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| Credit: Damon Winter/The New York Times |
My patient and I both knew he was dying. Not
the long kind of dying that stretches on for months or years. He would
die today. Maybe tomorrow. And if not tomorrow, the next day.
Was there
someone I should call? Someone he wanted to see? Not a one, he told me. No immediate family. No close friends. He had a niece down South, maybe, but they hadn’t spoken in years.
For
me, the sadness of his death was surpassed only by the sadness of his
solitude. I wondered whether his isolation was a driving force of his
premature death, not just an unhappy circumstance.
Every
day I see variations at both the beginning and end of life: a young man
abandoned by friends as he struggles with opioid addiction; an older
woman getting by on tea and toast, living in filth, no longer able to
clean her cluttered apartment. In these moments, it seems the only thing
worse than suffering a serious illness is suffering it alone.
Social
isolation is a growing epidemic - one that’s increasingly recognized as
having dire physical, mental and emotional consequences. Since the
1980s, the percentage of American adults who say they’re lonely has doubled from 20 percent to 40 percent.
About one-third of Americans older than 65 now live alone, and half of those over 85 do. People in poorer health - especially those with mood disorders like anxiety and depression - are more likely to feel lonely. Those without a college education are the least likely to have someone they can talk to about important personal matters.
A wave of new research suggests social separation is bad for us. Individuals with less social connection have disrupted sleep patterns, altered immune systems, more inflammation and higher levels of stress hormones. One recent study found that isolation increases the risk of heart disease by 29 percent and stroke by 32 percent.
Another analysis
that pooled data from 70 studies and 3.4 million people found that
socially isolated individuals had a 30 percent higher risk of dying in
the next seven years, and that this effect was largest in middle age.
Loneliness can accelerate cognitive decline in older adults, and isolated individuals are twice as likely to die prematurely as those with more robust social interactions. These effects start early: Socially isolated children
have significantly poorer health 20 years later, even after controlling
for other factors. All told, loneliness is as important a risk factor
for early death as obesity and smoking.
The evidence on social isolation is clear. What to do about it is less so.
Loneliness
is an especially tricky problem because accepting and declaring our
loneliness carries profound stigma. Admitting we’re lonely can feel as
if we’re admitting we’ve failed in life’s most fundamental domains:
belonging, love, attachment. It attacks our basic instincts to save
face, and makes it hard to ask for help.
I
see this most acutely during the holidays when I care for hospitalized
patients, some connected to I.V. poles in barren rooms devoid of family
or friends - their aloneness amplified by cheerful Christmas movies
playing on wall-mounted televisions. And hospitalized or not, many
people report feeling lonelier, more depressed and less satisfied with life during the holiday season.
New
research suggests that loneliness is not necessarily the result of poor
social skills or lack of social support, but can be caused in part by
unusual sensitivity to social cues. Lonely people are more likely to
perceive ambiguous social cues negatively, and enter a self-preservation
mind-set - worsening the problem. In this way, loneliness can be
contagious: When one person becomes lonely, he withdraws from his social
circle and causes others to do the same.
Dr. John Cacioppo, a psychology professor at the University of Chicago, has tested various approaches to treat loneliness. His work
has found that the most effective interventions focus on addressing
“maladaptive social cognition” - that is, helping people re-examine how
they interact with others and perceive social cues. He is collaborating
with the United States military to explore how social cognition training
can help soldiers feel less isolated while deployed and after returning
home.
The
loneliness of older adults has different roots - often resulting from
family members moving away and close friends passing away. As one senior
put it, “Your world dies before you do.”
Ideally,
experts say, neighborhoods and communities would keep an eye out for
such older people and take steps to reduce social isolation. Ensuring
they have easy access to transportation, through discounted bus passes
or special transport services, can help maintain social connections.
Religious
older people should be encouraged to continue regular attendance at
services and may benefit from a sense of spirituality and community, as
well as the watchful eye of fellow churchgoers. Those capable of caring
for an animal might enjoy the companionship of a pet. And loved ones
living far away from a parent or grandparent could ask a neighbor to
check in periodically.
But
more structured programs are arising, too. For example, Dr. Paul Tang
of the Palo Alto Medical Foundation started a program called linkAges, a cross-generational service exchange inspired by the idea that everyone has something to offer.
The
program works by allowing members to post online something they want
help with: guitar lessons, a Scrabble partner, a ride to the doctor’s
office. Others can then volunteer their time and skills to fill these
needs and “bank” hours for when they need something themselves.
“In
America, you almost need an excuse for knocking on a neighbor’s door,”
Dr. Tang told me. “We want to break down those barriers.”
For
example, a college student might see a post from an older man who needs
help gardening. She helps him plant a row of flowers and “banks” two
hours in the process. A few months later, when she wants to cook a
Malaysian meal for her boyfriend, a retired chef comes by to give her
cooking lessons.
“You
don’t need a playmate every day,” Dr. Tang said. “But knowing you’re
valued and a contributing member of society is incredibly reaffirming.” The program now has hundreds of members in California and plans to expand to other areas of the country.
“We in the medical community have to ask ourselves: Are we controlling blood pressure or improving health and well-being?” Dr. Tang said. “I think you have to do the latter to do the former.”
A
great paradox of our hyper-connected digital age is that we seem to be
drifting apart. Increasingly, however, research confirms our deepest
intuition: Human connection lies at the heart of human well-being. It’s
up to all of us - doctors, patients, neighborhoods and communities - to
maintain bonds where they’re fading, and create ones where they haven’t
existed.
Correction: December 24, 2016
Dhruv Khullar, M.D., M.P.P., is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter at @DhruvKhullar.
