• COVID-19

Professor RIM Dunbar of the Oxford Department of Experimental Psychology made a startling and important statement in 2018 based on studies of the brain1: ‘Friendship is the single most important factor influencing our health, well being, and happiness.’ Friendship can be added to a range or spectrum of much discussed emotions: sympathy, empathy, compassion, the provision of dignity, kindness and bringing cheer/joy. These are outputs of the mind dependent on the brain, but they differ in exactly what they express. Some, like compassion, have been discussed in this journal2 and of course in many others,3–5 and is especially a concern of caring.

‘Caring for life’ was a major theme of a conference held in Oxford in 2019 in the home of the father of modern medicine, Sir William Osler (1849–1919). The topics discussed included the benefits as well as some difficulties created by science or care technology, and the need to apply care attitude or humane education to assuage such difficulties.

Osler6 and his admirer John McGovern (1921–2007) both believed that science with its knowledge and skill needs the steadying infrastructure of humanistic values and objectives. During the conference, McGovern was quoted, as follows:

The practice of medicine requires knowledge and skill, frequently labelled as the science and art of medicine, yet knowledge and skill are incomplete without the steadying infrastructure of humanistic values and objectives. 7

Osler thought of compassion, defined by Sir Thomas Browne as a feeling that embraced the sadness of others; perhaps therefore causing one to feel sad. Many have emphasised the therapeutic power of Osler as a consequence of his friendliness.8 He believed in Robert Burton’s call ‘for a friend that made you laugh’9 and Osler wrote: ‘it is an unpardonable mistake to go about with a long face’.10

Chadwick,11 writing following the Francis Report on inadequate care, reminded us of some of the facts of what is needed. Fundamental standards include giving prescribed drugs, supplying food and water to sustain life, keeping patients and equipment clean and providing help to go to the lavatory. He said compassion is hard to define, impossible to mandate. Perhaps one should add a recommendation for fundamental behaviour such as friendliness with a smile.12 The cheerful nurse is a welcome attendant.

An article in press by lead nurses,13 based on a presentation at the centenary of Osler, discusses how science and humanity should be linked for nursing as well as medicine. Most of us are aware that for nurses to be able to manage intensive care, they must be technically skilled but when they are handicapped as in the recent pandemic by social distancing and by protective dress including masks, it becomes very difficult to demonstrate what we most need from a nurse—their humanity and at least their friendly demeanour.

In the UK, vaccination centres during lockdown have been rich in friendly smiling volunteers, well lit and cheery in decor: a very welcome change from isolation, surely adding to the therapeutic effect of vaccination which could be carried out by robots but would almost certainly have been much less popular. Science cannot claim that all this was its doing. It was people being humane.

Camaraderie and esprit de corps are aspects of friendship found to be of benefit in training for many aspects of life such as sport and for armed warfare and in a recent BMJ by doctors feeling the need to reconnect with friends.14

Janet Baker, the opera and lieder singer, wrote in her autobiographical journal ‘Full Circle’15:

Human friendship, at its deepest level, is perhaps the most important factor in our lives. It is the one relationship that keeps a space between people: what is given in friendship is always a bonus because no one owes anybody anything, or wants anything, there are no duties involved; one is quite free.

So much for human friendship. During the Osler centenary celebration, two international organisations launched ICARE. Both the organisations, Actasia and Join Hands, have websites.16 17 They have a link with two universities: London University’s College of Fashion to support clothing without fur from wild animals, and Oxford, which hosted the inauguration of ICARE.

One of them, Actasia, has as its logo ‘Through education we provide compassion for animals, kindness towards people and respect for the environment in China and throughout Asia’. It is a new joint approach from the UK, the USA and Australia with a background of Human and Veterinary Medicine. The Oslerian theme of friendship was added to the concept of ICARE as a need to add humane education to the classroom of primary children. This was a need aimed at and discussed at the Osler centenary, especially about the care of animals, and from China the care of the frail elderly and a presentation on the rehabilitation of the severe disability of 100% burns. Osler’s therapeutic power and the extent a doctor should have strong friendships with patients was a recurrent theme.

The meaning given to the above range of ‘feelings’ by longer or shorter dictionaries is quite varied but so is the range of the recipients for such feelings when one includes the entire animal kingdom and the environment. In Veterinary Medicine when addressing the topic of caged wild animals, is there for the caged animal an equivalent to health and well-being enhanced by friendship? What should children know about attitudes equivalent to friendship? One of the organisations attending the Osler centenary celebration was Join Hands from Pakistan which has since debated in a webinar care of donkeys and the meaning to the donkey of the carrot and stick. Following the inauguration of ICARE, exactly what schoolteachers should teach children about caring for domestic animals like the donkey has become a focus of attention in Pakistan. It is an important new approach widening the awareness of children of needs that they can meet.

The COVID-19 pandemic has highlighted much of what was discussed. Topics for discussion are isolation, social distancing, the loss of the visible smile due to masking and the closing of gatherings which enhance friendship in religious houses or educational centres. Care of the caged wild animal has also been discussed extensively. There has been an emphasis on listening to science but questions raised as to care attitude when science has cruelly isolated family members from each other or wild animals have been caged for prolonged periods.

Loneliness has become a revised topic of interest in the field of mental health. Its role in suppressing the immune system and enhancing the spread of infection does matter. Isolation was for a thousand years the treatment of choice for leprosy and in Oxford the Cochrane Annex of the Department of Dermatology was a late 20th century centre of research into the antibiotics making isolation unnecessary.18 Often in Asia, isolation is on mountaintops, away from the influence of the friendly and healthy, and even today new care homes in Asia do not expect a richly altruistic community of friendly neighbours. There is little planning expecting many volunteer helpers bringing joy. Scientific facts prevail even though the effect of friendship in counteracting the isolation which suppresses immunity and may kill is not discussed.19

We have in the UK a government struggling to show during the COVID-19 pandemic that it is listening to scientific evidence. Some of the scientific evidence presented on TV by scientists keen to impress has so emphasised ‘Truth’ and ‘Facts’ that according to Horton of the Lancet have failed to address ‘health as an instrument to cut across political divides’20 or perhaps to recognise that health and well-being is harmed by social distancing and by masking. COVID-19 has been a clear example of how advanced technology needs to be applied with care attitude and humanity.

Several authors including Osler have written that definite knowledge belongs to science, but science can destroy the natural systems that sustain life.21 People’s behaviour, likes and dislikes, and willingness to obey rules are not determined by science’s truths but more by their emotions, The role of the brain in the interpretation of emotions and how it induces and controls pathology is discussed in the article accompanying this editorial.22

Osler wrote: ‘a devotion to science, a saturation with its spirit, will give you that most precious of all faculties—a sane, cool reason which enables you to sift the true from the false in life and at the same time keeps you in the van of progress.’23

Osler also wrote: ‘science is organised knowledge, and knowledge is of things we see. Now the things that are seen are temporal; of the things that are unseen science knows nothing, and has at present no means of knowing anything.’24

Until recently, too little was known about the mostly unseen effects of emotions on the brain but neurosciences are changing that and difficult-to-define topics like friendship are studied. Humanity of uncertain meaning has become a focus for publications by organisations such as the Wellcome Trust.25

Actasia began by focusing on the fur trade26 and more recently organised primary schoolchildren to enter poster competitions about reducing caging of wild animals and most recently to stop boxing of domestic animals, cats, dogs and hamsters as gifts, since lorry loads of such boxes result in a large number of deaths of these potential pets. All such treatment of animals reduces their immunity to viruses and other infections and is relevant to new infections such as COVID-19. Chinese children will now understand and complain to their parents about the extinction of many animal species resulting from Chinese trade for food, traditional medicine, aphrodisiacs, ivory and fur. Actasia’s approach began as teaching primary schoolchildren humane behaviour to animals. Today it is humaneness to animals, friendliness to frail human beings and care of the environment making Actasia rated even in China as one of the most influential charities. If as in Asia, with some of the largest of the world’s populations, human and veterinary medicine adopts humane education to teach in primary schools, including friendship to enhance health and well-being, it will be of global benefit. It will also widen the influence of the father of modern medicine and founder of this journal.27

Terence Ryan is Emeritus Professor at Oxford University and Oxford Brookes University, and Curator of the ‘Open Arms’, Green Templeton College, Oxford.