For decades, public health experts have been sounding the alarm about a health hazard that’s underappreciated by the public as well as health care professionals, a killer that’s taken on even more significance since the pandemic hit.

But it’s not one of those usual-suspect diseases, bound in bodily organs and blood vessels. It’s rooted in our emotional well-being.

Social isolation—the objective state of a lack of social connections—affects nearly a quarter of Americans over 65. And loneliness—the subjective feeling of being isolated (regardless of the degree of contact with others)— affects more than one-third of Americans 45 and older. Both social isolation and loneliness are associated with a range of adverse health outcomes, including heart disease, stroke, dementia, depression and anxiety.

And that’s what we knew before COVID-19.

In a poll conducted by the University of Michigan in March through June of 2020, loneliness in older adults had doubled compared to two years before. Among younger adults in those early days of lockdown, a survey from the University of Miami found increased feelings of loneliness in some 65% of respondents.

In terms of health risk, flying solo is right up there with obesity or a lack of exercise, increasing the likelihood of death from all causes. In fact, evidence suggests that social isolation and loneliness can be every bit as dangerous as smoking 15 cigarettes a day.

Last year, the National Academies of Sciences, Engineering and Medicine released a report recommending increased focus on research into the biological mechanisms of these health effects, as well as effective strategies to combat them. Both of these areas are still in their infancy.

“The health care systems,” the authors wrote, remain “an underused partner in preventing, identifying and intervening for social isolation and loneliness among adults over age 50.”

A number of groups are especially vulnerable: older adults; individuals with chronic illness, hearing or vision impairment, or mobility issues; individuals who live alone; immigrants, who may lack support networks and language skills; and sexual- and gender-minority individuals, who may face stigma, discrimination and barriers to care.

Countries around the world are beginning to take notice of the societal impacts of social isolation and loneliness. The U.K. and Japan have each appointed a minister of loneliness in recent years. (In Japan, deat by loneliness has a name, kodokushi.)

Recently, Pitt Med sat down with two experts on the topic—Pitt’s unofficial ministers of loneliness—to talk about this all-too-common phenomenon and how providers can intervene.

Thuy Bui is associate professor of medicine, director of the social medicine fellows program and also director of the Homewood Produce to People home-visit initiative at the School of Medicine. Her clinical focus is care for high-need, complex and disenfranchised individuals, including those who are homeless, recent immigrants, refugees and uninsured individuals.

David Nace is associate professor of medicine, director of long-term care and clinical chief of geriatric medicine. He is also chief medical officer of UPMC Senior Communities, a network that provides long-term care services to more than 3,000 older adults in central and western Pennsylvania.

How can providers help people facing social isolation and loneliness?

TB: There’s still not a lot of awareness in the public about the danger of social isolation. We need to screen more often. And we need to do more to reduce the stigma around this issue.

In our practice here in Oakland, we ask patients things like, ‘How many times do you talk on the phone with family, friends or neighbors? How often do you get together with them? How often do you attend church or religious services? Do you belong to any clubs or organizations?’

Most do not answer those questions! I think that is because we ask them to fill out a lot [of paperwork]. [Laughs.] But I think there’s some hesitancy in answering that, as well. I have patients ask, “Why are you guys interested in knowing about these things?” Which is great, because then we can have a conversation.

DN: It’s one of the things that I always look at as I’m seeing patients. What is their support network like? How do they spend their time?

I find that often, when you screen for depression, somebody will say, “No, I don’t really feel bad.” [But if you ask], “Do you feel lonely?” it’s “Yeah, I do.” I’ve been amazed at how often they’re direct with me when it’s part of looking at their mood.

TB: Many primary care physicians ask these questions about social support in annual wellness visits, but then we’re not sure what to do with that.

What kinds of interventions do you find helpful?

TB: Volunteering 15 hours a week has been shown to improve cognitive function and delay the development of any kind of cognitive impairment in seniors. They’re happier, more physically active. There’s Experience Corps, a program matching seniors with students from kindergarten to grade five. I just love that intergenerational connection. [For more on this tutoring program and other resources, see sidebar.]

DN: In our long-term care facilities we have had all kinds of programs where we connect residents with elementary school and high school students. It is really something that the residents look forward to. We have people that come in and play music for our residents. We have art classes. The goal is to enrich the environment. Studies have shown that [people in] environments that are more stimulating have better physical outcomes, have less cognitive decline, less progression to dementia.

For individuals who might still be at home, and have had a loss of a spouse, connecting them with a pet is actually quite helpful. We find that that’s one of the protective factors against that sense of loneliness. There is also a lot of interest right now in artificial pets— robots as pets, essentially. In some preliminary studies that seems to have a positive effect, as well. It’s kind of unusual, maybe, for many of us, but that will probably change. Being able to pick up a phone and talk to somebody without it being connected to the wall was unimaginable 50 years ago. Having a robot that you connect with and have conversations with in the future might be much more common than we think.

What tools and strategies have you begun using since the COVID-19 pandemic?

TB: We did a lot of porch visits, which was fun. Now we we’re back into the home again. I can see the happiness in my patient’s faces with things slowly turning back to normal again.

DN: During the past year we had a lot of students sending postcards and letters. It was neat to see a younger generation learn about postcards! And also how well received that was by the older adults. Remote platforms have been extremely helpful for most of the residents in long term care. People could connect and FaceTime or Zoom with a family member. It was a good stand-in. We did have very positive responses with it.

It’s a tool. It doesn’t replace human contact. We found hearing impairment or visual impairment or cognitive impairment all affected the ability of the person to really get the full value from the platform or device. We also know that it’s not quite the same as having them in person with you, where you can hug each other and read each other’s expressions a little bit easier.

Even coming out of [lockdown], I think we learned that this is something that could be used moving forward in the future.

A lot of the museums started offering virtual tours, and that’s been helpful in getting people thinking and engage outside of the walls of where they were.

TB: Many of our patients don’t have access to broadband internet and the devices. From a tech equity digital divide, I think we could do better.

There are programs through Housing and Urban Development (HUD) called ConnectHome that bring internet services to senior high rises in the area.

The Jewish Healthcare Foundation launched programs called Senior Connections, and they also introduced the virtual Senior Academy, which is this free interactive platform that offers classes through video conferencing. That’s a way to kind of bring people together.

In addition to the adverse health effects, how do social isolation and loneliness affect the health care system as a whole?

TB: We know that those who identify as being lonely or socially isolated tend to use more health care, and increased costs go with that. There’s been some study out of the U.K., as well as in this country, looking at this issue. The question is why. And I think for many people, especially our elderly patients, contact with the health care system might be their main social contact in their daily activities. And with the higher rates of anxiety, depression and so on, that go with social isolation, they then look to health care providers as a form of social support, as well as trying to explain some of the symptoms they’re having from day to day.

It’s interesting that social isolation—even when it doesn’t go along with a feeling of loneliness—is bad for our health. How do you approach someone who’s not particularly concerned about loneliness but is really isolated?

TB: I’ve done home visits in Homewood and Wilkinsburg now for over 10 years. And I have recently focused on elderly individuals—men, specifically—who live alone and sometimes are estranged from families and friends for various reasons. They’re usually quite attached to their home, even when the home conditions are not conducive to healthy living. Some do not trust outsiders and often don’t want anyone to come. They don’t pick up their phone that often, and they don’t always have a smartphone or any other devices.

From my standpoint, it takes a little bit of pushiness and a lot of persistence to engage

these individuals. I’m always so thrilled and grateful that some of them allow me and the medical students that I work with to be part of their lives.

DN: There are certain individuals that are going to be happy being socially isolated, because that’s where they’re comfortable, and they may not have the loneliness. But those are the exceptions rather than the rule. Most of us are used to being around other individuals much more commonly. So when you start to see that loss of the spouse or family members, that becomes very worrisome.

I think back to my own parents. My mother died in 2003 and my father lived through 2010. For him, staying in that home was so important, but he was not able to maintain it. His friends weren’t coming around, because most had passed away. And that environment started to get smaller and smaller.

Then he was placed for the last six months of his life in a nursing facility because of some health issues. And that actually ended up being a fantastic experience for him. He got to know the staff. He would give them advice, whether they wanted it or not. [Laughs.] He took art classes I had never seen my father take art classes! He just really blossomed. Wonderful, meaningful relationships. And he even connected with old family friends [in the facility].

What’s on your wish list from a broader, societal perspective?

TB: I think we need to reimagine community spaces, transportation and housing that promote connectedness. Design the built environment to decrease loneliness. And I’m not sure if architects and city planning groups take this into account.

DN: With the development of highways, the suburbs and the distancing that goes on, we’re seeing these effects. But we’re starting to see a little bit of planning around making sure that our communities are adaptable throughout the lifespan to encourage physical activity as well as connectedness to other individuals.

It’s a critically important thing to do. And the hotel industry realized this years ago. Now, they’ll have a buffet, common areas where peoplecan accidentally bump into one another.

TB: Our society is becoming less community- engaged all the time. But once in a while, when I do see involved neighbors, it just makes me so happy and hopeful. I had one patient in the hospital, and he did say that he didn’t have electricity or running water in his home, and so I kind of pushed my way in, like, ‘Let me come visit you.’ And it turned out that he was very attached to his home, but during the winter he was sleeping in his car, with the car running. This had been going on for a while. So when I came to visit him, a neighbor across the street invited us in and said how concerned he was, and was there anything he could do to help? And it was just really nice to see.