Compassionate communities as the foundation of the next healthcare revolution

Abstract

Community matters, a lot. More than individual choices and more than most medicines. As we will show in this special issue, community and harmonious social relationships are deeply embedded into all of animal evolution but particularly in humans, the most social of animals. Community matters because our survival as a species is dependent on it. This has always been the case and is the case now, for the survival of our planet and life on it. A sense of belonging is one of the most powerful human drives we seek, and this can be found in relationships with family, friends, communities, workplaces and educational institutions, amongst others. But where is the evidence that community matters to the health of the individual and society as a whole? Once you look for it, it is everywhere. It is found in meta-analyses showing the beneficial impact of good social relationships and the detrimental impact of loneliness and social isolation. It is found in our biochemistry, our genomics, our immune system and our emotions. It is found in public health and community development research. And when community is seen as a therapeutic tool and applied to individuals and community alike, the results are transformative. This is not just for people who are unwell but for everyone.

Despite the accumulation of evidence, we appear to have forgotten the impact that communities have on our health. At least, some of us have. Many Indigenous cultures know the importance of community and have done for tens of thousands of years. This knowledge is passed down from generation to generation in their history, their culture and their stories. It is local, with wisdom of how to thrive in a connected state within nature, within the ecology of food. Community, and our interconnectedness with others, is where we can find greater meaning and purpose in our lives, which themselves are significant contributors to individual health. As the evidence presented in this special issue suggests, however, this is no longer the case in many Westernised individualistic societies, where the burden of non-communicable disease related to a lack of social support and community now threatens entire healthcare systems.

This special issue of Lifestyle Medicine brings together world-leading researchers in the fields of community and social connection who have summarised their latest findings. The topics covered build a full picture of the impact of community on health, starting with the extraordinary findings on the impact of positive social relationships by Julianne Holt-Lunstad and colleagues. Professors Slavich and Cole, along with Summer Mendelkoch, describe the intricate web of how social relationships affect the internal workings of the body in their ground-breaking work on human social relationships. Along with Julian Abel, Professor Allan Kellehear, the founding father of compassionate cities and public health palliative care, discusses the implications for the practice of public health. Cormac Russell, a leading international figure in asset-based community development, describes the principles of how this work can be community lead. Dr. Frances da Cunha and Dr. Helen Kingston provide an overview of how this can all be built into routine health care, using their remarkable work in Frome, Somerset, in the United Kingdom. The paper of Professor Fraser Birrell makes the point that treating people individually loses the benefit of building social relationships and advocates for building social relationships into routine treatment plans for chronic disease management through group consultations. The special issue therefore covers the ground of theory into practice, bringing all of this information together for the first time.

It is worth taking a brief look at why the importance of community is having to be rediscovered in the modern world.

At some point within the tradition of scientific rationalism, the primacy of the individual took the place of the importance of community. The powerful impact of Newton's laws of motion and the invention of differential calculus meant that it became possible to imagine the natural world being similar to a complicated clockwork. Everything could be explained through analysing the individual parts and putting them back together again. René Descartes, whose phrase cogito ergo sum is a hallmark of focusing on the individual over interconnection, was so obsessed with these ideas that he put people inside the automatons he made in order to ‘prove’ that mechanism underlies everything. Known as the Age of Enlightenment, or the Age of Reason, this type of thinking informed science, politics, economics, philosophy, arts and even religion. When Darwin wrote Origin of Species, Herbert Spencer used the phrase survival of the fittest to describe the dog-eat-dog interpretation of natural selection, placing importance on the individual over that of community. By seeing people as individuals out of the context of community, we were driven to ignore the connected nature of the world in which we live. The links of interdependence could be ignored. These links are extensively described in Buddhism, and this same emphasis is found in many indigenous cultures, in the language of interdependence, all my relations and kinship, referring to not just family members but the whole universe. It is found in Ubuntu, the African philosophy of I am because we are. Scientific experiments could be conducted by isolating variables, making changes to a single variable and watching the impact on the others as if these isolated systems (such as individual people) have an independence that is separate from the rest of existence. Systems could be cut from the links of interdependence as if they could be isolated without any consequence anywhere else. But the world does not work in this independent way; a change in one place has multiple impacts on others in a complex interwoven web. Based on the available evidence so far, it is highly likely that human social communities have emergent properties on human health – synergistic benefits over and above the sum of their parts that are incompletely isolated in traditional reductionist scientific experiments.

This loss of the awareness of interdependence has had serious consequences for the development of human health and the practice of medicine. The separation of thoughts and emotions from the physical body, the mainstay of scientific positivism, has meant that the main focus of medicine has been physiological and biochemical processes, ignoring the fact that relationships and a sense of belonging impact these exact same processes. Loss of this connection has meant that the communities in which we live are seen merely as a collection of individuals together rather than something that might have an extremely powerful effect on health and well-being. The impact of community and social connection on health appears to be greater than many of the medicines we have and equal at least to the impact of smoking and alcohol cessation. Unfortunately, the idea of community being critical to human health does not fit neatly into the modern evidence-based medicine framework, where diseases are thought to have single causes that are amenable to mechanism-driven treatments. Symptoms are the outcome of disease rather than a part of a complex interwoven web, where multiple conditions come together to result in ill health. The impact of relationships is so large that if ignored or seen as a side issue, medicine misses out on a powerful therapeutic tool. So, as we have said, communities matter a lot. And while evidence-based medicine may struggle with how the effects of community can be examined along traditional experimental lines, we argue that the accumulated evidence for community is already strong enough to warrant embedding it across all medical and healthcare systems.

This special issue of Lifestyle Medicine is devoted to putting together the most up-to-date information on the impact of social relationships and community on health and well-being. The starting point is to consider the evidence demonstrated so remarkably through the work of Julianne Holt-Lunstad and her colleagues. She published a groundbreaking meta-analysis in 2010 on the impact of good social relationships on reducing mortality,¹ building on the predictive work of House and colleagues from 1988, who postulated that good social relationships were likely to be as significant on health and well-being as other major public health risk factors such as smoking and alcohol cessation. As a result, they should be treated with equal seriousness from a public health perspective.² Holt-Lunstad went on to demonstrate that good social relationships are protective and that poor ones have a profoundly negative impact on health, in her meta-analysis of 2015 showing the negative impacts on mortality.³

In this issue, Proctor, Barth and Holt-Lunstad, in their paper ‘A Healthy Lifestyle is a Social Lifestyle’ describe how quantity and quality of social relationships are important.

The three aspects of social connection emerged from measurement approaches across scientific disciplines that generally converge to tap into (a) the need for humans to have regular contact with a variety of people in their lives (structural), (b) people they can rely upon to meet various needs and goals (functional) and (c) relationships and interactions that are positive (quality). Therefore, the multifaceted construct of social connection encompasses a range of experiences from protective to those that entail more risk.

The authors make clear the evidence showing that social stresses such as isolation directly affect gene expression in multiple ways. Surprising to many might be that perceived social threat, which in many ways is likely to be driven by society's obsession with individualism and comparison to others via social media, is the strongest trigger of epigenetic changes associated with social stress. This in turn stimulates a chronic inflammatory immune response that lies at the heart of so many of diseases of the Western world such as heart disease, autoimmune disease, metastatic cancer, degenerative disease of the nervous system and others. Social isolation has also been shown to affect hundreds of genes. These findings sparked the field of human social genomics, which has yielded exciting new insights into how a variety of positive and negative social factors are associated with changes in gene expression. This, as it turns out, often predicts human health and behaviour more strongly than even the genetic code with which we are endowed.

The multiple pathways of chronic pro- and anti-inflammatory responses to the social environment give a plausible explanation for why social relationships have such a dramatic impact on human health. Social isolation, a loss of a sense of belonging within a sense of community, is an important factor in the generation of these chronic diseases and is also implicated in the ever-increasing numbers of people afflicted by poor mental health. A sense of connection and well-being is important for all of us, not just for people who are unwell. Ill health is the flip side of good health and well-being. It is not just that diseases can be prevented and treated using the support of belonging, it is that the positive aspect of feeling well and of life having meaning and value, applies to everyone.

The central thesis is that health does not sit solely in the hands of services. Rather, health and well-being are intimately connected to communities and relationships. Communities are not limited to neighbourhoods but include workplaces, places of worship, public spaces, museums and galleries, educational instructions and others as well as health, social care and third-sector organisations. The evidence of Holt-Lunstad, Slavich, Mengelkoch and Cole is clear; relationships are fundamental to human health. Ignoring this overwhelming evidence cuts off a powerful way of improving health and well-being. Public health as a whole must balance the scientific insights of epidemiology and bench sciences with that of community knowledge and culture. Everyone's participation is critical.

The skills of community building are, for the most part, very different from those needed to run clinical services. Even the basis for community development, working with communities from the ground up is often an anathema and a challenge for health services, whether these be state-run, business or charitable sector. Cormac Russell in his article, ‘Understanding Ground Up Community Development from a Practice Perspective’, discusses these difficulties and provides concrete examples, based on over two decades of practice, on how to work with communities rather than doing something to them. He frames the problem in the context of three lenses – the relief lens, the reform lens and the community lens. The first two view communities from the perspective of what is not present, what needs fixing. This deficit-based approach makes a fundamental assumption that communities are not capable of discovering their own strengths or prioritising and identifying their problems and working out solutions that enhance community life. As we have seen from the previous articles, communities are not only capable but are also best placed to be the solution, not the problem. Community building enhances what is already strong, by identifying what is present in both people and place, building relationships and engaging neighbourhoods. A deficit-based approach built around needs diminishes community life. It is not a neutral act but causes harm, even when the people involved are well motivated. Instead, an asset- or strengths-based approach will increase a sense of belonging and connectedness, decreasing reliance on service delivery organisations.

These five points must all be done together. Leaving any of them out weakens interventions and decreases chances of improving health and well-being at a population level. Point five, reorientating healthcare services, is a critical step and is so often missed. It is not just that community development is needed, enhanced and encouraged by people who have community development skills, healthcare services need to reorientate themselves in line with strengthened communities.

This population-based approach means that the people in Frome have an increased sense of belonging. Frome has become known as a friendly town, and people have started moving there because of it, so much so that house prices have risen and the council is having to deal with a housing problem. This problem has been severe enough to declare a housing crisis.⁶ It is this sense of belonging and support that has had the profound impact on reducing healthcare usage, particularly emergency admissions to hospital at a time where there are no other interventions which have had this impact. And when the Covid-19 pandemic hit Frome, the health centre could use the community infrastructure built by Health Connections Mendip to help people through loneliness and isolation, to activate the community to look after each other. Even more impressive is the sense from the health centre that this way of working is not finished. There is always room for improvement and the open humility and honesty of using the continuous improvement of quality improvement methodology is embedded into their systems change.

In addition to communities built locally in-person, the commentary by Birrell, Collen and Gray entitled ‘Scaling Group Consultations – the Fourth Healthcare Revolution: A Call to Action to Save Primary Care’ provides a critical appraisal of how community can be built into a modern healthcare system. As waiting lists in the NHS and other countries get longer, the impact of group consultations to both increase access and improve patient outcomes is becoming increasingly apparent. Much as health care must move away from treating patients as individuals isolated from the environment and society, by treating patients as groups we can develop new communities as well as increase time and access to broader and less mechanistic – but more impactful – interventions such as those grounded in lifestyle medicine.

In summary, the unique collection of articles in this special issue of Lifestyle Medicine provides an overview of how healthcare services can change from management of ill health to that of improving health. Social relationships play a fundamental role not just in promoting good health but also playing a key role when illness strikes. The artificial separation of the mind and the body, a hangover from the Age of Enlightenment, is put to rest in the article of Slavich, Mengelkoch and Cole. Changing public health to incorporate communities is key and the practices of community development described by Cormac Russell. How these practices can pave the way for reorientation of health care, which are discussed by da Cunha and Kingston.

We can at last move from a model of medicine in which ill health is seen as having a single causative agent that will respond to the treatment with a magic bullet of medication or surgery. Instead, rather than seeing disease as having a single cause, multiple circumstances come together which result in ill health and sometimes brings diseases. Through taking this multifocal approach, which recognises the fundamental importance of social relationships, medicine can move back into community, both inside and outside of the clinical setting.

TRW is a paid scientific advisor for Hintsa Performance, Sidekick Health, Thriva LLC and Rewire Fitness, and is a founding trustee of the British Society of Lifestyle Medicine.