The power of social prescription

Transcriber: Naomi Ezaz
Reviewer: Eunice Tan

Since the onset of the COVID-19 pandemic,

as a family physician,

I’ve written a lot of prescriptions
for people affected by COVID.

I wonder if it would surprise you to learn

that some of these prescriptions
were for food bank deliveries

and others for rent relief
and some for emotional support.

We call these “social prescriptions.”

The global pandemic
has taught us many lessons,

but one of the most important, I think,
is one that most of us did not see coming.

In the midst of one of the greatest
medical challenges

that we’ve ever faced as a society,

we’re discovering that one of the more
powerful solutions isn’t strictly medical,

it’s social.

And more specifically,

it’s addressing the social inequity
in our communities.

The world has expended
incredible resources

on sophisticated new medical research

and really clever vaccines
and therapeutics,

and these are all vital.

But we’ve discovered
that these aren’t enough.

The phrase “it takes a village” has never
been more appropriate or more true.

In Whistler, it took our entire
community coming together

to look after the health of our village.

Many of you will have heard of Whistler.

It’s a world-famous mountain resort town
in British Columbia, Canada,

home to Whistler and Blackcomb Mountains.

In my 20s, I drove across the country

to spend a winter
skiing here with friends.

I’d only planned to spend the season,
but 30 years later, I still call it home,

and I feel incredibly fortunate to live
and work here as a family physician.

I have always been really passionate

about the value of full-service
family practice -

looking after people
literally from cradle to grave -

and I’m passionate about the concept
of embedding this care into community.

The COVID-19 pandemic has really
reinforced for me how important this is.

Spending a season in Whistler
is on a lot of people’s bucket lists,

and there’s a lot
of great reasons for this.

We have two world-famous ski resorts,

lakes, golf courses,
hiking and biking trails,

and breathtakingly beautiful
alpine and valley scenery.

And so you might envision
the residents of Whistler

living an active, affluent,
outdoor, healthy lifestyle.

And while this lifestyle may be true,
there’s quite a bit more to our community,

As most of us are aware,

with COVID-19, young people
are generally less medically vulnerable.

They’re incredibly unlikely
to be hospitalized or to die.

So a place like Whistler,
with a lot of young people,

you might imagine would be
minimally impacted by COVID, right?

But what if I were to tell you

that the young adults in Whistler
were actually the most vulnerable

because they’re socially vulnerable

and that that’s what actually drove
transmission in our community?

Their housing situation
and frontline work exposure

put self-isolation and quarantine efforts
out of reach for many

despite their best efforts.

This population was hit harder
than anyone had expected,

and it was only through the efforts
of our entire community working together

that we were able
to decrease virus transmission

and effectively care for everyone.

Imagine living in Whistler in your 20s,
living your best life.

Skiing and snowboarding every day,
having a job on the mountain,

maybe as a liftie,
maybe as a server in a restaurant,

more realistically, both.

Lots of friends, endless
social opportunities, a vibrant nightlife,

all in the backdrop of a beautiful
alpine mountain resort town.

There are some small trade-offs
for this ideal life.

Housing is incredibly expensive
and really scarce.

So many young people live
in really dense shared accommodation,

sometimes up to
15 to 20 people in a house.

And their jobs are usually
in the service sector

and often don’t pay a living wage
or have benefits or paid sick days.

So now imagine it’s November 2020,

and you’re in your early 20s,
and you’ve just arrived in town,

and you have amazingly found accommodation
in a house with, say, 11 other people,

and you’ve secured a couple
of part-time jobs,

and you’re just waiting
for the snow to fall,

the mountain to open,
and your dream season to begin.

Unfortunately, though, COVID case counts
are rising across BC at that time,

and towards the end of the month,

Whistler sees its first big surge
in COVID positivity.

Your social life is somewhat
impacted by this

as you try to follow all the new rules,

but the mountain is still open,

and you’re still living
your kind of modified dream.

That is, until the very end of the month,

when one of your 11 housemates
tests positive for COVID.

You feel fine, but public health
contact tracing calls

and tells you that you need
to self-isolate for 14 days

from the time that your housemate
is no longer infectious,

which will be 10 days from now.

So if you continue
to live in the same house,

your total isolation time is 24 days.

You might have two bathrooms,
a shared kitchen,

maybe even a shared bedroom.

I mean, imagine the 12 of you
trying to self-isolate from each other.

So not unexpectedly, a few days later,
two more housemates test positive,

increasing your quarantine
time to 26 days.

And so it goes on, your quarantine time
increasing every few days

as more housemates test positive.

It’s pretty unlikely
you’ve got family close by

or options of housing to move into.

It may be your first time away from home.

What would you do in this situation?

Remember that every day
you don’t go to work, you don’t get paid.

I mean, would you think about not even
getting tested in the first place?

Would you call the food bank?

Would you look for financial
assistance for rent relief?

One option you might consider would be
moving into your vehicle if you have one.

And while there is some romance
associated with van life,

in Whistler it involved using
the shower and toilet facilities

at our local community centre,

which was one of the first places
to shut down at the onset of the pandemic.

And van life in Whistler in November
involves rain, snow and cold.

This whole scenario could and did happen

several times over
the course of the season.

So not surprisingly,

transmission in this socially
vulnerable population exploded

and paralyzed our community.

It eventually led to the shutdown
of both mountains -

mountains that are pretty vital
to day-to-day life

for many of us and to our local economy.

Ultimately, it took the entire community
or “a village” to change this situation.

This experience ended up being
the evolution of a natural experiment

in something called “social prescription,”

which drew our town together

to not only meet our community’s
medical and social needs,

but it actually allowed us to completely
reimagine our community’s health care.

Social prescribing is a growing movement
in which health care professionals

connect people to non-medical,
community-based supports and services

for health and well-being.

Things like accessing healthy food
through the food bank

or counseling for emotional support
or financial aid or addiction supports

and many other social services.

Recognizing that
people’s health and well-being

is largely determined by set of social,
economic and environmental factors -

something which COVID
has graphically highlighted -

social prescribing attempts to meet
these needs in a really holistic way,

and it also intimately connects
health care to community.

I’d like to share how
our community found success

in a social prescription approach
through a really simple text.

Yes, the kind of text
that you get on your phone.

At the onset of the pandemic,

our group of family physicians
worked to create a safe space

to see patients with COVID symptoms.

You’ve got to remember that this was
a really daunting task back then -

there was a lot of associated uncertainty.

So we collaborated with
our health authority and municipality

to set up and site a really
well-ventilated trailer for this purpose.

And in an attempt to minimize or decrease

everybody’s in-person
or face-to-face time,

we also took detailed histories
from people over the phone

prior to their in-person appointments.

This made us realize

that the medical issues
were relatively easy for us to deal with,

but we were talking with a lot of people

that were really struggling with paying
the rent or accommodation or groceries

or just feeling really lonely
and unsupported

or even worse, living in their vehicles.

And we also noted that we were giving out

the contact information
for community-based social services

multiple times a day.

So we collaborated
with Foster Community Services,

a local nonprofit that manages
many of Whistler’s social services,

including the food bank,

and we agreed to put
their contact information

on a text that we sent patients
with their appointment information.

This text just asked, “Do you need help
with rent, food or accommodation?”

And we realized that just
by asking the question,

we seem to have decreased stigma enough

to make it OK for people
to ask for this help,

because Whistler Community Services

immediately noted a large increase
in demand for their services.

In the first week, their phone lines
were completely overwhelmed

and food bank visits
increased by over 300 percent.

This simple text
quickly developed into a model

that fully embraced
a social prescription approach,

and it also created a partnership
between our local medical team

and community-based social services
and nonprofits and our local government.

This was just the beginning

of an incredibly impactful
and increasingly connected relationship.

Clients were able to access
the supports they needed,

like food bank deliveries,
rent relief, emotional support,

temporary access to electronic devices
that allowed them to stay connected

to health care
and to public health supports,

and a two-week supply of toiletries
and personal necessities

for self-isolation,

which was funded by
the Whistler Blackcomb Foundation.

Through these collaborations,

the community was eventually
able to provide access

to temporary supported safe housing
for self-isolation.

All of this led to a markedly
different experience

for people affected by COVID
in subsequent waves of the pandemic,

and it interestingly led
to a markedly different experience

for the providers of that care.

Everyone involved in the care team
had renewed energy and improved morale,

despite much increased
community transmission

and massively increased workloads.

I think this is because they felt part
of an impactful, successful team

that was really providing
exceptional care.

In Whistler, as in many other
parts of the world,

COVID disproportionately affected
a really specific demographic:

those with the least social capital.

Many of the successes
in Whistler’s COVID response

were due to addressing these social
inequities collectively as a community.

Through our inadvertent trial
of social prescription,

we’ve created collaborations
between health care

and community-based social services
and nonprofits and local government,

which will last long beyond COVID.

We’ve also developed
an intimate understanding

of the social fabric of our community,

which has not only
greatly improved patient outcomes,

but also provider satisfaction.

And I think this really speaks
to how important it is

for primary care
to be deeply rooted in community

and in the social determinants of health.

There’s a word I love
that reflects this concept.

“Ubuntu” is a Zulu word,
which loosely translated means

“I am because you are”
or “I am because we all are.”

And it speaks to a common humanity

and how much we all rely on
and need each other.

Whistler won’t be OK
until all of Canada is OK,

and Canada won’t be OK
until all of Brazil and India are OK.

None of us are going to be OK
until all of us are OK.

COVID-19 has shone a light

on how family practice as a medical
specialty practiced in isolation

is no longer a tenable model of care.

If, as physicians,
we can only prescribe drugs,

we have really limited influence.

But if we can work with communities
to create social prescriptions,

then we can change so much more.

Health care, economic stability, housing -

they’re all interconnected,

and they all determine
our health and well-being.

And what we’ve demonstrated
is that it truly takes a village,

be that Whistler village
or the global village,

to manage a pandemic
and our health and well-being.