Loneliness is like a cold hand resting on your heart. It can tighten your chest, and make you desperate with longing for company and support. I have certainly felt it on many an occasion: while new to a place, recovering from a loss, a death, a fractured friendship. You may have too. It can only be shaken off by the warm hand of a friend, a loved one, or sometimes, even a stranger.
Vivek Murthy’s book Together, The Healing Power of Human Connection in a Sometimes Lonely World was written before the COVID-19 pandemic and was published in April 2020. Many of its observations, however, have a heightened bearing in the pandemic. In an interview published in the LA Review of Books, Murthy defined it eloquently: “Loneliness exists in that gap between the social connection we need, and the social connection we feel is available to us.” In the book, he calls loneliness “the great masquerader” as it can appear in different forms such as “anger, alienation, sadness, and a host of distressing emotional states.”
Vivek Murthy comes across in this book as a gentle soul, deeply understanding of the feelings of loneliness from his own life experiences. This understanding, coupled with his medical training, scientific bent, intellectual curiosity, keen powers of observation, and obvious commitment to public health makes this a very readable, thought-provoking book.
His tone, sincerity, and story-telling skills reminded me of another physician and author, Abraham Verghese, whose book The Tennis Partner is a beautiful account of friendship, addiction, and loneliness.
Murthy starts by laying out the different types of loneliness identified by research:
- Intimate, or emotional, loneliness – the longing for a close confidante or intimate partner;
- Relational, or social, loneliness – the yearning for quality friendships and social companionship and support;
- Collective loneliness – the hunger for a network or community of people who share your sense of purpose and interests.
All three dimensions are needed for us to thrive; one may have fulfillment in one or two areas but still feel lonely.
Murthy makes the case for how loneliness has evolved, the scientific, neurological underpinnings. Throughout history and evolution over millions of years, humans have depended on community for survival. Together, humans were stronger and better able to withstand dangers, such as attacks by other groups. When one strayed or was separated from the group, one’s very life could be at risk. Hence, the importance of community is practically hardwired into us.
The science underlying loneliness, along with the implications to one’s health, is well researched by Murthy and presented with the requisite references. Dr. John Cacioppo, one of the founders of the field of social neuroscience, first likened loneliness to hunger and thirst, as an important warning signal with biochemical and genetic roots, calling it “a biological and social imperative rooted in thousands of years of human evolution.” The work of Dr. Julianne Holt-Lundstad, a health and social psychologist, showed that weak social connections can be a significant danger to our health.
There are fascinating accounts of research into brain activity during the times we are engaged with others. One of the most striking findings for me was to learn that the same part of the brain that responds to physical pain also responds to emotional pain. Connecting the dots, Murthy makes the connection clear: that people in emotional pain and despair often reach for a numbing drug or drink, as they might for physical pain. This is particularly insightful for the opioid epidemic, from which society is currently reeling.
Murthy’s relates several examples of how people’s lives have been affected by loneliness: children, young, middle-aged, and older adults, both men and women. His account of his own childhood, being bullied for looking and sounding different, will strike a chord with many who have struggled with fitting in and felt they didn’t belong. In a section of friendships among middle school girls, I paused to remember my own daughter’s deep sadness when a close friendship broke off. So many children go through this in middle school, a critical period in their social and emotional development. Support and love are essential to help them tide over such times, until they feel more secure in themselves.
Some of Murthy’s accounts of children subjected to toxic stress (from neglect and or abuse) were heartbreaking. He said studies that have shown, mercifully, that all it takes is one caring adult to prevent and reverse the effects. He gives the example of Big Brothers and Big Sisters of America, a non-profit which matches children with supportive adults in one-to-one mentoring relationships.
While the physiological underpinnings of loneliness are the same for all, circumstances may vary, and the effective countermeasure depends on individual inclinations, preferences, and reservations people may have. It’s no big secret or surprise that men are typically less inclined to openly share what is troubling them than are women. Their styles of communicating, and hence their preferred ways of seeking and finding comfort and support, are very different. For example, “Men’s sheds”, local non-profit organizations where men gather around a common activity, build trust, companionship, and community, is an initiative that was started in one locality in Australia and has spread to different parts of the world.
In the second section of the book, he speaks of the different ways we can connect with one another to preempt or assuage loneliness, and with that, be on the path to a healthier life and a healthier society. The circles of connection he describes track with the different types of loneliness; the friendship circles consist of:
- an inner circle of close friends and confidants,
- a middle circle of occasional companions, and
- an outer circle of colleagues and acquaintances.
In a beautiful section on the importance of solitary reflection, Murthy encourages us to tune in to ourselves with an analogy to the heart pumping blood: while the heart pumps blood in systole, it is in diastole that the blood is supplied with oxygen. Hence, “pausing is what sustains the heart.” Art, music, reading, and being in nature are all experiences that can be enjoyed in solitude but make us feel connected with others. One shining example for me is that of Andrea Bocelli on Easter Sunday, singing “Amazing Grace” from the Duomo Cathedral in Italy at the height of the pandemic, bringing the whole world together as we all sat apart in fear and worry. I wrote of this and other ways we have been able to come together during the pandemic.
Murthy describes the three-way relationship between service, loneliness, and addiction. He quotes Rabindranath Tagore, India’s Nobel laureate poet, and from the scriptures of Hinduism, Christianity, Judaism, and Islam, all of which have service written into them. I was reminded of a prominent scientist in the bay area, the late Nagesh Mhatre, who would exhort people “If you are feeling down, find someone who is suffering more and help them. You will both feel better.” The very act of helping someone makes one feel more needed, less lonely, adds a feeling of self-worth.
There are several inspiring examples of individuals, a college freshman named Serena Bian, for one, who surmounted her feelings of loneliness and depression. Even with these inspiring anecdotes and observations, the second section doesn’t hold together as well as the first. There are newer problem statements: connecting kids in the digital age, seeking support from one’s community during parental crises. Parents struggle with childcare. When anything goes awry, a carefully constructed day can fall apart in minutes. While this book was written in pre-pandemic days, parents’ struggles have only become greater. Being responsible for months for children’s schooling from home has stretched many a family to breaking point. Those who must work outside the home have sometimes been forced to make a choice between work and caring for their children. Most of the time, the burden falls on women. The economics are sobering. There have been articles stating that in the workplace, the pandemic will set back women by decades.
While the last two chapters are filled with inspiring anecdotes, I am left wondering how all this can be formalized, how scalable the approaches are without a coordinated nationwide initiative. It requires effort, work, to build community, and it might take more energy than many have when they are burdened by their circumstances or depression.
In America, we live in a deeply individualistic society. Murthy seems optimistic of the ways in which we can build community even with everything that keeps us apart. I find myself less hopeful: since this book was published, we have had the most sobering, divisive period in American history since the struggle to end segregation. Building community seems harder now than ever. On the positive side, we have a new administration, of which Murthy is an important part, and perhaps there will be change for the better.
Towards the end of the book, Murthy’s states surprisingly that “as hard as we may work… the future will depend on our children. It’s up to all of us to teach them how to build a more connected and compassionate world.” Indeed it is, we must strive to be good parents. But are we to just kick the can down the road to our children? I was reminded of Greta Thunberg’s outrage at the 2019 UN climate summit when she exclaimed to the adults who had left things to her generation: “This is all wrong. I shouldn’t be up here. I should be back at school on the other side of the ocean. You come to us young people for hope. How dare you?”
This book presents an important concept that leads to a policy focus on child development. How about assuring social-emotional development at the national level, instead of relying on countless non-profit organizations to pick up where schools and society have dropped the ball?
In Amanda Gorman’s powerful words, delivered at the inauguration of President Joe Biden.
“…our inaction and inertia will be the inheritance of the next generation.
Our blunders become their burdens.
But one thing is certain:
If we merge mercy with might, and might with right, then love becomes our
legacy and change, our children’s birthright.”
Vivek Murthy has used his pulpit to shine a light on a key contributor to our health and well-being. This book explicitly callout loneliness as a critical contributor to much of what ails us, our physical health as well as the health of our society. If the purpose of the book is to increase awareness and understanding, it has succeeded. If it is to show a clear path forward, it falls short. A diagnosis is the first step. A remedy must follow. In the UK, in 2018, an initiative to combat loneliness was started at the ministerial level. It is not clear what progress has been made. Perhaps the US needs to follow suit.
Dr. Murthy is in a position to chart out the role the government might play, now that he is starting his second stint as Surgeon General, this time in the Biden administration. With his deeply realized perspective on loneliness and health, perhaps we can expect to see more work on this front.
All the best, Dr. Murthy, and Godspeed.
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Raji Pillai lives in the SF Bay Area and writes at www.rajiwrites.com where this article was originally published.
Dr. Narula frequently sees social isolation and loneliness in her practice. Urban centers like the Bay Area are melting pots that draw transplants from different parts of the world with different cultures, languages and lifestyles who come there for work, many bringing their families. They face many challenges adjusting to a new way of life, including loneliness. A few patients open up and willingly share their feelings; more often, she finds them either shy or nervous, with some unwilling even to acknowledge loneliness because of the huge stigma associated with it. Spouses and family members who do not work are especially susceptible because they lack even the social aspect of the workplace, and sometimes face additional barriers of transportation and language. Regardless of ethnic, social or cultural background, loneliness is more common in adults over 45; however, there’s a higher prevalence in seniors – those over 65. Studies show that nearly one-fifth of seniors live alone and over 40 percent report feeling lonely on a regular basis. Family physicians increasingly observe it in adolescents and pre-teens as well, who tend to be very active on social media, but have difficulty forming real relationships.
Loneliness is an evolutionary phenomenon designed to make humans seek protection in a group for survival by triggering a physiological response: the release of stress hormones like cortisol. In small doses these hormones help solitary humans be more aware of surrounding dangers. However, repeated long-term occurrence results in damage to health leading to high blood pressure, increased inflammation, a weakened immune system, and consequently a reduced life span. Additionally, without the emotional support of family and friends, people who are lonely often stop exercising, overeat and tend towards substance abuse, further compounding impact on health. 
