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Why loneliness should be treated as a public health crisis

Infrastructure, stigma, ageism, education and inequality all contribute to the costly burden loneliness creates

Illustration by Michelle Budge

Before the COVID-19 pandemic sent kids home from schools, drove parents from workplaces and locked frail older Americans in their rooms in long-term care facilities, people in growing numbers said they were lonely.

The challenge of loneliness has been particularly acute for older adults and the effects at all ages can be devastating. The National Academy of Medicine reported that prior to the pandemic, 35% of Americans 45 and older said they were lonely at least sometimes; for those over 60, the share was 42%.

In the past 20 years, research has shown that prolonged and severe loneliness harms an individual’s health and welfare. When it affects lots of people, it harms society itself, according to Dr. Linda P. Fried, dean of the Mailman School of Public Health and co-director of the Robert N. Butler Columbia Aging Center at Columbia University. She also directs the Age Boom Academy, a fellowship program for journalists focused on issues of aging.

Fried is among a growing body of experts who believe loneliness is not just a sad situation for those who feel its bite. Rather, loneliness is a public health challenge that needs to be treated as such, with solutions that target everything from community attitudes to physical infrastructure, social networks and more. They call loneliness a “social determinant of health,” and Fried recently told academy journalists the factors that increase loneliness have been “societally designed in,” which means society should also be able to design them out.

The perception of loneliness is getting a makeover, researchers led by academy expert Roger O’Sullivan, director of aging research and development at the Institute of Public Health in Ireland, wrote last year in Will the pandemic reframe loneliness and social isolation, a study published in Lancet.

“For many years, loneliness and social isolation were seen as a social problem among primarily older people as a natural part of growing older,” he wrote. “More recently, they have been framed as a public health issue that can affect people of any age.”

There’s no pill for loneliness, said Fried, noting it should not be “medicalized” and treated as an illness; counseling one person at a time is impractical and less effective, since it’s a societywide problem. Instead, policymakers, health care providers and others should consider what’s needed to build social networks, infrastructures like jobs and volunteer opportunities to bring people together to foster well-being, experts said during a three-day reporting conference on loneliness and old age.

Loneliness as a social determinant of health

There’s a difference between “social isolation” and “loneliness,” though many use them interchangeably. Social isolation can be measured by the number of one’s connections. Loneliness is a subjective feeling, the gap between the connection you feel with others and what you’d like to have.

In a 2020 study for Generations Journal, Fried wrote that “the evidence that much of loneliness in older age is socially constructed and that the resulting loneliness has serious adverse effects on health and well-being lays the basis for considering loneliness to be a 21st century social determinant of health.”

The U.S. Office of Disease Prevention and Health Promotion defines social determinants of health as conditions in the environment — social, economic and physical — where people are born, live, work, play, worship and age. The office said those affect quality of life outcomes, risks, health and well-being, among other things.

The National Academy of Medicine says public health focuses on science-based actions the public needs to take as a group to protect everyone’s health. Social distancing was a recent example of a public health approach to COVID-19.

Living conditions, the structure of different communities, socioeconomic factors, even ecological factors like pollution can keep people inside and away from each other, experts told the Deseret News. We walk faster, which is not conducive to connection. At work, we eat at our desks. We drive alone.

Using the loneliness scale developed by the University of California Los Angeles, researchers found older adults who report feeling lonely are at greater risk of other health conditions, loss of independence and even death, said Dr. Carla Perissinotto, of University of California San Francisco. She told reporters that the health impact can include more cardiovascular disease, depression and dementia. She also noted the majority of those in one study who said they were lonely lived with others and most of them were married.

Social connections are protective. The risks associated with lack of those connections are bigger than smoking, obesity and pollution, said Perissinotto, who wonders why loneliness doesn’t grab as much attention as it should.

One upside to the pandemic, she added, was it got people talking about loneliness and made them more aware of others.

How older adults got left behind

Though nuclear families have great strengths, Fried and other experts say older adults have often found their roles shrunk. In addition, ageism makes elders invisible and devalued, she said. And older adults have been segregated in work, housing and their volunteer roles. Those factors have made the United States “among the most age-segregated society in history, with a resulting loss of intergenerational contact and solidarity.”

The authors of the Lancet article said the pandemic created — and sometimes simply highlighted — problems, but also possible fixes. “There is now a potential opportunity to build on the greater empathy, compassion, caring and concern that have been shown towards those experiencing loneliness and social isolation, and to set in place policies and structures to address root causes and to support healthy choices,” they wrote. Loneliness and isolation must be public health priorities because they are “not just issues facing individuals, but society as a whole.”

When he talks about loneliness as a public health crisis, O’Sullivan presents a pyramid with socioeconomic factors at the broad base and different challenge and solution levels that get closer to helping an individual. At the bottom, poverty, education, inequality, ageism, housing, transportation and both man-made and natural environment form the structural underpinnings to loneliness and its subsequent health and quality-of-life impact.

If people live far apart or have no transportation to get to church or congregate in meal settings, or they can’t afford to go out with friends, the likelihood of loneliness grows.

The next level is just slightly narrower and addresses healthy choices and making it easier for groups to connect in the community, changing work environments and increasing opportunities to build trust.

Narrower still are protective interventions like public awareness campaigns and efforts to reduce stigma and boost the number of people engaged with their communities, including as volunteers.

On a smaller level is creation of group and individual interventions, like befriending someone who is alone or small gatherings like the “men sheds” popular in Europe, where men bond around some shared interest. Book clubs exist on this level, for example.

The specialist interventions that top the pyramid are more the role of health professionals who work with individuals.

One big question is “how can we make healthy choices, easy choices that allow people to connect with others, to build trust and relationships,” O’Sullivan told the Deseret News.

He said individuals can greatly reduce the risk of becoming lonely if they make it a point to connect with others, to build out friendships and form different types of relationships. But O’Sullivan also acknowledged that being able to do so “varies according to where you are on your journey with loneliness.”

The late John Cacioppo, renowned worldwide for cutting-edge research on the topic, likened loneliness to how one’s body says it’s hungry or thirsty or needs a restroom. “It’s your body telling you to take action,” O’Sullivan said. People can reduce their own loneliness by trying new things and also by doing something nice for others.

But chronic, enduring loneliness makes it very hard to reach out, to help others, to ask for help, he said.

Group approach to a singular sorrow

The solution is prevention and big parts of that are a public health focus and community will.

The steps to forging strong, connected communities aren’t particularly fancy. O’Sullivan was impressed by restaurants in Scandinavian countries that created a “talking table” where diners can choose to visit with strangers while they eat. “It’s not a date,” he said, but rather a place for small gathering of those who don’t want to be alone.

Walking groups that are welcoming can accomplish the same goal. Exercise classes have done that forever, providing a chance for people to get to know those around them while sharing an activity.

People don’t have to say they’re lonely to find solutions. After all, said O’Sullivan, if the sign over a door said “Loneliness Room,” who would ever turn the doorknob? Activities get people to fling the door wide.

The experts also say loneliness should not be a taboo topic, though it’s sometimes difficult to broach.

“I do find it helpful to ask people how they solve things, which is a good way to get into deeper emotions because they’re not stigmatized; they’re fixing something,” O’Sullivan said.

Screening for loneliness should be part of routine health care practice, as well, Perissinotto said. “We screen for many things, but not loneliness and isolation.” Conversations about health need to include ideas on the importance of social connections.

Providers may not get that training. In medical school, she said, she learned “zero” about loneliness and social isolation — and very little about older adults.

Perissinotto said it’s vital to strengthen the ties between the health care systems and community-based networks and resources, too. Meals on Wheels is an example of that potential, because the relationship with the delivery person provides benefit that may be as valuable as the meal.