Dr. Kate Mulligan is an Assistant Professor at the Dalla Lana School of Public Health at the University of Toronto. With the Alliance for Healthier Communities, Kate directed Canada’s first large-scale social prescribing project, implemented in community health centres across diverse urban, rural, Francophone, and Northern regions in the province of Ontario. This initiative, winner of the first International Social Prescribing Award, aims to improve health outcomes for marginalized and socially isolated people and to reduce health systems utilization by creating a clinical pathway between mainstream health systems and community and voluntary supports. She also sits on the board of Toronto Public Health and 880 Cities, and is the Senior Director of the Canadian Institute for Social Prescribing.

We sat down with Dr. Mulligan to learn more about her innovative work on social prescribing within Canada and how nature prescribing fits into the overall landscape, tips for self-care, and her favourite ways to connect to nature with her family.

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Can you tell me about your early experiences and education, and how they led to your career today?

I grew up outside of Orillia, a small town in Ontario. I spent a lot of time in nature, at provincial parks, and hanging around outside—you know, playing with frogs and enjoying being part of the world. That was really a formative experience for me. I have three brothers, so we were a family of six, and didn't take exotic vacations. We went camping, we went hiking, we hung out outside. My parents are still very interested in spending time in nature, and so instilled that, I think, in in all of us. Two of my brothers went on to become water engineers, and we've all continued with that environmental interest for a long time.

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But I've also had a strong interest in health equity and justice, so that's also been part of my life experience. From childhood on I was involved in activities that got me around other people, and tried to make the world a fairer and healthier place. That’s taken me all over the world, working in Latin America, Southeast Asia, doing work in rural communities or cities, and then taking me to my PhD, which was in health geography—continuing that interest in the relationship between people and places, and how that impacts our health and well-being.

I’m a political ecologist of health which really just means I understand health as produced in that relationship between people and power and places. I’ve worked with Toronto Public Health doing environmental health work, active transportation, climate change analyses, and again, trying to get communities out, participating in their in their local neighbourhoods and being outdoors. For the last number of years I've been working on the point that really connects us, which is social prescribing: a way to use health care to help connect people to non-clinical supports and services that we know can help improve their health and well-being, address the social determinants of their health, and hopefully improve our health systems along the way.

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Tell us about the history and concept of social prescribing globally and within Canada. How do you see nature prescriptions fitting into the overall landscape of social prescribing?

Social prescribing has been around for a long time. I mean, the idea of people connecting one another and finding health in their relationships and communities is as old as humanity.

But what's new is the idea that we can very deliberately reconnect people with their communities, and with those activities that we know support them. And reconnect them with place, reconnect them with nature, and remind ourselves that we are biological creatures, and that biology drives us to spend time in our ecologies and to spend time around other human beings.

Those are some of the things that I think connect the nature prescribing that's of interest in parks with the broader social prescribing movement which could include other activities like arts and culture, more material determinants of health like food, housing support, income—a range of things that we know can be helpful to people.

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Over the last 10 years or so, it's really grown around the world, starting primarily in the United Kingdom, where the government decided to take a leap of faith, and really invest in social prescribing at a grand scale. Now they've got thousands of people working as link workers to support the clinicians and the participants to make those referrals and connections, and follow through to track the impact to see what's happening to people's health.

We've been learning from what they do in the UK and trying to adopt it here in Canada, and we now have a number of significant initiatives happening right across the country. The United Way in BC is doing a lot of work, for example, with older adults, community health centers and seniors. Active Living centers are doing a lot in Ontario, and there are many, many small pilots right across the country. That's all feeding into the work that we're doing now, which is to launch a new Canadian Institute for Social Prescribing, which we hope will link together all these disparate activities into a network so we can learn from each other, celebrate our growth, and continue to demonstrate momentum for something that we are really confident helps people.

We received a grant from the Ontario Ministry of Health to try out social prescribing in 2018 and 2019—we were early early adopters in social prescribing in Canada. I was working with the Alliance for Healthier Communities, which is the organization representing community health centers and other team-based, primary healthcare models. That's when we really started to do implementation research, to see what worked for what people, under what circumstances. We learned from UK mentors who came to visit us and worked directly with practices right across the province, and learned how to adapt it across really different contexts. So, you know, a remote Northern Francophone community health centre, or a suburban community health centre in Toronto serving new immigrant populations, a rural centre serving retirees; all different kinds of communities who had different kinds of services around them, different populations, different needs, and figuring it out in ways that made sense for them.

Social prescribing really, really needs clinical champions to succeed. Some of those early adopters and innovators and leaders out there taking a risk on something that not everyone will understand or respect or value—that's what we need.

We need people who can really be those champions for this to really get a foothold in the mainstream. I think there is a lot of energy and interest behind it—it's expanding across Canada and growing so fast. With PaRx it sounds like you’ve created a model that's really low-barrier for clinicians to get involved, which is awesome. I think that's a really smart way to do it so they can just get started, and then iterate in their own practices to do what matters to them.

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What is your favourite social prescription to fill?

I'm a mom of three young kids—I have two seven year olds and a ten year old—so I really enjoy spending time outdoors with them. On Mother's Day we all grabbed our bikes and went down to the Leslie Street Spit here in Toronto, which is close to where we live, and stopped for a picnic and spent time exploring nature there. It's a really special place because it really shows how urban life and nature can come together to create something that's surprising, and different. It's made from construction fill and grows every year, and is always being reclaimed by wildlife in interesting ways. But it's also used by people, and the evidence that it's made by humans is there, too, with, bricks and metal pieces, and all sorts of interesting things around the way.

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It really is just that reminder that whether we recognize it or not, we are always part of a co-creation between our environments and our health and well-being and ourselves.

The girls loved it—they were so fascinated to be able to explore this strange mash-up of things that are happening there. But it's wild in a way that is meaningful to them. I grew up in a smaller community so spent a lot more time unsupervised in nature, and they don't have that same experience. So we have to be more intentional about how we do it, and we have to recognize that for them it looks a little different—it looks urban, and that’s okay.

They have also spent a lot of time also visiting grandparents and being outside, just being themselves, less structured, less scheduled. We had been part of this community called YMCA Geneva Park in Orillia, where I used to work at the nature center. Unfortunately, this place has recently just been sold to private interests, and we're all experiencing a bit of grief about losing it as a not-for-profit community space, when right next door there was another land sale in the same week or two that returned land to the Rama First Nation.

These two different potential stories really show the different paths that we could or should be taking. One is reclaiming land, and turning land back to original stewards and owners, and one is more of the privatization and the grief we feel when we lose something that we felt was more collective. We've been involved in trying to think through what we want those futures to look like for our kids.

I think the main thing for me is to remember, as a political ecologist, that those power relationships are always part of it. It's not just us going out into some sort of pristine nature. There's a history here, there's the history of colonization of capitalism, of privatization, and that really complicates things.

But that has always been part of it, and we need to just make that visible, so that we we're aware of it, and we can learn, and we can try to tackle some of the dynamics that allow some people in but not others.

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What’s your perspective on the importance of self-care in being an effective health professional?

Trying to deal with the significant power dynamics during the pandemic was very challenging for me. I experienced burnout after the first year of the pandemic, really being at the front lines of trying to advocate for health, equity, and often not being heard or feeling heard, yet sometimes having important successes. But it was really exhausting. I had to remember to take the time to make it sustainable for myself, to remember that any of us doing this work is not doing it alone. That if we step back things aren't gonna’ fall apart—we're doing this as a community. If I can't do it, I can step back and I can do that self-care to be able to re-enter it in a way that's more sustainable or healthy for me.

I've really taken that to heart, trying to make sure that I am not over-committing and over-inflating the importance of my own individual contribution at any time. Sometimes it's not that we think we're the most important, but we feel like if we're not doing it then somehow it's not going to happen. That just isn't true. There's a community, and that's why we're growing it together.

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What projects are you working on right now?

As I mentioned we have this new project called the Canadian Institute for Social Prescribing. It's a bunch of community organizations, interested health care people and others who are coming together to really think about what social prescribing could really be here in Canada.

It has two components. One is a collective impact project anchored by the Canadian Red Cross that will bring us together to have some important conversations about where to take social prescribing. Where the opportunities are, and coming to some consensus around what we think social prescribing is and what it isn't, so that we know collectively how to make this happen at a policy level or in systems, or help people implement it in their local work and in their local practices.

The other part is much broader, and it's just being a happy and healthy and supportive network for people doing this work. I hope that we'll be doing a lot of knowledge mobilization, webinars, and sharing of good practices. Just, you know, being online and celebrating good work, connecting researchers and communities helping clinicians and others who want to do this work take their next steps. And hopefully creating an inclusive community that's collaborative, that puts community voices first, and is very much focused on equity, so that we don't end up with social prescribing as a rebrand of things that are already happening, and haven't been as healthful for us. We want it to be something new that pushes us toward a healthier and more equitable and more sustainable way of doing things.

From my own research and experience, I think there are some core things that make social prescribing social prescribing, and not something else. And a lot of those something elses are really great and important, but maybe just don't fit under what we would call social prescribing.

First, there needs to be a connection between health care and social services, or social supports. So if we're just out there doing the social side that's great, but it's not prescribing. And likewise, if we're doing a community referral but we're not really empowering that person through the process to make their own decisions about what they need, how they want to access things, and what supports they might want, that's probably not social prescribing either. That’s what we might call sign posting, just saying or suggesting activities.

And then we want to ideally have a link worker or community connector, somebody who spends time with the person to have that conversation, to shift the focus away from what's wrong to what's strong, or from what's the matter with you, to what matters to you. And in that conversation, again, building that empowerment and that that self-determination. There's some real power in that, I think; we don't want to maintain a totally medical model of just moving people along a system, but put that health promoting lens in there.

Lastly, I think the important thing beyond actually attending and getting the support you need to do the social prescription is some data tracking and learning, so we can find out whether it's working, whether it's impacting your health outcomes or your self-reported health, whether it's having an impact on health systems. Maybe we're using upstream health services that are more appropriate and less expensive. So ideally, social prescribing should have most of those components in it to really be a model that we think is going to be transformative.

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Where’s your favourite place to spend time outside?

As a parent, I think most of it happens out front of our home. We live in a nice, connected community, and that's a real privilege. We suddenly had a couple of warm days starting yesterday, so we were out spraying the hose on the neighbourhood kids, and enjoying our backyard food garden, which is small, but really fun and a great place to learn with kids. We have a robin who's nested right on our front porch, and we're checking on her and her eggs every day. So just those little things—the little neighborhood parts are where I am in my life with a busy career and three kids and lots to manage. We're not going to be getting out on huge expeditions anytime soon. But all these little magical components of daily life can be full of wonder for us at any age.

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I also spent quite a bit of time working in Latin America on water in sanitation projects within rural Indigenous communities in particular, and supporting their self-determination in accessing resources that they needed in culturally appropriate ways that were affordable. Just being in the landscape, being on the Altiplano, the high plains, I really felt a sense of welcome and community there. It was a really impactful time in my life.

I would love to go back and spend lots of time living in Bolivia, where it's a similar post-colonial context, but they do things differently. There is poverty just like there is here, but there is also lots of richness and wealth in community, and to see that expressed in outdoor life is really fantastic.

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What’s your top tip for health professionals who want to ensure they’re prescribing nature, or other social prescriptions, effectively?

My top tip is to remember equity. Remember power relationships in that political ecology of health. That just suggesting activities can maybe even cause harm to people if we can't support them to follow through. There is a reason why people are disconnected from time in nature, and if we're interested in nature prescribing, we need to ask why.

We need to think about what barriers people are facing to being involved in nature. Are they proximal barriers, like transportation or cost? Are they accessibility barriers for physical access?  Are they cultural barriers due to communities that have lost connections or traditions about being outdoors over the years?

And there's also some support that might be needed to make sure we can swim safely if we haven't received swim training—those kinds of things. And of course, there's trauma for people who have been displaced from their communities around the world, for Indigenous peoples who have been displaced from their lands here in Canada. For people experiencing poverty. There's a lot of layers to people's relationships with nature as individuals, and as populations in those communities. And so we need to be accountable for how we engage with people under those circumstances.

I think the pandemic has opened many people's eyes to some of those inequities that they maybe didn't really recognize before, to recognize that a universalist approach to this kind of thing is not going to be appropriate. And so we need to do that individual, slow, talking with people, figure-it-out kind of thing, and we need to listen. We need to listen to the communities and the community leaders who are saying this and can help explain how to do this in safer ways, and we want to support them. We want to support their leadership where possible, so that they can be the ones leading the work for themselves in their communities. That community-led equity piece is the part that I think really, really needs to happen.

If we're not sure how to do that we should be reaching out to our local community organizations and leaders to begin those conversations. That would be an important next step, I think, is to talk to some of your small local community organizations that work with populations you might be also working with to get a sense of those power dynamics, those barriers, and how we can, authentically move through them together as a community.

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Any last words of wisdom?

There are so many things I want people to know. I want them to know that they can be involved with our new Canadian Institute for Social Prescribing, so keep an eye on it—we're brand new. I want people to ask for this when they're with their healthcare providers, or they're advocating for the people that they care for. This will come as much from community demand as anything else. So keep asking your health care providers about it, and let's just be open to those conversations.

I think the world we've built around us reflects the values that we have, and as we start experiencing climate impacts, we need to be supporting people through new health challenges that are going to emerge, that will make it more difficult in some ways to be out in nature—if it's extremely hot, or we have flooding, or other barriers that come up.

We have to think at that individual supportive level of getting people outside, and also to what end? How is that going to help us build more power to take action on some of those bigger things that are causing our disconnection in the first place? That's where I'm interested in going next.

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Find more about Dr. Mulligan’s research interests here.

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