze has become increasingly myopic, to the point where we are treating fewer people at higher costs while the needs of so many are not being met. The greater our efforts go towards breaking down and categorising diseases, the less we can make sense of the whole. Western medical culture does not exist in a Hippocratic bubble isolated from the last 60 years of neoliberal capitalism but is situated within it. One consequence is that we have tended to assume that the best way to understand the world is by atomisation: viewing people and things in isolation, breaking them down into the smallest parts that can be studied, measured, manipulated, monetised and managed by specialists with little interest in how they all fit together. The objective view, in which the observer is at pains to exclude, ignore or deny their own ideas, feelings, assumptions or intuitions has been dominant for so long that there is an increasing loss of empathy between people providing care and those receiving it. Modern individualism has encouraged people to think of what ails them as their problem, and theirs alone rather than the symptoms of a sick society.

Alongside this, there have also been moves to standardise medical practice so that everyone with the same diagnosis receives the same treatment based on guidelines and protocols which are built into apps and other software making them less like guidelines and more like clinical tramlines, bringing in an era of digital doctors and enabling professionals with less training, less experience, less human contact and bigger patient caseloads to dispense treatment. Healthcare today has evolved through legacies of patriarchy and colonialism in which women and minorities have experienced discrimination as providers and recipients of healthcare.

‘We need to put aside debates about nature vs nurture and start learning how to practice deep-medicine’

With the loss of subjectivity, increasing specialisation, fragmentation, digitisation and lessening human contact there is a collective loss of knowledge and experience of the role and importance of relationships in health and healthcare.

Patients and GPs who have experienced continuity of care value it more than those who have not, no matter how much evidence is published to show how important it is. The longer that healthcare is objective, specialised and atomised the less we will value relationships. The relationships that matter are not just between people. Covid-19 has bought this to our attention most recently. Covid-19 is a coronavirus with respiratory, cardiovascular, immunological, autonomic, haematological, neurological, cognitive and psychological effects and more. One reason that it has been hard to treat is that there is no specialty that has the necessary expertise to manage such a wide array of disruption. Covid has highlighted how inseparable different bodily systems are; disruption of one causes a cascade effect upsetting all the others. Beyond the body, excess mortality among ethnic minorities and deprived communities in the UK and globally has shown us that the conditions under which people live and work affects their likelihood of catching the disease. Underlying vulnerabilities including obesity and long-term conditions such as diabetes which also disproportionately affect deprived communities, worsen the chances of survival. The inescapable fact is that biology, biography, society and psychology are all part of a complex adaptive system which determines what impact an infectious disease has on someone, but we are ill equipped to understand it because for we have become too fragmented in our interests and expertise.

(re)Wilding nutrition

Ecologically impoverished communities suffer from a lack of nutritional diversity. (Re)wilding would involve the secure and sustainable provision of a diverse range of affordable, palatable, culturally acceptable, sustainable wholefoods and fresh fruits and vegetables. Diets that contain fewer processed carbohydrates and more whole grains, vegetable protein and fresh vegetables are associated with lower rates of obesity and diabetes.

(re)Wilding the built environment

Reducing motor vehicle monoculture would help make space for a greater diversity of less polluting, safer, more sustainable forms of transport. Investing in spaces where people with a wide range of backgrounds and interests can come together has been shown to reduce mortality and morbidity in times of social and environmental stress (Klineberg, 2020).

Key species

(re)Wilding can be given a helping hand by the judicious introduction of species such as large herbivores that would not have returned without support. In healthcare this could entail the re-introduction of children’s centres, community centres and public health departments, libraries, parks and green spaces.

Another principle of (re)wilding is having the humility and curiosity to understand the local ecology. In healthcare this would require an awareness that the local community contains a rich source of healthy knowledge that needs to be uncovered and dug into the design and development and running of services. It means that it will be unique to that community and will also enable relationships to flourish.

Holistic science takes the view that different types of knowledge are all equally important: reason, emotions, senses and intuition. What we know is no less important than how we feel or what we have experienced directly and what our gut instinct tells us. Ecology is about balance, and we need to take seriously things we’ve previously paid too little attention to, especially people and communities who have experience of illness, disease and discrimination.

Complex adaptive systems

In a complex adaptive system, health and illness arise as emergent properties of the system rather than due to its individual constituents. While it may be possible to isolate, study and control parts of the system, the emergent properties are unpredictable because they depend on the nature of the relationships between parts which may be known, unknown or unknowable. Understanding this requires humility, trust in a healthy ecology and attention to the outcomes that emerge. It requires that we recognise that if we manipulate one constituent, the whole system will be affected in ways that cannot be fully anticipated.

Syndemics

A syndemic refers to synergies of epidemics. In Rethinking Diabetes, anthropologist Emily Medenhall shows how epidemics of poverty, trauma, patriarchy, racism and displacement all contribute to the epidemic of diabetes (Medenhall, 2019). Covid-19 is also syndemic and syndemic thinking helps to shine a light on the ways that social, contextual, historical and political factors intersect.

Nature dancing with nurture over time

We need to put aside debates about nature versus nurture and start learning how to practice deep medicine (Shonkoff & Garner, 2012). To do so we must cast our gaze beyond the light shone by our own specialist interests and embrace the lessons of deep ecology.

References

Blaxter M (1978) Diagnosis as Category and Process: The Case of Alcoholism. Social Science and Medicine, 12, 9–17.

Davis A (1987) Let us all rise together: Radical perspectives on empowerment for Afro-American women. Address given to the National Women’s Studies Association, Spellman College.

Klineberg E (2020) Palaces for the people: How to build a more equal and united society. Vintage Publishing.

Marya R & Patel R (2021) Inflamed: Deep medicine and the anatomy of injustice. Allen Lane.

Mendenhall E (2019) Rethinking diabetes: Entanglements with trauma, poverty and HIV. Cornell University Press.

Shonkoff JP & Garner AS (2012) The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129 (1) e232–e246.

Tudor Hart J (2010) The political economy of health care (2nd edition). The Policy Press.