European Journal of Physiotherapy

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Paradigm shifts are hard to come by: looking

Filip Maric & David A. Nicholls

To cite this article: Filip Maric & David A. Nicholls (2020) Paradigm shifts are hard to come by:
looking ahead of COVID-19 with the social and environmental determinants of health and the UN
SDGs, European Journal of Physiotherapy, 22:6, 379-381, DOI: 10.1080/21679169.2020.1826577

To link to this article: https://doi.org/10.1080/21679169.2020.1826577

Published online: 09 Oct 2020.

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LETTER TO THE EDITOR

Paradigm shifts are hard to come by: looking ahead of COVID-19 with the social
and environmental determinants of health and the UN SDGs

Dear Editor, Along the same lines, the use of digital means in education
and clinical practice merely continues our professions long-
As the COVID-19 pandemic continues to hold the world in
standing affinity to machines, mechanics and technology,
check, physiotherapy clinicians, researchers, educators and
rather than represent a major paradigmatic shift [15].
students are having to invent new approaches to everything
Though it certainly comes with and will bring about many
they do and adapt to drastically different ways of learning,
more changes, it does not represent a paradigmatic change
teaching, practicing and researching physiotherapy. So des-
in any fundamental sense.
pite the challenge that COVID-19 is presenting to physio-
To be clear, this is not to say that paradigmatic change,
therapists and patients around the world, much
or even innovation are goals that should be pursued over
commendable work is being done at quite astonishing rates.
and above the issues they ultimately seek to address.
Physiotherapists have assumed a key role in the acute
Following a kind of principle of exclusion, the value in recog-
treatment of COVID-19 on ICU-wards, as well as the long-
term rehabilitation of patients struggling with a yet to be nising what continues along established paths lies in reveal-
understood array of post-acute symptoms. Clinical and aca- ing where we will not find the novel responses we need to
demic research the world around is supporting this work meet the new challenges we are facing today. If our predom-
with a quickly growing list of publications refining our inant focus as a profession has thus far been on the reactive
understanding of the pathology, treatment and rehabilitation treatment of pathologies, then a first alternative might direc-
of COVID-19. Equally immediately, first attempts at delivering tion might lie in a stronger shift of our focus towards (the
corresponding education for future and current physiothera- broad vicinity of) prevention.
pists have been made and are undergoing contin- Contrary to what has been suggested, we believe that
ued refinement. this cannot mean that ‘physical therapists need to redouble
National and international physiotherapy organisations their efforts to address NCDs by assessing patients for risk
around the world have equally been quick to support the factors and manifestations and institute evidence-based
compilation and sharing of knowledge deemed relevant to health education (smoking cessation, whole-food plant-based
physiotherapy in the context COVID-19 so far (e.g. World nutrition, weight control, physical activity/exercise)’ in the
Physiotherapy COVID-19 information hub). Much of the context of the ongoing COVID-19 pandemic [9]. It can also
physiotherapy conferences that had been scheduled for this not mean that we simply push for more self-management, or
year and next, have not only quickly switched to online for- for no-touch modalities for either the prevention, or treat-
mats in a near-Herculean effort, but are also adding entire ment and rehabilitation of COVID-19.
streams on the health impact and treatment of COVID-19, as What prevention means in the context of COVID-19 is
well as its effects on physiotherapy education. something rather specific that has thus far been well outside
Though there will undoubtedly be more innovation com- of our established practices and professional preferences.
ing out of the COVID-19 pandemic as time progresses, much The outbreak and rapid spread of SARS-cov-2 is fundamen-
of what is being developed in the immediate response phase tally and, in fact, causally related to the environment and the
that we have seen so far can roughly be grouped into two environmental crises of our time. Being a zoonotic disease, it
categories: Firstly, acute and long-term treatment approaches cannot be considered in full without considering human-ani-
for a previously unknown pathology [1–6]; and secondly, mal relations and the biodiversity crisis in general, and meat
new approaches to the delivery of physiotherapy and physio- consumption and production more specifically [16,17]. More
therapy education with a heavy focus on transitions to broadly still, driving the more frequent emergence and more
digital tools and telerehabiliation [7,8]. rapid spread of zoonotic diseases are issues like deforestation
While all of this is highly necessary, should continue, and and urban expansion, travel and mobility, and a complex
continue to be supported, there is also a limit to the extent array of deeply intertwined social and cultural issues [18–21].
that we can consider these efforts innovative, let alone repre- This means that prevention, in the context of COVID-19,
sentative of paradigm shifts borne out of the COVID-19 pan- implies a broader perspective that includes social, cultural
demic. The acute treatment and long-term rehabilitation of and environmental determinants when it comes to health
pulmonary, neurological, musculoskeletal and cardiovascular and its healthcare professional support.
pathologies has been the mainstay of physiotherapy for well Even if we decide to teach current and future physio-
over a century now, particularly in times of crisis [9–13]. therapists primarily about the acute treatment and long-term
Responding in like manner to a new disease is therefore rehabilitation of COVID-19 and keep with our well estab-
quite rightly the continuation of ‘business as usual’ [14]. lished frame of thinking that considers pathologies in the
380 F. MARIC AND D. A. NICHOLLS

context of their causes, it would seem logical to include contribute there. Are there ways that we could support
these drivers, that reach beyond the boundaries of the indi- access to affordable and clean energy (SDG 7)? What is our
vidual body, into our respective courses. If we do so and potential role and contribution to, for example, the develop-
simply continue as before however, we will have to answer ment of sustainable cities (SDG 11), to life below water (SDG
to our reason for continuing to give pathology and its treat- 14), to peace, justice and strong institutions (SDG 17), to
ment such precedence, rather than turning our gaze more reducing hunger (SDG 2), or climate action (SDG 13)?
resolutely towards causative issues and the prevention of To be clear, all of the latter and the remaining SDGs have
pathology in this sense. But to do this, physiotherapists been clearly identified as quintessential to the achievement
would have to recognise that the profession has given little of good health and wellbeing (SDG 3). In other words, good
attention to questions of social determinants, equity and health and wellbeing will not be achieved without the devel-
social justice. opment of responsible consumption and production patterns
The physiotherapy profession has assiduously avoided talk (SDG 12), without gender equality (SDG 5), quality education
of ‘upstream’ social justice issues in the past. Unlike many other for all (SDG 4), and so on. If that is the case, then we must
orthodox and alternative health professions, physiotherapists ask ourselves whether we can really justify continuously and
have shown little interest in addressing the profession’s North exclusively keeping our eyes on the treatment of already
Atlantic bias, it’s ‘white middle-class’ heritage [22], it’s exclusion rampant pathologies, rather than getting engaged in matters
of disabled people from training [23], women’s division of that are necessary for their prevention. If we are to ‘hike
labour, and gender diversity [24–26], its focus on the body-as- upstream’ and contribute to latter, we will have to jettison at
machine and distaste for the political leverage a profession can least some of our fixation with pathology, acute self-limiting
bring to questions of poverty, inequity and oppression [27]. It conditions, the body-as-machine, expensive secondary
has preferred to remain close to its biomedical heritage and healthcare, our fixation with cure, etc. [30].
recommend people do more exercise, and advise on smoking As a political strategy heavily shaped by neoliberal values
cessation, behaviour change and weight loss.
and problematic conceptions of economic growth (SDG 8)
There is a parallel here to the way in which the UN Agenda
and development, there is much to be thought about care-
2030 Sustainable Development Goals (SDGs) are now gradually
fully and critically in regard to the UN Agenda 2030. Yet,
being woven into physiotherapy curricula. Based on personal
much like resonant publications it clearly identifies that
communications with colleagues around the world, we have
transformational change is needed if we are to achieve its
noted a predominant focus on the integration of SDG 3 (good
social and environmental goals [31–33]. In the face of
health and wellbeing) into physiotherapy curricula. This is
COVID-19, it is clearer than ever that this transformational
logical since it is about beginning our engagement on ‘home
change is about grounding human life on earth on social
turf’ and a kind of strengths-based approach to contributing to
justice and environmental responsibility, and that it must
the SDGs. As a healthcare profession, most of what we do has
take place at all levels an all sectors of society. Physiotherapy
long contributed to the good health and wellbeing of people
can be no exception here and continue to sideline the inter-
and there is no doubt that improving our efforts in this area
will also improve our respective contribution. Such an approach connected social and environmental determinants of health.
to the SDGs, however, does not reflect what the SDGs are Because of our physical-rehabilitation-focussed history we
about, namely, understanding and acting upon the many ways are maybe particularly susceptible to ‘the very real danger’
that all 17 goals are interconnected and underpinned by social pointed out in a recent editorial to the Lancet Planetary
and environmental justice. Precisely, ‘if we are to take the UNs Health: ‘that COVID-19 looms so large in our minds that we
Sustainable Development Goals (SDGs) seriously’ then we must miss the obvious writing on the wall about the other prob-
heed their imperative call ‘to acknowledge the social determi- lems we must still address’ and which fundamentally under-
nants of health and to understand health in the broadest of lie this current pandemic in the first place [34].
contexts’ [28]. There is certainly potential for a veritable paradigm shift
It is certainly true that this also means that improving the here, though we also know for well that these require funda-
health and wellbeing of people is likely to have positive mental changes in our basic concepts, understandings and
effects for life on land (SDG 15), life below water (SDG 14), approaches of ourselves, the world we live in, and those we
reduced inequalities (SDG 10) and reducing poverty (SDG1) share it with [35,36]. To bring about such a paradigm shift, it
and there is good indication to support these assumptions will undoubtedly be critical to recognise that, to paraphrase
[29]. At the same time, however, we believe that we should an argument recently made [28], addressing environmental
not make things quite so easy for ourselves and, in that way, issues and ‘doing away with health disparities and social
limit ourselves to established conceptions of physiotherapy inequality is not just social justice’ and environmentalism,
that fail to address the root causes of the problems that but ‘indeed pandemic preparedness’ and healthcare at its
have prompted the SDGs. To break out of our habitual pat- best. The question then is simply how physiotherapy will
terns and develop appropriate new ways of responding to participate in such best practice as we go forward.
the pressing health challenges of our time, starkly defined by
social and environmental determinants, it might be far more
fruitful to look to places we have not been before first, and
Disclosure statement
then see what they might mean to us and how we could No potential conflict of interest was reported by the author(s).
 EUROPEAN JOURNAL OF PHYSIOTHERAPY 381

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