Former Surgeon General Stresses Personal Connection in Time of COVID

Doug Brunk

August 13, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Of the new books to debut during the first quarter of 2020, perhaps none was more timely than Together: The Healing Power of Human Connection in a Sometimes Lonely World, by Vivek H. Murthy, MD, MBA, who served as the 19th surgeon general of the United States.

Just as copies of the Harper Collins title became available, the COVID-19 pandemic began a chokehold on American life that has yet to subside. Schools shuttered. Millions lost a steady paycheck. The healthcare system faced its ultimate stress test. The pandemic "turned physical human contact into a potentially mortal threat," Murthy writes in his book. "The novel coronavirus was on the loose, like an invisible stalker, and any of our fellow human beings could have been its carrier."

In Together, Murthy discusses how loneliness evolved as a human condition, why it's more prevalent than ever, and what we can do about it. He crafts a prescription based on his own personal struggles with loneliness, on evidence-based medicine, and on interviews with hundreds of people about the topic. In the following Q&A, Murthy discusses why building and maintaining social connections are more important today than ever before.

Dr Vivek H. Murthy

You mentioned that during your "listening tour" of America shortly after your tenure as surgeon general began in 2014, you heard stories of loneliness and isolation from US citizens in all corners of the country. Was that your main inspiration for writing Together?

It was. So many of the stories I heard around the country when I was surgeon general — whether they were stories of addiction, or violence, or depression, or other chronic illness — had threads of loneliness woven throughout. That stuck with me. People would say things like, "I feel like I have to carry all of these burdens on my own," or, "I feel if I were to disappear tomorrow, no one would care," or, "I feel invisible."

I heard that again and again from people across the country — from college students on campuses, from parents, from people in remote fishing villages in Alaska, from successful business people and academics, and from members of Congress themselves, who would admit to their own loneliness behind closed doors. Hearing this so consistently made me realize there was something deeper happening that I hadn't been aware of.

It reminded me of struggling with loneliness as a child in elementary school. As a shy kid, I had trouble making friends and felt profoundly alone. During lunchtime in elementary school, I would walk into the cafeteria each day and worry that there would be nobody to sit next to.

It also reminded me of my experiences in the hospital. From my third year of medical school on, I saw many patients come into the hospital alone. Even at critical moments when we had to give them a difficult diagnosis or have a tough discussion about changing our treatment strategy, I would ask, "Is there somebody I should call to be a part of this conversation?"

So many times the answer was, "No. I wish there was someone, but there isn't." My conversations with people as surgeon general made me realize that what I had seen in my clinical work and my own personal life were not unique to me; they were part of a deeper phenomenon of loneliness sweeping the country.

What role did your experience growing up as the son of immigrants play in your decision to write this book?

My parents are originally from India, and we moved to the United States when I was 3 years old. They brought me up to know what my cultural roots were and to be proud of them. Growing up as an immigrant and the son of immigrants, I was acutely aware of how different I was from people around me, and not always in a good way.

In elementary school, there were many kids who didn't quite understand our background or didn't understand why I had a funny sounding name, or why we had food at home that was so different from theirs. That contributed to the sense of isolation I felt as a child, but it also made me more sensitive to the cultures and traditions of those from other parts of the world.

From stories my parents told of their time in India, I was aware of how caste-based discrimination could separate people from each other, how it could fracture communities and could make people feel inferior or "less than." That, in turn, created its own loneliness. Part of the reason my parents came to America was that they wanted their children to grow up in a country where we wouldn't be judged by the color of our skin, our caste, or the fact that we had a funny sounding name, but instead, where would we be embraced on the basis of our ideas and our willingness to work hard.

That piece of our immigrant story played an important role in how we thought about community and connection. Because of that background, my parents had a hunger to build community here. So, as much as I did feel lonely in elementary school, the longer we stayed in the United States and the more community my parents built, the more I started to feel like we were embraced and understood.

Your book has been out about as long as most areas of the country have been in and out of some stage of lockdown because of COVID-19. Are there lessons about the importance of human connection you learned while writing this book that resonate with you even more now?

I never imagined that we would be in a pandemic that would separate us even more deeply and so rapidly from each other. Because this pandemic has physically separated us from one another at a time of great stress, it has underscored the importance of our connections with each other.

Even though loneliness is a topic I was deeply immersed in and committed to, this period of separation from family and friends has been hard. It's led me to feel even more strongly that we need to build a people-centered life and a relationship-centered society if we truly want the greatest chance at fulfillment, good health, and deep happiness. Many of us build our lives around work. We put work at the center, and we fit people and relationships in where it's possible. For me, the pandemic has underscored that we must reverse that paradigm. We have to put people and relationships at the center and fit work in where there's room. If we do that, then we will be truly prioritizing people.

If you stop 100 people on the street and ask them what their top priority in life is, almost all would name a person or a group of people. But if you look at how we actually live our lives, where do we spend the majority of our time, energy, and attention? Many times it's not on those relationships or on people. Early in my medical training, I spent the bulk of my energy and focus on school and on work. While nobody criticized me for that, I came to realize in my residency training that wasn't necessarily going to bring me the happiness and fulfillment I craved.

When I was an intern, I remember being on the oncology service, and I had six patients with late-stage gastric cancer who were all in their 20s. I was in my 20s, too. I remember thinking, "That could be me lying in that hospital bed with very little time left in this world." As I went through residency caring for patients who were in their final days and weeks of life, it pushed me to think more deeply about how I'm spending my time.

At that point, I made a commitment to go home and see my parents and sister more often and to make more trips to see close friends, even if I only had a day or a weekend with them. It was still worth it to see their faces and hear their voices and give them a hug, however brief the time together. This pandemic has cemented the idea in my head and in my heart that the path to fulfillment is through a people-centered life.

Early in the book, you state that your medical education did not prepare you to recognize the impact of social connection on health, nor did it give you the tools to help patients who were struggling with loneliness. Have things improved on that front since your days of medical training?

I don't know that much has changed in terms of medical education giving us the training to recognize and address loneliness and isolation, but I think a lot has changed for the better and that we're more embracing of the idea that physician well-being is important. We're more open to the fact that mental and physical health are critical for patients and clinicians.

But we've only started to scratch the surface when it comes to preparing clinicians to be able to recognize loneliness and isolation and to be able to work together with community partners to address that loneliness.

Other parts of the world are ahead of the United States in this regard. The United Kingdom and Australia, for example, have been thinking deeply about how to address loneliness and are building national strategies, including initiatives such as social prescribing, an approach through which clinicians can partner with community organizations to help patients who are lonely.

As clinicians understand the powerful health impacts of loneliness, I suspect they will recognize loneliness is important to address. The real question is how to address loneliness and what role clinicians can play. We need clinicians engaged in such an effort, but we also need workplaces, schools, faith organizations, and other community institutions to be involved in helping to open conversations about human connection and create spaces where people can build a genuine relationship with one another.

This is a difficult time for many people in the healthcare workforce, some of whom have made great sacrifices by living away from their families to minimize the risk of passing along the virus to loved ones at home. Some have fallen ill themselves. What messages do you have for healthcare workers on the front lines about the importance of maintaining social ties?

In times like this, we must double down on our connections with one another. Because we are wired to connect with each other, just a little high-quality time with someone you care about can be extraordinarily renewing and refreshing. If you've ever spent a few minutes with someone who's listening deeply and fully present, someone with whom you can be open and honest, you know that 5 minutes of conversation like that can be more powerful than an hour of distracted conversation.

It could be a short phone call we make to someone we care about on the way home, or video conferencing with someone we love briefly in the morning. It could be sending a brief note to an old friend or mentor that we've been thinking about. Small steps make a big difference in how connected and fulfilled we feel. As human beings, we've evolved to not just process the content of what someone says but to appreciate their facial expression, their body language, and the tone of their voice.

The more we communicate with people in ways that we can experience those aspects of them, the richer our communication is. Whenever I have the opportunity to call rather than text, I will choose to call. If I have an opportunity to video conference and see someone's face versus just hearing their voice, I will opt to see their face. We can't always do that, but whenever possible, if we can enrich our form of communication, that usually leaves us with a more fulfilling interaction. It's the quality of time that matters more than the quantity.

You write that the biggest challenge we face in staying connected may be the sheer pace of change. You note that advances in technology, for example, "set up a state of competition between tradition and innovation, between old and young, between online and physical communities, and between transactional and human interactions." How can people best prepare for such inevitable change without feeling left behind?

The pace of change is only getting faster, and it is harder to keep up. This is true in medicine as well. Medical knowledge is expanding extraordinarily rapidly, and it's hard not to feel like you're always behind in some way. One of the questions this raises for me is the deeper question of where our self-worth comes from.

When I feel bad about not being able to keep up with what's happening in the world, I realize that sometimes I'm allowing my own sense of purpose and value and worth to be determined by extrinsic conditions. The world around us emphasizes that connection between extrinsic markers and our intrinsic worth by telling us that we have value as human beings if we're successful, and we're successful if we've acquired one of three things: wealth, fame, or power.

This is true in medicine as well where publications, promotions, and positions are proxies for fame and power. The importance of these extrinsic factors is emphasized in social media and many other avenues, and it sets us up for inevitable disappointment and self-doubt, because there are times in our life when we won't meet all those external markers.

What's essential is that we reorient our understanding of where our worth comes from and recognize that it does not come from these extrinsic markers. Our worth as human beings is intrinsic; it comes from our ability to give and receive love, kindness, and generosity. And the most natural way that we experience love, kindness, and generosity is through our relationships. That's why strong relationships make us feel so good and why they reaffirm our sense of self. That, to me, is the heart of what we need to build our society around.

You recommend intentionally reserving time for solitude on a daily basis. What's your preferred way to practice solitude?

Time for solitude has been challenging for me during this pandemic because we have two small kids. I'm at home with them, my wife, my parents, my sister, my brother-in-law, my grandmother, and three cats. Life is full, but there are two ways in which I try to enjoy some solitude: through meditation and through walking in nature. Those really help me feel more grounded and recentered.

You wrote that we could emerge from the COVID-19 pandemic "feeling closer to friends and family members than ever before." What gives you hope for such an outcome?

What gives me hope is seeing people awakened to the power of and importance of human connection during this pandemic. This is an extraordinarily hard time for so many of us, but it has also had unexpected silver linings. One of them is the deeper joy some of us are finding in our relationships as we're quarantined with our parents or our children. Many of us are starting to realize we want to focus more on our relationships once we're through with the COVID-19 pandemic, and even during it.

I see more clearly than ever what really matters in life, which is our relationships with one another. My belief is that this pandemic will take us in one of two directions. It will either take us down a path of deepening loneliness and separation, which would be the path of a social recession, or it will take us down the path of social revival, where we use this moment to step back and take stock of our lives and to recommit to our relationships. If we use this as an opportunity to prioritize people and commit to building a people-centered life, then I think that we can emerge stronger, more connected, and more resilient than we were before this pandemic began.

In the acknowledgments section of your book, you say that you wrote much of Together at Abe's Cafe. Where is this cafe and what made that spot an ideal environment for you to write in?

Abe's Cafe is located in downtown Washington, DC, in the neighborhood in which I live. I needed to go somewhere to write because, while I love being at home, my wife, Alice, and I have two small children, who weren't always excited about me writing at home. What stood out about Abe's is how friendly the people are who work there.

They always looked out for Alice and me and asked how we were. They'd make our favorite dishes even before we asked for them, because they knew what we liked. They would ask how the book was going and were always interested in hearing updates. I like bubble tea, and my favorite part of it is the bubbles — the tapioca pearls. The staff caught on to that, so they would give me small cups of tapioca pearls without the tea. It felt like home.

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