Mar 16, 2020
Deborah Johnson Lanholm, 63, lives in Sicklerville, New Jersey. A retired nurse, she’s the primary caretaker for her older sister, Helen Palese, who lives with amyotrophic lateral sclerosis, or Lou Gehrig’s disease. “She’s nonverbal,” Deborah says. “I do her speaking for her. So every other day, we do something together. We go to the movies. I take her to my crocheting group. We go out to dinner or the mall. But she’s with other people. All of that will have to stop because she’s too compromised.”
And it won’t just stop for Helen. It’ll stop for Deborah, too. “I’ll have to change my routine because I have to care for her,” Deborah says. “I won’t go out in crowds or be in places where I’ll be exposed.”
Make no mistake: The rapid implementation of social distancing is necessary to flatten the coronavirus curve and prevent the current pandemic from worsening. But just as the coronavirus fallout threatens to cause an economic recession, it’s also going to cause what we might call a “social recession”: a collapse in social contact that is particularly hard on the populations most vulnerable to isolation and loneliness — older adults and people with disabilities or preexisting health conditions.
A tension in the coronavirus response is that it’s so difficult to get people to accept social distancing that few want to muddle the message with worries about social isolation. But if the ultimate concern is the health and well-being of the most vulnerable, then both dangers need to be addressed.
“We’re now officially in a pandemic,” says Eric Klinenberg, a New York University sociologist who has studied the way social isolation leaves older Americans vulnerable in emergencies. “But we’ve also entered a new period of social pain. There’s going to be a level of social suffering related to isolation and the cost of social distancing that very few people are discussing yet.”
Congress and the administration are, even now, debating the best tools to deploy in fighting the coronavirus’s economic effects. Washington is deep in a debate over payroll tax cuts, industry bailouts, and paid sick leave. But there are fewer policy tools to fight a social recession. What all the experts I spoke to agreed on was this: Just as it’s incumbent on those of us least affected by coronavirus to take precautions to limit its spread, it’s also important that we reach out to limit its social damage.
“The brunt of Covid-19 will be borne by the poor, elderly, and sick,” says former US Surgeon General Vivek Murthy, “and it is up to us to ensure they are not left behind.”
Isolation and loneliness are health problems, too
The Centers for Disease Control and Prevention has already warned Americans over age 60 to “avoid crowds,” cancel “all nonessential travel,” and “stay home as much as possible.” William Schaffner, a CDC adviser and infectious disease expert at Vanderbilt University, went even further. “The single most important thing you can do to avoid the virus is reduce your face-to-face contact with people,” he told CNN, adding that he is only going shopping late at night, when the stores are empty, and his wife is giving up attendance at her bridge club.
“It worries me both for my patients and the larger community and my own family members,” says Cynthia Boyd, a geriatrics specialist at Johns Hopkins University. “My mom and dad live near me now. I definitely feel like I’m not going to pop over as much with their grandchildren.”
Boyd was a contributor to a major National Academies of Sciences report on the health consequences of social isolation and loneliness in older adults. The researchers found that even before the coronavirus, about a quarter of older adults fit the definition of socially isolated — which measures routine social contact — and 43 percent said they felt lonely. You can be socially isolated without reporting feelings of loneliness, and you can be lonely without being socially isolated. But both conditions seem to inflict harm on physical and mental health.
“Social isolation has been associated with a significantly increased risk of premature mortality from all causes,” the report found, including a “50 percent increased risk of developing dementia,” a “29 percent increased risk of incident coronary heart disease,” a “25 percent increased risk for cancer mortality,” a “59 percent increased risk of functional decline,” and a “32 percent increased risk of stroke.” The mental health risks are also profound. The researchers reviewed dozens of studies and found a consistent relationship between social isolation and depression, anxiety, and suicidal ideation.
“The health effects of loneliness are astounding,” says Carla Perissinotto, the associate chief for geriatrics clinical programs at UC San Francisco and a contributor to the NAS report. “At any point across the life span, the things we’re most worried about is losing our independence, losing our minds, and heart attack, and these are all affected by loneliness independent of other risk factors.”
Humans are social animals, and coronavirus threatens those connections
Human beings evolved to feel safest in groups, and as a result, we experience isolation as a physical state of emergency.
“Over thousands of years, the value of social connection has become baked into our nervous system such that the absence of such a protective force creates a stress state in the body,” wrote Murthy in a review of the emergent evidence. “Loneliness causes stress, and long-term or chronic stress leads to more frequent elevations of a key stress hormone, cortisol. It is also linked to higher levels of inflammation in the body. This in turn damages blood vessels and other tissues, increasing the risk of heart disease, diabetes, joint disease, depression, obesity, and premature death.”
If stress is the pathway by which loneliness damages health, then even beyond its direct dangers, coronavirus is a dual threat: It’s simultaneously terrifying and isolating. Alice McHale is a 70-year-old living outside Indianapolis with chronic obstructive pulmonary disease. “I am having extra anxiety now and have trouble concentrating and sleeping,” she says. Already a self-admitted “homebody,” she says concern about coronavirus has left her afraid to leave the house. “I decided that for me, the easiest way to cope with it all was to pretty much stay home,” she says.
No one quite knows how the isolation enforced by an epidemic disease will affect those at the highest risk, but even those who avoid the worst consequences will see their quality of life degrade. Local clubs, religious services, and time with family bring social structure and joy to many of our lives, but they are particularly important touchpoints for those who don’t work or can’t go out on their own, due to age or health conditions. If older and sick people have to refrain from these activities for months on end, their lives will be worse, and the rhythms and relationships that once sustained them may prove hard to rebuild.
“We don’t really know what the dose-response curve is for loneliness and isolation,” Perissinotto says. “But the longer it is, the bigger impact it will have, and the harder it will be to reestablish connections.”
Fighting the social recession
There is no stopping the social recession. It’s an inevitable byproduct of public health recommendations. But there are actions and policies that could ease it.
“Obviously, we want people to follow the public health recommendations about social distancing and quarantining,” Boyd says, “but at the same time, we want to try and enable people to remain as connected as possible. We need to be thinking about what individuals can do, but also what we as neighbors and a society can do, to not make it worse than it might otherwise feel for people.”
Many of us will face the same choice as Deborah Lanholm: limiting our level of social activity to make sure we can safely visit with at-risk friends and families. The more the young and healthy are careful in their daily activities, the safer it will be for them to see more vulnerable friends and family members. The less careful we are, however, the more we will stay away from older, sicker relations out of caution, worsening their isolation.
But even where some risk is inevitable, there are ways to mitigate it: A walk outside or even a picnic is safer, from a public health perspective, than a dinner in a crowded restaurant. That will, of course, be simpler for some than others. “People who have easy access to safe and verdant outdoor space are going to feel more comfortable in public,” Klinenberg says. “I’m speaking to you from Manhattan, where it’s gray and crowded in many neighborhoods and being outdoors feels more stressful. You always feel like you’re about to get coughed on.”
Just as countless businesses have moved to remote work and teleconferencing to balance social distancing and the need for continued collaboration, every expert I spoke to emphasized the promise of virtual options to ease isolation. Vivek, the former surgeon general, told me that “to compensate for the reduction in in-person social interaction, we must ramp up our virtual communication and ensure we are not losing touch with friends and family.” Video conferences and phone calls, he said, are “more rich than texting or emailing alone.”
Sadly, the hardest-hit populations are often the least technologically savvy. So one simple way to help may just be to act as tech support for the people in your life. McHale told me that an unexpected blessing for her was that her computer died last month, and the tech support she received when setting up its replacement “made me a much better tech user.” That’s been a boon as she’s begun to self-quarantine, as it’s allowed her to connect with others online.
But the hardest hit, by definition, will be those without robust networks of family and friends who can advocate on their behalf. “When we rely on our personal networks, we guarantee the most isolated and disadvantaged people will be excluded,” Klinenberg says. “By definition, they are not in our networks; they are the least likely to get assistance. This is an area where government can help by funding and supercharging community organizations.”
As with so much else in the coronavirus pandemic, the response here will depend on the level of social solidarity we feel, and the degree to which we’re willing to look out for each other. Social isolation and loneliness among older, sicker populations isn’t something caused by the coronavirus, but it will be worsened by it. The question is whether the intensity of the problem will force us to see, and respond, to pain we typically ignore.
“A lot of my work is premised on the idea that extreme situations like the one we’re in now allow us to see conditions that are always present but difficult to perceive,” Klinenberg says. “We’re going to learn a lot about who we are and what we value in the next few months.”