Social Prescribing

Smoking for Health

My Aunty Eileen was an asthma sufferer who was regularly at the Doctor’s. During one visit, he suggested to her a new approach:- take up smoking.

Asthma, the Doc explained, was a failure of the breathing tubes to open up properly and to get enough air in. Cigarette smoking, the Doc advised, would train Eileen’s lungs – and also her – to breathe more powerfully and inhale deeply. Aunty Eileen, then in her 20s, took up smoking (along with who knows how many other patients who had also been given this advice).  

Cigarette smoking, the Doc advised, would train Eileen’s lungs – and also her – to breathe more powerfully

By her 50s, Eileen suffered every winter from bronchitis that left her bedridden for weeks. In her 60s, she developed COPD and eventually died, too young, in hospital. By then she’d had one foot and a lower leg removed, and her only outings were in a wheelchair, from the ward, down to the hospital grounds, for a fag. 

The doctor’s advice was, of course, terrible. But you have to understand that back in the 1960s, ashtrays and smoking were everywhere and a part of life: in the cinema, the home, the pub, on the bus and – yes, even in doctor’s waiting rooms. 

But the doctor’s intentions were good. He had noted Eileen’s shallow breathing and wanted to offer her something other than a lifetime prescription of drugs that would have long-term side effects on her heart. He wanted to find a behavioural solution – something that would help Eileen to exercise her lungs and change her breathing patterns and habits.

Singing for Health

50 years later, I’m reading a bunch of reports about doctors who prescribe singing – usually in a choir context – for patients with asthma.

This has been thoroughly tested by now and, to quote one medical journal, can offer “notable improvement in asthma control”. SLH (singing for lung health) is reported in a global systematic review of the evidence to be especially effective for COPD sufferers. In 2021, a 6-week pilot project with the English National Opera and Covid patients who suffered long-term breathlessness – ENO Breathe – offered singing and breathing lessons to a trial group. The results were encouraging – with The Lancet reporting ‘significantly reduced dyspnoea and anxiety’ and an 11 % reduction in breathlessness. The Breathe Programme became a mainstream part of UK social prescribing. 

SLH (singing for lung health) is reported, in a global systematic review of the medical evidence, to be effective

(Nature, Dec 2016)

There are loads of choirs running in Worthing – and the people who take part in them certainly look like a cheerful bunch.

We recently attended a concert done jointly between Superstar Arts and the Brooksteed Singers (who sing at the Brooksteed pub under choirmaster John Azzopardi – pub landlord and trained choirmaster. Yes. I know. Worthing never fails to amaze.)

This was part of Brooksteed’s ongoing collab with Superstar Arts, our local charity doing creative projects with and for people with learning disabilities. It was powerful to hear the songs and experience the enthusiasm – and skill – of the singers. It was also beautiful to be in an integrated and disability-friendly space.

Social Prescribing

You might not yet have heard about ‘social prescribing’ – but you will. In the face of the startling statistic that between 2% and 28% of GP appointments could be saved by interventions that offer non-clinical solutions, there’s a big push all over the UK to roll out and trial the efficacy of a range of activities. I’ve been finding out about it.

You might not yet have heard about ‘social prescribing’ – but you will.

People visit their GP for a range of reasons. Some of the reasons are connected to health issues that may call for a mixed treatment approach (think of a broken arm, needing a cast, painkillers and physio); some of those GP visits relate to long-term chronic problems that there’s really no cure for – in which case, you have to find ways to live with it and manage it well (think arthritis, Type 2 diabetes); and some of those visits translate (when the GP decodes them) as being embedded in underlying social problems like poverty, poor housing, or social isolation. A great many GP visits involve complicated issues of health (including mental health) or wider well-being; this demands a complex approach.

You’re asking why people visit the Doctor for all this? The full answer would get long and complicated (you know how I can go on …) so let’s keep things simple.

Doctors are figures of authority and hope.

Part Parent, part Deity, and more than a bit Priestly (oh, the magical listening-with-confidentiality that appears in the confessional and the consulting room!)

Fix-It fantasies settle around medics. Doctor as Superhero.

It’s worth a momentary detour on why people expect Doctors to have quick and easy fixes for things.

Biomedicine has led to the ‘magic bullet’ approach to health: an implausible belief that there must be a simple quick medical/pharmacological cure for everything.

Western medicine (I’ll call it ‘biomedicine’ to be a bit more accurate here) diverged from other traditions when it left behind a holistic approach and developed a ‘cut-up’ and fragmented path towards diagnosis, treatment – and people. Biomedicine has pursued goals of highly targeted interventions – with plenty of success. But it’s also led to what gets named in research around health behaviours as the ‘magic bullet’ or ‘silver bullet’ approach to health: an implausible belief that there must be a simple quick medical/pharmacological cure for everything.

How often have you heard of people who demand antibiotics because they can’t wait out a virus (or understand how antibiotics work); people who dismiss their specialist as ‘useless’ because they’ve been unable to cure chronic back pain; or people who prefer a statin over a diet change, and sod the side-effects? All this is related to that unrealistic expectation – drip-fed to us for years now – that there’s always a Doc and a med that can fix it for me.

One of my fave bloggers, the geek anthropologist, neatly puts together the Euro-American belief in ‘magic bullet’ cures and our obsession with superheroes.

The geek anthropologist neatly puts together the Euro-American obsession with ‘magic bullet’ cures and our obsession with superheroes

Geek Anthropologist

As Emma Louise Backe points out in a beautiful analysis of the ways that Spiderman movies, Covid and public health are all connected, Magic Bullet Heroism

All of this matters because we are still in the midst of a pandemic and the US has almost exclusively invested in a vertical approach—that of vaccination. We could have distributed free masks and tests to every home; disbursed regular payments to citizens to offset financial losses; incentivized and ensured that people could stay home and remain healthy; and invested in more training and resources for front-line workers including teachers. Essentially we could have radically rethought how we invest in all the other forms of social infrastructure needed to help people stay safe and healthy, rather than pushing a “return to normal” ethos that was already perpetrating health discrimination and inequity. And a system that already wasn’t working for those with disabilities and chronic illness. Instead the US government prioritized getting people back to work, emphasizing labor and productivity over other kinds of collective care.

There’s not a lot of scope for personal investment in the future, let alone something as abstracted as a person’s own ‘future health’

In the Uk, a recent joint study from the Universities of Newcastle & Durham warns against overlooking the importance of structural factors (poverty, poor housing and so on) in people’s health status. The study goes beyond this point – obvious to many of us – and steps out to talk in detail to a range of people about their lives and health. This led to the finding that many people – such as those on benefits or in precarious living situations – are forced to live on short horizons. In this kind of life situation, there’s not a lot of scope for personal investment in the future, let alone something as abstracted as a person’s own ‘future health’. The authors warn against policies, public health strategies, and moralising positions that would make this individualising move, familiar to us in Uk from Victorian bootstrapping through Thatcherite rhetorics and present-day neoliberal logics: –

It masks the effects of class by discursively positioning those without access to the legitimated capital required for engagement as individually and morally failing to invest in their health and wellbeing.

The UK government’s enthusiasm about social prescribing leaves us unimpressed about their motives. We notice also that NHS England has adopted social prescribing as a core strategy in its goal of supporting people to take responsibility and control of their own health, while the NHS is shifting (slowly) towards more holistic and complex understandings of people’s wellbeing and the determinants of health. You might well scoff – cost-cutting exercise, or pass the buck to social and community sectors: the political aspect is clear.

Many studies are warning that we need to address those structural factors that contribute to poor health and low well-being, as well as thinking globally about what phenomena like the WHO’s commitment to low-cost low-tech solutions in primary healthcare might mean in practice. Anthropology has, since the 1990s, been taking account of structural violence, and how it condemns certain populations to premature death and disability.

As usual, it’s all bloody ambivalence, isn’t it? The cynic in us will be suspicious or mock. And yes, we absolutely must remain attentive to bigger questions of infrastructure and social inequalities even as we embrace more holistic and person-centred approaches to public health.

Given that, cynicism is very last century. We can hold the ambivalence and still welcome the change. We’re grown-ups, after all, and we can hold onto complexity. Not either/or but yes/and also.

We can welcome the chances being offered to us to try new things.

The National Academy for Social Prescribing (NASP) website has resources such as clinical reports and real-life stories of people, communities and projects under the Social Prescribing umbrella. Here’s a recent short film explaining how social prescribing has built a sense of thriving and genuine connectedness in some parts of UK.

Joining a community choir, a walking group, or getting access to free pilates sessions, is something that can improve all-around health and boost that ‘future self’ towards a healthier outcome. (And yes, a good moment to reflect that we’re every one of us mortal, in a perishable body, and ageing every day. Sorry, love, but no – you can’t turn back time and age is not just a number).

Sorry, love, but no – you can’t turn back time and age is not just a number

Singing for asthma to improve lung health feels fairly obvious and intuitive, but Social Prescribing extends far beyond. It also includes things like digital literacy training, advice sessions around housing, salsa dancing and cook-from-fresh classes. I’m thinking it’s a bit like a mashup of school PHSE / PE / Arts / Music – for adults.

In Worthing, you can search the ‘Going Local’ webpage or ask at your GP surgery about social prescribing activities currently available locally. 

An aspect that’s grabbing my attention is the growth of opportunities for people to get involved in creative stuff. A massive scoping exercise of over 3000 studies recently done for the WHO concludes that involvement in the arts and in creativity plays a significant role in the prevention of ill health, promotion of health, and management and treatment of illness across the lifespan. Launching into new creative avenues – done badly and with great joy – helped me through lockdown, for sure.

So – hey! You know how, doing sport can be more fun than simply watching it. What about singing, then? Or textile printing? Or creative writing? Oh, please don’t say you can’t: every toddler sings, dances, scribbles, and it’s only school (and mean-spirited people) that make any of us think as adults that we can’t do that or we have no talent. You don’t have to be Jadon Sancho to enjoy a knockabout. Same goes for anything else you might fancy trying out – or getting back to.

Watch out for a post soon about my recently reignited love for quad skating after a 50-year break. Slower, less reckless, never gonna be one of the multistorey car-park street-skate boys, but that does not matter. The process, it’s all about the process.