During his tenure as the 19th Surgeon General of the United States, Dr. Vivek Murthy took on some of the country's most urgent public health issues, including the opioid crisis, alcohol and drug addiction, in addition to encouraging healthy eating and physical activity to create a culture of prevention from obesity, diabetes and heart disease.
With the release of his first book -- "Together: The Healing Power of Human Connection in a Sometimes Lonely World" -- on April 28, Dr. Murthy explores how loneliness is a key factor in many mental and physical illnesses in this country and around the world.
Dr. Murthy spoke with NBA.com's Brian Martin about some of the key takeaways from the book, the importance of recognizing loneliness during the current COVID-19 pandemic and ways to strengthen human connection even during a time of social distancing.
This interview has been edited for length and clarity.
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Why did you feel it was important to write a book about loneliness?
When I was Surgeon General, I spent a lot of time talking to people in living rooms and town halls all across the country, and one of the things I started to notice was that behind many of the stories of addiction, violence, depression and anxiety were threads of loneliness.
People would say things like ‘I feel like we’ve got to deal with all of these problems on our own’, or ‘I feel that if I disappear tomorrow nobody would even notice’, or ‘I feel like I’m invisible.’ This kept coming up again and again whether I was talking to people in small fishing villages in Alaska, members of congress in DC, or parents in small towns in the Midwest. There was this deeper emotional pain that was often manifest as loneliness.
These conversations reminded me of two things: one was my own personal experiences struggling with loneliness, and the second was my experience in medicine, where I saw many patients come into the hospital all alone. Even at critical moments such as a major diagnosis or a key decision about treatment, these patients had no one they could call. And even at the time of death, I remember instances when my colleagues and I were the only ones to witness their passing.
I was reminded of these experiences during my travels as Surgeon General. I recognized that what I was seeing across America was part of a much broader wave of loneliness that people in the United States and around the world were experiencing.
How do you define loneliness? Is this something that only emerges when we are physically alone or can we experience loneliness when in the company of others?
Loneliness is different than isolation and solitude. Loneliness is a subjective feeling where the connections we need are greater than the connections we have. In the gap, we experience loneliness. It’s distinct from the objective state of isolation, which is determined by the number of people around you. You can be surrounded by many people but still feel quite lonely if you don’t have strong connections and if you feel you can’t be yourself with them. Conversely, you can just be around a few people, but feel deeply connected to them.
There’s been a greater focus on mental health in recent years, but what is it about our current society that has contributed to the increased prevalence of loneliness specifically?
There are several factors in modern society that contribute to loneliness. One is that we are more mobile than we have been in decades past, which is fantastic in many respects, but also leads to us to move away from communities that we grew up with and got to know over time.
The second factor has to do with how we use technology. Technology can help or hinder connection depending on how we us it. For example, if I use FaceTime to communicate with my family in India, then that may enable me to strengthen my connection with them. If I post on Facebook or on another social media platform that I’m coming to California and want to meet up with any friends who are available for lunch or dinner and we actually meet up, then that online to offline bridge can be fantastic for strengthening our connection with each other.
The challenge with technology is when we use it in ways that take away from the quality of in-person interaction. What I worry about is the sheer quantity of screen time; sometimes it edges out our time in person with people. And even when we are in person, technology can often dilute the quality of our conversation. Our cell phones readily creep into our dinner time conversations. When we’re on the phone catching up with our friends, we might find ourselves flipping through our feed on Instagram, or refreshing our inbox, or Googling the answer to a question that just popped into our heads. We might think we’re still being attentive, but the science is very clear that human beings are not good at multitasking. What we do is task switch. When our attention is on our Instagram feed, it is not on the conversation we’re having. We may be able to remember the words that were said, but words alone are not the full extent of what constitutes communication between two people. We miss the way in which the words were said and the meaning behind those words.
A big concern I have with young people and social media platforms is that it can accelerate the culture of comparison in modern society, a culture where we constantly feel that we’re not enough – not fit enough, not good looking enough, not rich enough, not famous enough, not athletic enough – you name it. We feel like we’re always chasing an ideal. That ideal is usually framed for us through the media we consume, and it is accelerated on social media platforms, which deliver messages at a speed that we have not seen before.
When you’re constantly bombarded with messages that tell you about all the ways that you are not enough, that can chip away at your sense of self and self-esteem. And when you’re at a place where you feel like you’re not enough, where you’re disconnected from your source of self worth, then that can actually make it harder to connect with other people.
Perhaps the most insidious and challenging driver of loneliness has to do with modern day culture and how we determine what constitutes success. If I asked you what your top three priorities were in life, my guess is that people and most likely your family and close friends would top that list. But if you look at the way a lot of us live our lives, and I’ll use myself as a prime example, there’s a disconnect between our stated priorities and our lived priorities. If I look at where I put the majority of my time, focus and energy, it is overwhelmingly on work and other concerns, even though I deeply value the people in my life. It’s not to say that I need to be spending the majority of my waking hours with the people I love, but it’s about the quality and quantity of the time; it’s about the energy and focus and attention that you bring to your interactions, so one of the things that I realized is that I need to close that gap in my life.
I think many people today grow up receiving the message that success is not determined by your ability to build good relationships with friends and family, but rather on your ability to acquire one of three things: wealth, reputation or power.
It’s ironic to me that when I meet people who have achieved in those areas – and in some cases in all three – if they don’t have strong relationships in their life, the high of those successes doesn’t last very long, and they often feel quite hollow and quite lonely. All of these factors together are what contribute to loneliness in the modern age. As you can see it’s complicated and cannot be solved by changing one policy or one habit.
In general, what are the physical and mental effects of loneliness?
Researchers have found that loneliness is associated with an increased risk of heart disease, dementia, depression and anxiety. It’s associated with fragmented sleep, so you may sleep the same number of hours as somebody who’s not dealing with chronic loneliness, but the quality of that sleep is lower; it’s less restful. And we know how important sleep is for our overall health.
It also turns out that people that suffer from loneliness appear to have shorter lifespans. The mortality impact of loneliness seems to be similar to the mortality of smoking 15 cigarettes a day, greater than the mortality impact of obesity and sedentary living. I say that as someone who served in a position as Surgeon General in an office that spent an extraordinary amount of time and resources focused on smoking, obesity, physical activity and sedentary living. Yet loneliness was not really on the radar much at all because few of us recognized that this was a significant health challenge, but it turns out that is really is.
What are the specific effects for young people?
While these effects I’m talking about are true for all of, I particularly worry about loneliness with young people for a couple reasons.
First, contrary to most people’s assumptions that loneliness predominantly affects the elderly, it turns out that one of the greatest spikes in loneliness that we see across the age span takes place among young people -- Gen Z and the Millennials. This is counterintuitive for people who may think that the young are connected to others on technology and always seem to be engaged with other people. How could they be lonely? That comes back to what we talked about earlier: it’s about the quality of connections that matter, and sometimes if we use technology in ways that either edge out in-person relationships or dilute our connections or chip away at our self esteem, then it can ultimately harm the ability to connect with others.
I also worry when I see the high rates of depression and anxiety among young people. I’m worried that part of the reason we see growing concerns with the mental health of younger generations is the quality of social connection that they are experiencing.
I think many people today grow up receiving the message that success is not determined by your ability to build good relationships with friends and family, but rather on your ability to acquire one of three things: wealth, reputation or power."
One of the key realizations that has stood out for me during my exploration of loneliness is that social connection is an extraordinary resource for improving our health, enhancing our performance and increasing our fulfillment. It’s a resource that we often overlook. As a doctor who has written prescriptions for many powerful medications over the years, I know that science has blessed us with tools that can help improve our health, but that doesn’t mean that we should forget the old resources that we have.
Human connection has always been as a powerful resource for us, but it has receded to the background as a tool that is useful for improving our health and our performance. The truth is that social connection is extraordinarily powerful. I realized when I was working on this book that if we really want to address some of the major issues that are confronting society today -- like the addiction crisis, violence, and chronic disease -- if we really want to improve how people are functioning in schools, in the workplace and with their families, we’ve got to think about how we invest in strengthening social connection.
What should we be concerned about or particularly focused on in regard to loneliness and mental health generally in the context of the current global pandemic?
This is such an extraordinary and difficult time. We will remember what we went through with COVID-19 for the rest of our lives. What I worry about is that as we continue to be physically distanced from each other, that will deepen our loneliness and will potentially lead to a social recession, where we become further and further separated from each other, not just physically but also emotionally. I think that would have serious implications for the health of individuals and the health of society. But we have a choice about whether we go down that path of a social recession, or whether we use this moment to strengthen our social connection.
From my own experience during this time, I’ve realized that I not only miss being physically present with my close friends, but I miss basic interactions with strangers at a coffee shop or in the grocery store aisle. I find that when I’m on a walk in the neighborhood, when I pass somebody, who inevitably stays at least six feet away, that they wave vigorously and enthusiastically, and I find myself waving right back enthusiastically because we’re both hungry for company, for being beside another human being.
When I think about the experience even over the past few weeks, I recognize that I have not been giving the time, but also the quality of time to my friends and family that I want to be giving and I want to recommit to doing better. And that can start right now; we can take some simple steps that can help us strengthen our connection with other people even when we are physically distanced.
We can make it a point to eliminate distraction when we’re talking with others. I’ve been struck in my own life ... how powerful it can be when someone listens to you and they’re fully present in conversation? Imagine being able to give somebody else the gift of your full attention, of being able to share with them openly and to be present fully with them and you start to realize that five minutes of that kind of engagement can often be more fulfilling and more healing than 30 minutes of distracted conversation.
One of the realizations I had in writing the book was that service is a powerful antidote to loneliness. I think the time of COVID-19 presents an opportunity for all of us to find ways to serve others. Service could be checking on a neighbor to make sure they’re doing okay, calling a friend whom you know is struggling, or dropping food off to a work colleague who may be having a hard time teleworking and homeschooling their kids at the same time.
There are many ways in which we can serve, and this is a particular moment where if we look around us, we’ll realize that all of us are going through challenging times, that all of us are hurting in some way and are struggling to make sense of not just what’s happening now, but also the uncertainty of what lies ahead. So in an environment like this, simply reaching out to others to check on them, simply giving them the gift of our attention and presence, can be acts of service that ultimately strengthen our connection to others.
The NBA family (like our global community) is varied and diverse, and this pandemic is impacting communities in different ways. What concerns you most about recent data that shows the pandemic is most severely affecting black and Hispanic communities specifically?
It’s deeply concerning because it follows a pattern where minorities and groups that have traditionally been underserved in society continually bear the greater burden of major stressors, whether those are pandemics or natural or man-made disasters. What COVID-19 has done is pull the curtain back on deeper structural inequities that have existed in our system for far too long.
We know that in the United States, for example, that black and Hispanic families suffer with a greater degree of poverty than do their white counterparts. We know they experience disease -- like heart disease and diabetes -- at greater rates, and we also know that this is not all about genetics, it’s about social determinants. It’s about poverty, access to health care, access to healthy food, access to education and well-paying jobs. It’s a very complicated web, but it has to do with structural factors that drive so many downstream outcomes that we care about, including health.
When stressors like this get applied to society, we start to see where we have failed in supporting segments of our community, which often are minority communities. Unfortunately we’re seeing that now and it’s heartbreaking, but it should be a call to action for all of us to ensure that health equity is a guiding principle in how we design our health policies and how we run our health care institutions and how we think about public health and prevention. Unless we’re making sure that everybody has access to good health and the tools to live a healthy life, then I don’t think we’re doing our job in society. I don’t think we’re fulfilling our responsibility to each other, and that’s the message I’d take away from these terrible inequities that we’re seeing when it comes to the COVID-19 outcomes.
For the millions of people around the world who play and watch, sports can provide a sense of community and belonging and also serve as an outlet for stress and anxiety. How can we fill that void and stay connected in this time of physical distancing and sometimes, reduced physical activity?
As a sports fan, I miss sports a lot. Sports are an incredibly important part of community and I’m really hopeful that we’ll be able to get back to experience sports in the way we did before.
But in this time, it’s especially important that we reach out and stay connected to the people in our lives, to our friends, to our family, even some we may not have been in touch with for a long time.
In addition, physical activity is exceedingly important, not just for our physical health but also for our mental well-being. One of my concerns is that as people stay at home and as they find themselves on video conference calls for hours and hours throughout the day that they may not be getting as much physical activity as they normally get.
There are many ways in which we can serve ... So in an environment like this, simply reaching out to others to check on them, simply giving them the gift of our attention and presence, can be acts of service that ultimately strengthen our connection to others."
It’s important in this time to see if you can build activity into your life, both your social and work life. While you may have to do some calls by video conference, if you can do others by phone so you can be walking while you do them, that’s great. If you can work out with a friend while you’re on the phone with them that’s good too. If you can do virtual dance parties, as I’ve found a growing number of friends and work colleagues doing, as ways to substitute what used to be coffee breaks, that’s a creative way to be social and also be physically active.
This is really important because when we come out of this pandemic, when we start to resume our lives, we need to be healthy -- both physically and mentally -- and the measures we take now to stay socially connected to each other and stay physically active will keep us in better shape so we’re more readily able to get back on track once the pandemic is over.
What do you hope people learn or takeaway from reading the book?
I thought about this so much as I was writing the book, and it really only became totally clear to me at the end. If I had a credo for this book it would be three simple words: put people first.
One of the things I learned is that we are social beings that derive so much from our relationships with others, but we have drifted further and further away from relationships -- and we’ve done so at the expense of our health, our happiness and overall well-being.
In the absence of strong relationships, our ability to talk to each other breaks down. We become more divided. Our ability to show up fully and demonstrate our full potential in the workplace or in school is diminished. And our overall health and happiness on an individual level is compromised. And that’s why, as I left my time in government and began to think about what I could work on that would address the deeper root cause of so much of what ails us, I kept coming back to this issue of loneliness and social connection.
As common as loneliness is, as consequential as it is, I ultimately am optimistic of our ability to build people-centered lives and a people-centered society because this is how we evolved to be. This is really who we are. We’re social beings. We’re people-oriented creatures, and we seek out relationships. To me, this quest to build a people-centered life is not an effort to transform us into something we’re not, but it’s really a call to return us to who we really are.
If we have concerns about someone in our personal lives, concerns that they may be feeling lonely or isolated, what can we do to engage them?
Given how common loneliness is, it’s exceedingly likely that we all know people who are lonely even if they don’t express that to us. One of the most important things we can do for others who are lonely is simply to show up in their lives, to ask them how they are doing, to spend time with them, give them our full attention, sharing ourselves and being open and vulnerable. These are all key components to strengthening our connection with others and helping them feel seen and valued.
It’s not easy to be vulnerable in the modern world where displaying emotion is often equated with weakness. But the reality is that we’re all struggling in some way, in some portion of our life. We may not talk about it, and we may be ashamed about it, but it’s true. In those unguarded moments where we’re able to open up and be honest with others about what we’re dealing with, we often find that it not only makes us feel better, but it also empowers them to be open and vulnerable as well. That’s one of the great gifts you can give someone else too: that permission to share and to feel, and you can do that by demonstrating that yourself.
As we look ahead to Mental Health Awareness month, is there anything you’d like to share or a closing message that you would like to leave with us?
I would simply say that our mental health is as important as our physical health and that we’re mental, emotional and physical beings. Our mental and physical health are deeply connected to each other so you cannot be healthy without being both mentally healthy and physically healthy. The truth is that we all have struggles from time to time when it comes to our mental health. If we recognize that, it will make it make it easier for people to come forward and to share when they’re struggling as well.
We’ve got to make it clear that talking about your mental health challenges is not a sign of weakness, it’s a source of strength. It’s a demonstration that you recognize that all of us are vulnerable when it comes to our health, and it’s a demonstration that you have the courage to stand up and to share what you’re going through.
I really applaud people in sports that are standing up and openly sharing what they are dealing with in terms of their mental health challenges. They give courage to the rest of us to be open as well. A big part of addressing mental health challenges has to do with removing that stigma around mental illness, and it has to do with building relationships, recognizing that our social connections to each other are an extraordinary source of healing both for our mental and physical health.