Loneliness is a serious public health problem

LONDON, says Tony Dennis, a 62-year-old security guard, is a city of "sociable solitaires." Residents want to get to know each other but have few ways to do it. Tonight, however, is different. Dennis and a few dozen other locals join a monthly quiz hosted by the Cares family, a charity dedicated to fighting loneliness.

Competitors are a deliberate mix of older residents and young, novice professionals in the area. "Young people also feel increasingly disconnected," says Alex Smith, the foundation's 35-year-old founder. He hopes that such nights will foster a sense of belonging.
Doctors and policymakers in rich countries are increasingly worried about loneliness. Campaigns to reduce it have been launched in Britain, Denmark and Australia. In Japan, the government has investigated hikikomori, or "people who lock themselves at home." Last year, Vivek Murthy, a former US surgeon general, described loneliness as an epidemic, comparing its impact on health with obesity or the consumption of 15 cigarettes a day. In January, Theresa May, the British prime minister, appointed a minister of loneliness.

That the problem exists is obvious; its nature and extent are not. Obesity can be measured on scales. But how to weigh an emotion? Researchers begin by distinguishing several related conditions. Loneliness is not synonymous with social isolation (how often someone meets or talks to friends or family) or loneliness (which involves choosing to be alone).

Rather, researchers define loneliness as perceived social isolation, the feeling of not having the desired social contacts. Of course, objectively isolated people are much more likely than the average person to feel alone. But loneliness can also hit those who apparently have a lot of friends and family. Loneliness is not always a bad thing. John Cacioppo, an American psychologist who died in March, described this reflex reflex refined by natural selection. The first humans would have been disadvantaged if they were isolated from a group, he noted, so it is logical that loneliness arouses a desire for companionship. Transient loneliness still serves this purpose today. The problem comes when it is prolonged.

To find out how many people feel this way, The Economist and the Kaiser Family Foundation (KFF), a non-profit, health-oriented US group, surveyed nationally representative samples of people in three rich countries *. The study found that 9% of adults in Japan, 22% in America and 23% in Britain still or often feel alone, or lack of camaraderie, or feel marginalized or isolated (see Figure 1).

The results complement academic research that uses standardized questionnaires to measure loneliness. One of them, written at the University of California at Los Angeles (UCLA), contains 20 statements, such as "I have no one to talk to" and "I find myself waiting for people to call or write ". Responses are marked by the extent to which people agree. Respondents whose score is above a threshold are considered to be alone.

A study published in 2010 using this scale estimated that 35% of Americans over 45 were alone. Of these, 45% had felt this for at least six years; An additional 32% for one to five years. In 2013, the UK Office for National Statistics (ONS), by simple questioning, ranked 25% of people aged 52 and over as "sometimes lonely", with an additional 9% "often isolated" .

Other evidence indicates the extent of isolation. For 41% of British over 65, television or a pet is their main source of business, according to Age UK, a charity. In Japan, according to a 2016 government report, more than half a million people would stay at home for at least six months at a time, without contact with the outside world. According to another government study, 15% of Japanese eat regularly alone. A popular TV show is called "The Solitary Gourmet".

Historical data on loneliness are rare. But isolation seems to be increasing, as is loneliness. Consider the increase in solitary life (see Figure 2). Before 1960, the share of isolated households in America, Europe and Japan rarely exceeded 10%. Today, in cities such as Stockholm, most households have only one member. Many people choose to live alone, as a mark of independence. But there are also many people living in rich countries who live alone because of divorce or the death of their spouse.

Isolation also increases by other means. From 1985 to 2009, the average size of an American's social network - defined by the number of confidential people - decreased by more than a third. Other studies suggest that fewer Americans join social communities such as religious groups or sports teams.

The idea that loneliness is bad for one's health is not new. One of the first tasks of the Royal Canadian Mounted Police in the Yukon was to monitor the well-being of gold diggers who could spend months without human contact. The evidence indicates the beneficial power of a social life. Suicides fall at football World Cups, for example, perhaps because of the transitory feeling of community.

But it is only recently that medicine has studied the links between relationships and health. In 2015, a meta-analysis led by Julianne Holt-Lunstad of Brigham Young University, Utah, synthesized 70 articles, which followed 3.4 million participants over an average of seven years. It found that those considered to be alone had a 26% higher risk of death, and those who lived alone, a greater chance of being 32%, given age and health status differences.

Smaller studies have found correlations between loneliness and isolation and a range of health problems, including heart attacks, strokes, cancers, eating disorders, substance abuse, sleep deprivation, depression, alcoholism, and anxiety. Some research suggests that unattached individuals are more likely to suffer from cognitive decline and faster progression of Alzheimer's disease.

Researchers have three theories about how loneliness can lead to health problems, says Nicole Valtorta of Newcastle University. The first covers the behavior. For lack of encouragement from family or friends, the lonely person may fall into unhealthy habits. The second is biological. Loneliness can increase the level of stress, for example, or hinder sleep and, in turn, harm the body. The third is psychological, loneliness may increase depression or anxiety.

Or is it the opposite? Maybe sick people are more likely to feel lonely. In the KFF / Economist A survey of six out of ten people who said they were alone or socially isolated attributed specific causes, such as poor physical or mental health. Three in ten said their loneliness made them think of hurting themselves. A study conducted by Marko Elovainio of the University of Helsinki and his colleagues, using the British biobank, a voluntary database of hundreds of thousands of people, suggests that this relationship works both ways: loneliness leads to health and vice versa.

Other studies show more about the causes of loneliness. A common theme is the lack of a partner. Analysis of the survey data showed that married or cohabiting people were much less lonely. Having a partner seems particularly important for older people, as they generally have fewer (but often narrower) relationships than younger people.

Yet loneliness is not particularly a phenomenon in the elderly. Polls did not reveal a clear connection between age and loneliness in America or Britain - and in Japan, the youngest were actually more lonely. Young adults and very old people (over 85, for example) tend to have the highest proportion of unattached individuals of all age groups. Other research suggests that loneliness in older people tends to have a specific cause, such as widowhood. For youth, there is usually a gap in expectations between their relationships and those they want.

Whatever their age, some groups are much more likely to feel lonely. One is about people with disabilities. Migrants are another. A study of Polish immigrants to the Netherlands published in 2017 found that they reported much higher loneliness rates than people born in the Netherlands aged 60 to 79 (although migrant women tend to be better off manage only their male counterparts). A poll conducted by a Chinese union in 2010 concluded that "loneliness is the defining aspect of the migrants' experience."

Regions left behind by migrants, such as rural China, often have higher rates of loneliness. A study of elderly people in Eastern China's Anhui Province, released in 2011, found that 78 percent of those surveyed said "a moderate to severe level of loneliness," often as a result of moves of younger parents. Similar trends can be found in Eastern Europe where young people have gone to look for work elsewhere.

The best explanation for loneliness is usually the result of individual factors such as disability, depression, widowhood, or leaving home without a partner. Some commentators say, however, that larger forces, such as "neoliberalism," are at work.

In fact, it is difficult to prove that an abstract noun creates a feeling. And research on reported loneliness rates does not support the idea that rich and individualistic societies are more lonely than others. A study published in 2015 by Thomas Hansen and Britt Slagvold of the Metropolitan University of Oslo, for example, found that "fairly severe" loneliness ranged from 30 to 55% in Southern and Eastern Europe, compared to 10 to 55% in South and East Europe. at 20% in Western and Northern Europe. "It is therefore paradoxical that older people are less isolated in more individualistic and less familiar cultures," the authors concluded.

Their research led to two explanations. Most importantly, Southern and Eastern European countries are generally poorer, with unequal welfare states. The second reason is about culture. The authors argued that in countries where older people expect to live nearby and be cared for by younger parents, the shock when it does not happen is greater.

Another villain in the contemporary debate is technology. Smartphones and social media are held responsible for the rise of loneliness among young people. It is plausible. Data from the OECD's mostly rich-country club suggests that in almost all member countries, the proportion of 15-year-olds reporting that they feel lonely at school has increased between 2003 and 2015.
The smartphone makes an easy scapegoat. A clear decrease in the frequency at which American teens leave without their parents began in 2009, around the time mobile phones became ubiquitous. Rather than meeting so often in person, the story goes that young people connect online.

But that should not make them alone anymore. Snapchat and Instagram can help them feel more connected with their friends. Among those who reported feeling alone in the KFF / Economist According to the survey, about as many people found social media useful as they did not feel worse (see Chart 3). Some psychologists say that scrolling through others' photos carefully can make people feel forgotten and alone. Brian Primack of the University of Pittsburgh and his colleagues found in a study published in 2017 that the quartile that used social media most often was more than twice as likely to report loneliness as the one using the social media less.

It is unclear whether this is an intensive use of social media leading to loneliness, or vice versa. Other research shows that the correlation between the use of social media and, for example, depression is low. The most rigorous recent study on the use of social networks by British adolescents, published by Andrew Przybylski and Netta Weinstein in 2017, revealed no link between "moderate" use and measures of well-being. They found evidence to support their "digital Goldilocks hypothesis": neither too much nor too much time on the screen is probably better.

Others are convinced that technology can reduce loneliness. At the top of a hill in Gjøvik, two hours by train from Oslo, lives Per Rolid, an 85-year-old widowed farmer. A girl lives nearby, but he admits to feeling lonely. He therefore agreed to participate in a test of Komp, a device manufactured by No Isolation, a startup created in 2015. It consists of a basic computer screen, a bit like a hot engraving. The screen rotates the images sent by his grandchildren and the large print messages of them and other relatives.

No Isolation also manufactures AV1, a recovery robot in the form of a disembodied white head with cameras in the orbits. It allows users, often out-of-school children with chronic illnesses, to be present in the classroom. The AV1 can be placed on a desk so that absent children can follow the activities. If they want to ask a question, they can press a button on the AV1 application and the top of the robot's head lights up.

"Social robots", such as Paro, a stuffed robotic seal, have been used in Japan for some time. But they become more sophisticated. Pepper, a human robot manufactured by a subsidiary of SoftBank, a Japanese conglomerate, can follow a person's gaze and adapt his behavior to the human reaction. Last year, Southend Town Council, an English seaside town, began deploying Pepper into nursing homes.

Other healthcare providers are experimenting with virtual reality (VR). In America, UCHealth is conducting VR treatment trials that allow some cancer patients to experience something new, such as skiing in Colorado. In 2016, Liminal, an Australian RV company, partnered with Medibank, an insurance company, to create a virtual experience for single people who could not leave their hospital beds.

As technology becomes more human, it may be able to do more and more to replace human relationships. In the meantime, services offering a single human contact will flourish. In Japan, this translates into agencies and apps that allow you to rent a family or friend - a friend for a singleton, a grieving person, or just a companion with whom to watch TV.

Such products are not just Japanese quirks. One Caring Team, an American company, calls and controls elderly single elderly parents for a monthly fee. The Silver Line, a similar (but free) helpline, is run by a UK charity. Launched in 2013, it requires nearly 500,000 calls per year. Staff at its headquarters in Blackpool are supported by volunteers from across the country in the Silver Friend service, a call organized in advance between a volunteer and a senior.

Most conversations last about 15 minutes. Those who contacted the help line during your correspondent's visit addressed a general topic: weather, pets, what they did that morning. Their real reason for calling appeared only later, through a casual comment. It often referred to the need for a partner and the camaraderie he would bring. Others call but hardly speak, noted a Silver Line staff member.

For many, phone calls do not replace society. Nesterly, founded in 2016, is designed to make it easy for older singles with vacant rooms to rent a rent discount. The platform has "fallen into solitude," notes Noelle Marcus, its co-founder. Users register on the platform and create a profile, then create a list for their room. Last year, the startup teamed up with the city of Boston, Massachusetts, to test the initiative across the city.

Homeshare, a network of charitable organizations, operates in 16 countries, including Great Britain. Elsewhere, policy makers are experimenting with incentives to encourage young and old to mix. In cities such as Lyon in France, Deventer in The Netherlands and Cleveland in Ohio, retirement homes or local authorities offer students free or cheap rent in exchange for help with housework.

That so many young companies want to "disrupt" loneliness helps. But most of the burden will be borne by health systems. Some companies try to solve the problem at the root. Last year, CareMore, an American health care provider owned by Anthem, an insurer, launched a specific program. "We are trying to reformulate loneliness as a treatable health condition," says Sachin Jain, its president.

This means, first, to track loneliness among its 150,000 patients. People at risk are asked if they want to register for a "solidarity program". This involves phone calls from staff members called "connectors" that help transport to events and ideas for socializing. Patients are encouraged to visit clinics, even non-urgent ones, to play games, a "seniors' gym" and chat.
For its part, the National Health Service in England is increasingly using the "social prescription", sending patients to social activities rather than giving them drugs. More than 100 such programs are underway in Great Britain. However, last year, a review of 15 documents concluded that the evidence to date was too weak to support conclusions about program effectiveness. This poorly reflects the state of mind on loneliness. The reasons to take seriously its effects on health are not lacking. But the quality of the evidence on effective remedies is dismal. Unfortunately, loneliness should remain a subject that causes enormous anxiety without much relief.

* A detailed report on the survey results is available at https://www.kff.org/other/report/loneliness-and-social-isolation-in-the-united-states-the-united -kingdom-and-japan-an-international-survey

Correction (August 31, 2018): A previous version of this article stated that UCHealth was conducting tests in nursing homes. It's not. This has been changed.