Holistic lessons from a pandemic - a new spotlight on old problems
Rapid restructuring of healthcare systems in response to the COVID-19 pandemic has exposed numerous cracks in our National Health Service (NHS). We have seen how racial disparities disproportionately affect Black, Asian and Minority Ethnic staff and patients; a worsening mental health crisis continues to go underfunded, and understaffed wards rely on student-nurse participation to function safely. But what has the pandemic taught us about how we approach holistic medicine?
Last year, I volunteered at a medical practice in central London specialising in homeless healthcare during the pandemic. Due to the ongoing and far-reaching impact of COVID-19 on medical education, student volunteering experiences represent an important opportunity for reflective learning. My personal experience has been invaluable in terms of my professional development and highlighted some poignant lessons about the realities, limitations and misconceptions of holistic healthcare, particularly for stigmatised populations such as those experiencing homelessness.
The COVID-19 response strategy, put together by Dr Al Story and Professor Andrew Hayward, aimed to reduce the risk of infection and serious illness among homeless populations (1). GPs, nurses and community outreach workers identified rough sleepers and those living in communal accommodation, carried out triage assessments based on symptoms and clinical risk factors and offered hotel accommodation provided by local authorities. As a volunteer, my job was to assist in any way I could: helping people settle into hotel rooms, recording personal details and giving advice on social distancing.
Curious about potential ethical tensions and systemic pressures of this response strategy, I began to question my role as a medical student and the quality of care I was helping to provide. We spent the first day calling people who were already in hotel rooms and making sure they weren’t developing any symptoms/generally checking how they were doing. Immediately, the medical and ethical challenges of this operation became apparent. The healthcare needs for this group are complex and intersectional. Many people experiencing homelessness are affected by ‘tri-morbidity: physical illness with mental illness and drug or alcohol misuse’ (2). As such, meeting the needs of mental and physical health is a delicate balancing act: successful intervention for one might mean exacerbation of illness for the other. Isolation in a hotel room offers protection from COVID-19, but isolation in a hotel room with depression, anxiety, alcohol/drug dependence or post-traumatic stress due to a history of abuse is problematic.
As the number of people in the hotel rose, the number of problems and practical limitations became increasingly apparent. A call about a symptomatic woman who needed to be moved into the hotel posed problems about where to place her teenage son: should we offer them a room together and risk him also getting infected? Or do we offer the son a place elsewhere? There were no guidelines for this, so what are the options? Unforeseen problems required rapid responses and the attempt to be holistic was often abandoned due to lack of staff, time or resources. There simply was not enough time to collect a full history, learn about financial factors or family members.
Resources were also limited: we did not yet know how many people would need a hotel room, what if there wasn’t enough space? In an acute medical crisis, there lies a tendency to categorise people by their situation: you are homeless, you are elderly, you are your pre-existing medical conditions, you are a key worker. This categorisation aids public health intervention in managing the population and spread of disease, but it rarely considers an individual as a whole. What if you are simultaneously homeless, elderly, with pre-existing medical conditions and a key worker – then what? The management of these choices often lies in the hands of a clinician yet the struggle to provide a holistic service was in no way an indictment of the values of the staff. They were upset, exasperated and bound by limited time and resources: it was not uncommon for conversation to become emotional.
I also became disheartened about our inability to meet the needs of those who were filling the hotel rooms. Sharing these worries with my friends and family revealed an interesting dichotomy between what I considered to be good and what others considered to be good enough. There was a general assumption that everyone who had been offered a hotel room would be overwhelmingly grateful – of course, many people were thankful to be offered shelter and protection from the spread of COVID-19, but this situation was far from perfect. If the aim was solely to get people off the streets and into hotels, then yes, we had done a good job. In fact, a modelling study estimated that a 'do nothing' scenario would have resulted in 34% of those experiencing homelessness contracting COVID-19, with 364 deaths, 4,074 hospital admissions and 572 critical care admissions in a six-month period (3). Fortunately, the COVID-19 response strategy (1) mitigated this outcome. However, for the nurses, GPs and community outreach workers, their job represented so much more: caring for the holistic needs of individuals. It seems as though the very notion of holistic medicine in the homeless sector is misunderstood and overlooked, not by the staff who deliver the care, but by wider society.
This experience has taught me that holistic medicine is not synonymous with perfect medicine. Holism is about choices, priorities and compromise. We see this in the rise of social prescribing, complementary therapies and the devoted healthcare professionals who work alongside voluntary groups in the homeless sector. However, in some cases patients are still not receiving the comprehensive care they need.
Holistic medicine is entangled with diverging utilitarian and deontological principles, responsibility to the population and to the patient. Public health emergencies such as the COVID-19 pandemic require intervention at a population level. Such interventions commonly favour utilitarian ideologies: maximising utility and resources whilst saving the greatest number of lives. As the focus shifts from individuals towards a population-based approach, we may perceive the rise in utilitarian discourse as a threat to the prime position of holistic medicine. But what if COVID-19 itself is not the threat, but a spotlight illuminating the real barriers in the delivery of holistic healthcare.
Using this spotlight, the task of treating the whole individual becomes enmeshed in politics and societal perceptions. As an organisation, the NHS has been criticised for having a poor understanding of homeless healthcare and holistic medicine in general (2). Problems manifest as practical limitations sustained by policy and resource allocation. Public opinion also plays a part, particularly where stigmatisation results in social exclusion and misunderstanding of healthcare needs. The existing cracks in our healthcare system, as highlighted by the COVID-19 pandemic, should not be overlooked. Improving how we approach holistic healthcare is dependent on the reflective practice of healthcare professionals and the open-mindedness of those with the power to change the systems.
Story A, Hayward A. Clinical Homeless Sector Plan: Triage – Assess – Cohort – Care’ [Internet]. 2020 [cited 13 July 2020]. Available from: https://www.pathway.org.uk/wp-content/uploads/COVID-19-Clinical-homeless-sector-plan-160420-1.pdf
Halligan A, Hewitt N. Perspectives on the homeless patient [Internet]. College of Medicine and Integrated Health. [cited 15 July 2020]. Available from: https://collegeofmedicine.org.uk/perspectives-on-the-homeless-patient/
Lewer D, Braithwaite I, Bullock M, Eyre M, Aldridge R. COVID-19 and homelessness in England: a modelling study of the COVID-19 pandemic among people experiencing homelessness, and the impact of a residential intervention to isolate vulnerable people and care for people with symptoms. 2020.