The Public Health Epidemic Exacerbated by COVID-19
For some individuals, isolation and loneliness aren’t a result of social distancing efforts, but a chronic and dangerous condition. The pandemic may offer an opportunity to address this threat.
There is a killer among us. It’s a silent, unnoticed killer that reaches into bustling cities, suburban communities, and the countryside. It reaches people of all classes and backgrounds. What is this serious but underappreciated public health threat? Social isolation and loneliness, which—just like the novel coronavirus pandemic—present life-threatening health risks, especially for older adults.
The current pandemic—and the stay-at-home orders that have followed in response—has heightened public awareness of the psychological impacts of social isolation (a lack of contact with others) and loneliness (the feeling of being isolated) that many people experience, not just during this time of enforced social distancing but in everyday life. The pandemic has also instigated concerted efforts, both public and private, to encourage people to reach out to others virtually or physically. Public service messages and testimony by experts remind people to stay a safe six feet apart, and to be equally mindful of making social connections through computer screens, telephones, or windows. These efforts are workable for people who have access to a computer or smartphone, can use a variety of social media tools, and are reasonably comfortable with technology. They’re feasible for people who are able to leave their homes to walk around the neighborhood or who can travel to the store to pick up groceries.
These measures are not so helpful for people who are unable to physically leave their homes or who have cognitive deficits that prevent them from understanding how to turn on an iPad or join a Zoom meeting. In those circumstances, the social disconnection caused by this pandemic is even more pronounced. What are the solutions for older adults with mental and cognitive impairments who depend on routine and stability to function optimally? The impact on people who cannot comprehend why their world is constantly disrupted, who cannot grasp the “new normal,” is yet to be determined.
A recent National Academies of Sciences, Engineering, and Medicine report recognized the important role of the health care system in identifying adults age 50 and older who may be at higher risk for social isolation and loneliness. Indeed, for older adults who are at highest risk, the health care system, in the form of doctors’ appointments or home visits by nurses, may be their only connection to the community, making this point of contact critical for mitigating the health problems exacerbated by isolation and loneliness. If not identified by the health care system, many older adults will remain unrecognized in their own communities.
At a time when the response to COVID-19 has overwhelmed and depleted medical resources nationwide, treating patients affected by the virus is understandably the primary concern of medical professionals. But as a result, individuals who are isolated and lonely will continue to remain undetected unless health and social service systems are able to systematically identify persons at risk and provide assessments and referrals to programs and initiatives to reduce isolation and loneliness.
Health hazards of social isolation
Social isolation increases a person’s risk of death and physical decline, and poses mortality risks comparable to those associated with smoking, obesity, and a lack of physical activity. The risk of death from social isolation and loneliness is comparable to the risk of smoking 15 cigarettes a day. And there are consequences for a person’s psychological well-being too. Loneliness is associated with higher rates of depression, anxiety, and suicidal ideation. It impacts memory as well, and social isolation has been linked to increased risks of developing dementia. All these factors leave older adults even more susceptible to adverse impacts caused by additional stressors and harmful events. As James Lubben, a pioneer in the field of social connections, so aptly declared, “The scientific evidence is convincing. Strong social ties are good for one’s health!”
Social isolation and loneliness can affect health throughout one’s lifespan. However, people over 50 are at increased risk due to predisposing factors such as the loss of family and friends, chronic illnesses, cognitive and physical challenges, and sensory impairments. Social isolation and loneliness can be experienced as an episode following an event, such as the loss of a spouse, or it can be chronic and ongoing. People who have faced adversity for decades may also be at heightened risk for adverse effects of isolation and loneliness. Older people in certain populations, such as low-income, minority, and LGBT communities, may be disproportionately affected because of structural disadvantages and discrimination in the health care system.
Of heightened importance today, many of the people who are particularly vulnerable to social isolation are also vulnerable to COVID-19. The disease is particularly dangerous for people with underlying conditions, with 90% of hospitalized patients identified through COVID-NET having one or more underlying conditions, and persons over 65 having the highest rates for hospitalizations. African Americans are disproportionately impacted by COVID-19: although only 13% of the US population is African American, a recent report found that African Americans comprise 33% of patients hospitalized from the disease. These vulnerable populations are also at risk for isolation and loneliness, and many have a history of poor health care across their lifespan.
The isolated and lonely are at greater risk of remaining unnoticed and unconnected during this pandemic. And the numbers of people isolated and lonely will increase as social distancing becomes the new norm and extends into the future.
Remedying isolation in communities
As mentioned, for many who are isolated and lonely, interactions with the health care system are their one connection to the outside world. Therefore, the health care system is a key partner to identify those isolated and lonely. It should play the primary role in identifying, preventing, and mitigating the adverse health impacts of isolation and loneliness through the development of assessment processes to detect social isolation and loneliness. Once a person is assessed to be at risk, continued monitoring, follow up, and referrals to appropriate services should be employed to address isolation.
However, the current pandemic has pushed the US health care system to the limits. To add one more task would be too much without also providing additional help. One promising example would be to enlist community partners to help overburdened health care systems in addressing social isolation and loneliness.
The health care system is just one component of a broader community. Policy-makers must address social isolation and loneliness among older adults through public health campaigns and the development of initiatives and services that extend beyond wealthy and middle-class environments. A prerequisite for any government, social, and public health response is to ensure there is equitable access of goods and services in these times of greatest need, particularly in communities hardest hit by this pandemic. Everyone should be afforded the same protections. The development or expansion of outreach services within social service agencies is one way to reach those who are unable to leave their homes. Social workers have a unique skill set to implement such programs, given their expertise in building networks and community responses. Connections to neighborhood ambassador programs and local hospitals and clinics can provide a means of reaching individuals needing assistance.
Potential sources of funding for this type of community response could be provided by the US Department of Health and Human Services through its Administration for Community Living. Also, Congress’s recent five-year reauthorization of the Older Americans Act provides a 35% increase in funding, and mandates addressing both social determinants of health and social isolation and loneliness. The reauthorization provides unique opportunities to develop new models of health and community care.
New funding mechanisms could also be developed within Medicare or Medicaid for hospitals and health clinics to develop community outreach partnerships that focus on building a stronger response to identifying people at risk for social isolation and loneliness. The 2019 expansion of Medicare Advantage coverage to address social determinants of health is an example of a recent funding mechanism that could be part of the solution. Additional government and philanthropic funding could also support and strengthen ties between health care, social service, and neighborhood communities.
Community leaders and civic associations located in at-risk communities would be important members in such partnerships, to work alongside health care and social service systems and providers. These partnerships should focus on the development of effective team-based care to address both health (assessment, diagnosis, and treatment) and social (adequate nutrition, housing, and transportation) needs. They should also help develop tailored community-based services to address disparities and social isolation and loneliness. And not to be overlooked, education and training can be key components of successful community partnerships, and should be designed to reach the public and professionals.
Once developed, these new community responses should be widely advertised through a mass media campaign in partnership with community groups, places of worship, and neighborhood associations to ensure that at-risk communities—which by definition can be difficult to reach—receive this important information. Messaging about the current pandemic provides an opportunity to include content on social isolation and loneliness and to showcase solutions to this issue in public health campaigns about COVID-19.
A community response to isolation and loneliness is demanded now more than ever. Time will tell if current responses to isolation and loneliness will have a lasting impact on defeating this silent killer and the COVID-19 virus. After the current crisis recedes, will we look back and find that it made a difference in how we respond to isolation and loneliness? Or will we discover yet another missed opportunity for society to recognize and respond equally to everyone impacted by isolation and loneliness?