Together: Why Social Connection Holds the Key to Better Health, Higher Performance, and Greater Happiness

by Vivek H. Murthy

In these instances and so many others, I could see the vital role that social connections can play when individuals, families, and communities face difficult problems. While loneliness engenders despair and ever more isolation, togetherness raises optimism and creativity. When people feel they belong to one another, their lives are stronger, richer, and more joyful. And yet, the values that dominate modern culture instead elevate the narrative of the rugged individualist and the pursuit of self-determination. They tell us that we alone shape our destiny. Could these values be contributing to the undertow of loneliness I was witnessing?

To be at home is to be known. It is to be loved for who you are. It is to share a sense of common ground, common interests, pursuits, and values with others who truly care about you. In community after community, I met lonely people who felt homeless even though they had a roof over their heads.

the topic of emotional well-being, in general, and loneliness in particular, received the strongest response from the public of any issues I worked on as surgeon general. There were few issues that elicited as much enthusiastic interest from both very conservative and very liberal members of Congress, from young and old people, or from urban and rural residents alike. After my presentations to city mayors, medical societies, and business leaders from around the world, it was what everyone seemed to want to talk about. I think this is because so many people have known loneliness themselves or have seen it in the people around them. It’s a universal condition that affects all of us directly or through the people we love. The irony is that the antidote to loneliness, human connection, is also a universal condition. In fact, we are hardwired for connection—as we demonstrate every time we come together around a common purpose or crisis.

What exactly has led to the fraying of relationships in communities and such high levels of loneliness? What other aspects of health and society are affected? How can we overcome the stigma of loneliness and accept that all of us are vulnerable? How can we create stronger, more enduring and compassionate connections in our own lives and communities, and a more unifying sense of common ground in our larger society? How do we shift the balance of our lives from being driven by fear to being fueled by love?

The first section of the book is focused on the underpinnings of loneliness and social connection—the reasons why loneliness evolved in our highly social species and the ways in which different aspects of culture may help or hinder our efforts to bond with others and establish a sense of communal belonging. The second section addresses the process of connection that each of us individually must navigate in our own lives, beginning with our relationship with ourselves and moving outward through family and friends to ultimately build a more connected world for coming generations.

In the writing of this book, I’ve come to realize that social connection stands out as a largely unrecognized and underappreciated force for addressing many of the critical problems we’re dealing with, both as individuals and as a society. Overcoming loneliness and building a more connected future is an urgent mission that we can and must tackle together.

My focus as a physician was medical. The social issues, as wrenching as they were, seemed outside the domain of doctoring. It would take a patient named James to teach me just how wrong I was about this.

Too late, James realized that it had been a terrible mistake to do what he thought a lottery winner ought to do, instead of heeding his own heart. “I traded in my friends and a job I loved and moved to a neighborhood where people keep to themselves in their giant houses. It’s lonely.” James’s experience was an example of how what we seem to value most in modern society—status, wealth, achievement, and fame—doesn’t guarantee happiness. With more money, we can purchase more privacy, we can live on secluded estates, we can even travel exclusively on our own boat or plane. While all of these privileges have their appeal, there can be a hidden human cost. If we’re not vigilant, such success can lead to a life that feels increasingly lonely as the distance between the individual and other people grows.

Many people think of loneliness as isolation, but the difference between these two terms is substantial. Loneliness is the subjective feeling that you’re lacking the social connections you need. It can feel like being stranded, abandoned, or cut off from the people with whom you belong—even if you’re surrounded by other people. What’s missing when you’re lonely is the feeling of closeness, trust, and the affection of genuine friends, loved ones, and community.

three “dimensions” of loneliness to reflect the particular type of relationships that are missing. Intimate, or emotional, loneliness is the longing for a close confidante or intimate partner—someone with whom you share a deep mutual bond of affection and trust. Relational, or social, loneliness is the yearning for quality friendships and social companionship and support. Collective loneliness is the hunger for a network or community of people who share your sense of purpose and interests.

Unlike the feeling of loneliness, which is subjective, isolation describes the objective physical state of being alone and out of touch with other people. Isolation is considered a risk factor for loneliness simply because you’re more likely to feel lonely if you rarely interact with others. But physically being alone doesn’t necessarily translate into the emotional experience of loneliness.

What defines loneliness is our internal comfort level. This is what makes loneliness distinct from solitude. When we feel lonely, we’re unhappy and long to escape this emotional pain. Solitude, by contrast, is a state of peaceful aloneness or voluntary isolation.

Unlike loneliness, solitude is not burdened with shame. Rather, it can be a sacred state. Solitude also can feel a bit daunting, even scary, since it allows both positive and negative thoughts and emotions to surface. The space where we confront our demons is not always a space we enter willingly. But it’s in the grappling that we work through issues, gain clarity about our feelings, and build comfort with ourselves. Developing comfort with solitude, then, is an essential part of strengthening our connection to ourselves and by extension enabling our connection with others. Solitude, paradoxically, protects against loneliness.

What prevents all these people from simply joining a club, making new friends, or reconnecting with family and old friends? In a word, loneliness itself. When we already feel lonely and then see others having fun together, enjoying the company of those around them, there’s a natural tendency to withdraw instead of approaching the group. We fear being labeled and judged as social outcasts. (To understand this worry, just spend some time in a grade school cafeteria or playground.) So we hide our true feelings even from those who may try to connect with us. Shame and fear thus conspire to turn loneliness into a self-perpetuating condition, triggering self-doubt, which in turn lowers self-esteem and discourages us from reaching out for help. Over time, this vicious cycle may convince us we don’t matter to anyone and that we’re unworthy of love, driving us ever inward and away from the very relationships we need most.

By learning to recognize and address the signals early, we can intervene to forge connections when loneliness strikes, instead of allowing it to become a constant in our daily lives. A first step is to acknowledge the vital need that all humans have for social connection. Quite simply, human relationship is as essential to our well-being as food and water. Just as hunger and thirst are our body’s ways of telling us we need to eat and drink, loneliness is the natural signal that reminds us when we need to connect with other people. There’s no cause for shame in that. Yet hunger and thirst feel much more acceptable to acknowledge and talk about than loneliness. To combat this silencing effect, then, we need to more deeply appreciate the relationship between loneliness, social connection, and physical and emotional health. In so doing, we can lift the burden of shame, blame, and criticism that fuels the stigma around loneliness. We’ve seen this approach work with conditions like depression.

Julianne’s study showed that people with strong social relationships are 50 percent less likely to die prematurely than people with weak social relationships. Even more striking, she found that the impact of lacking social connection on reducing life span is equal to the risk of smoking fifteen cigarettes a day, and it’s greater than the risk associated with obesity, excess alcohol consumption, and lack of exercise. Simply put, Julianne had found that weak social connections can be a significant danger to our health.

Five years later, Julianne published another massive analysis of data confirming the higher risk of early death among the lonely.18 By that point, a growing number of research papers were reporting that loneliness was associated with a greater risk of coronary heart disease, high blood pressure, stroke, dementia, depression, and anxiety. Studies were also suggesting that lonely people were more likely to have lower-quality sleep, more immune system dysfunction, more impulsive behavior, and impaired judgment.19

What these doctors were beginning to grapple with was the link between social and emotional health that often shows up in the physical health of medical patients. If neglected, loneliness can have long-term health implications, yet it is not a state that can be fixed with a pill or a procedure. It is a human condition that reminds us of our need for the love, compassion, and companionship of fellow human beings. Helen’s approach to helping Enid followed a practice known as social prescribing. Clinicians recommend—or “prescribe”—resources and activities in the community that can help patients forge healthy social connections. This practice reflects a recognition that loneliness affects our health, and we have a universal need to connect with one another.

In 2017, Sachin and his team launched the Togetherness Program to identify and assist patients who are lonely. Within a short time, they’d enrolled six hundred patients in the program, which included home visits, weekly phone calls, and connection to existing social programs in the community.

Medicine and technology may fail us at times, but human connection grounded in love and compassion always heals. Perhaps the sense of loneliness and disconnection that comes with death can’t entirely be prevented, but it can be eased. Helping patients and their families feel known, helping them feel seen and loved, is perhaps the most powerful medicine we have.

With every true friendship, we build more firmly the foundations on which the peace of the whole world rests. —Mahatma Gandhi If we have no peace, it is because we have forgotten that we belong to each other. —Mother Teresa

When driving one day, he accidentally struck a horse, totaling his car and injuring himself so severely he nearly died. During those moments when he thought his life was ending, his thoughts flew to the people he loved. Not to his work or reputation, but to the people he loved. The experience caused him to reexamine his life and his academic focus with fresh eyes. What mattered most in life was love and human connection. This realization was at once obvious and profound. It led him to change the direction of his studies and research to focus on the biological underpinnings of human relationships and on the tension between social connection and loneliness.

Together, they founded the field of “social neuroscience,” which focuses on understanding the interaction between biological systems and social processes.

“Loneliness is like an iceberg,” John said in a 2016 interview with the Guardian. “We are conscious of the surface, but there is a great deal more that is phylogenetically so deep that we cannot see it.”

As humans developed, evolutionary pressure selected for more cooperation because of the advantages it conferred. Cooperation made it possible to plan for the future. Division of labor became feasible. In groups, our hominid ancestors could take turns keeping watch for wolves or sabretooths, and if they were attacked, they could organize to fight back, increasing their chances of overpowering the tiger and saving one another. They could pool the food they hunted and gathered, making it less likely that any individual would starve from day to day. As an early human, you soon learned that your odds of being attacked or of starving would increase dramatically if you became separated from your people. But that wasn’t the only reason to stick together. Connecting in groups also provided the numbers and security for individuals to mate, which enabled the tribe to multiply and endure. Cooperation further helped safeguard the tribe’s survival through extended families of trusted adults who shared the responsibility of parenting. It made for efficiency when the work of teaching and protecting the tribe’s children was a communal rather than a private enterprise. So, it wasn’t only the individual whose survival depended on social connection, but our entire species. Beyond basic survival, though, connection increased the rate of human innovation and empowered the tribe’s creativity. “We’re the only animal on the planet,” Bill told me, “that goes out of its way to share the contents of ...

Even in the absence of others, stories make individuals feel connected and promote a sense of belonging. This helps to explain the enormous role that storytelling plays in securing human values, purpose, and identity, and in bonding us emotionally. Ever since the first cave drawing, we’ve been encoding our experiences in stories through words, pictures, music, and rituals to be passed down generation to generation. These tales help us understand who we are. They give meaning to our struggles, and comfort us when we are suffering or afraid. They bring us together.

“If I’m not sharing knowledge and emotions, then I feel lonely.” The reason for that, according to John Cacioppo, is that loneliness “serves as a signal to attend to and take care of the social connections that define us as a species.”5 We know we are attending to those connections when we feel “at home” with a closely knit group or family. We’re wired to associate belonging with the sharing of stories, feelings, memories, and concerns. That’s why our bodies relax and our spirits lift when we connect in genuine friendship and love. Strong personal relationships not only add joy and meaning to our lives, but they have positive effects on our health, mood, and performance.

humans rely on two separate networks to process social and nonsocial thinking. He likens the back-and-forth activity between these networks to a “neural seesaw.” When we’re doing our taxes or chemistry homework or engineering a bridge, our nonsocial pathways are active. When we’re meeting a friend for lunch or helping our kids with their homework, the action shifts to the social network. But what happens, he wondered, when we’re just kicking back and doing nothing? What’s our default network? The answer astonished him. “Whenever we finish doing some kind of non-social thinking,” he told Scientific American,8 “the network for social thinking comes back on like a reflex—almost instantly.” In other words: “Evolution has placed a bet that the best thing for our brain to do in any spare moment is to get ready to see the world socially. . . . We are built to be social creatures.”

Newborns come into the world without preference. They are drawn to faces, and for the first month or two, almost any face will do.11 They’ll pay as much attention to a monkey’s face as to their own father’s.12 Moreover, infants have an astonishing ability to tell individual faces apart—even those of individual monkeys. They also can distinguish between faces of any race.

By the age of three months, however, research has found that babies start to favor faces of their family’s race and ethnicity. A process that researchers call perceptual narrowing begins to blur faces that are different from those within the infant’s small, trusted circle. As a result, babies start to view members of other races as indistinguishable from one another, even as they become more closely attuned to the nuances and subtle signals from the people who are closest and most familiar to them—the people the child most depends on.

Given the complexity of close human interactions, this narrowing serves a practical function. For babies to develop a strong connection with their caregivers, they need to learn how to read their cues, including body language, tone of voice, patterns of speech, facial expression, and eye movements.

It’s worth mentioning that not even the most sophisticated artificial intelligence today can match these intricate signaling systems, much less the profound human connections they generate as they circuit through the brain. This is one reason why the social network of technology is—and likely always will be—an inferior substitute for face-to-face interpersonal communication.

When we feel lonely, our bodies still react as if we were lost on the tundra surrounded by wild animals and members of alien tribes. When loneliness persists, the same stress hormones that surged to provide short-term protection instead begin to produce long-term destruction as they increase cardiovascular stress and inflammation throughout the body. This, in turn, damages tissues and blood vessels and increases the risk of heart disease and other chronic illnesses. Studies have also found that loneliness leads to changes in gene expression in white blood cells, which in turn results in increased inflammation and reduced defenses against viruses.16

John Cacioppo helped us understand an additional way loneliness causes mental and physical exhaustion: it takes a toll on the quality of sleep. When we’re profoundly lonely, we tend to sleep lightly and rouse often, just as our ancestors did to prevent being overtaken by wolves or enemies.

lonely brains detect social threats twice as fast as non-lonely brains.18 This may seem like a paradoxical response to a mechanism that evolution designed to prevent isolation, but from an evolutionary standpoint it makes sense. When our ancestors were separated from the safety of the group, they needed to react defensively even to marginal threats, since they might well turn out to be lethal. But in modern life that same hypervigilance causes us to misread harmless or even welcoming people and situations as threats. Fleeing into self-preservation mode, we’ll avoid people and distrust even those who reach out to help us. With prolonged loneliness, we’ll decline invitations and stop answering the phone. Hypervigilance also creates an intense preoccupation with our own needs and security, which can appear to others as self-involvement.

Then the reactions begin. Those who’d like to help start turning away, leaving us feeling even more alone. Before long we’re trapped in a vicious cycle of suspicion, jealousy, and resentment. Loneliness thus fuels more loneliness until the fracture leads to severe alienation. Clearly, the solution is more complicated than telling someone who’s lonely to go to a party or “just be with people.” “What’s disturbing about this,” Steve Cole observed, “is that we have created a culture of living which is different from our historical default state. I think we are relaxed and at ease by default and are bonding oriented in our resting state. But few of us feel this way. It’s less common for us to be sitting around our fire talking with neighbors. Instead, we are racing around trying to get work done all the time. So, I think our current state is different from what our physiology is engineered to support.”

After studying data from more than ten thousand people aged fifty or older, they concluded that the tendency to feel lonely over a lifetime, rather than just occasionally due to circumstance, is between 14 and 27 percent heritable based on an analysis of common gene variants. Other studies, including twin studies, looking at the total heritability of loneliness have pegged that number as high as 55 percent.21 But it’s important to note that loneliness is not a discrete condition but an emotional response. “What’s being inherited is not loneliness,” Cacioppo said, “it’s the painfulness of the disconnection.”22 What he meant is that the overall experience of loneliness is a complex product of our genes, past experiences, current circumstances, the culture in which we live, and our personalities. Which of these factors causes us to feel lonely on any given day is nearly impossible to say.

It’s not easy, she’s found, to explain how the experience of loneliness differs from that of depression or social anxiety, and how the three overlap. “I think it’s a really difficult distinction to make,” Michelle said. “Being lonely can lead to mental health issues. And also, mental health issues make you more susceptible to loneliness. It’s very hard to understand yourself when you’re dealing with depression and anxiety, let alone to let someone else in to try and understand it. When I struggle with my mental health, I can push people away, for fear of judgment or just not wanting to be honest about it. That has led to losing friends, which then sort of perpetuated that feeling of loneliness.”

Dr. Guy Winch, the author of Emotional First Aid. “I see them more as distinct clinical entities,” he told me. “Somebody can feel lonely, but still feel very interested in the things they do to keep themselves occupied or in their hobbies, or in their work. Someone who’s depressed, they’re not going to show a lot of vitality, or interest or passion about anything. It’s much more global and much more systemic.” “Why do they so closely resemble each other?” I asked. “Someone who’s been chronically depressed for a long time can end up being lonely just because they’re not cultivating their relationships,” he said. “Somebody who’s lonely can become depressed when their isolation becomes profound. And it can be profound for people very quickly.” To illustrate, Guy described a client who came for therapy thinking he was depressed, but in fact he was feeling disconnected from his spouse. When the man was able to reengage with his spouse, the depression lifted. “It really was about the loneliness, not about the depression.”

Steve Cole explains, “Human beings are great assets to other human beings, but they can also be great threats.” John Cacioppo put it this way: “You’re motivated to connect. But promiscuous connection with others can lead to death. A neural mechanism kicks in to make you a little skeptical or dubious about connecting.”23 And if you’ve been wounded deeply and frequently in prior relationships, that neural mechanism can become agonizingly powerful.

Cole, who studies the effects of loneliness at the molecular level, says that repeated or extended experiences of threat will actually change the brain. People who carry emotional scars develop a “kind of neurobiological sensitivity to threat and rejection.” This sensitivity mirrors the instincts of people who are born with social anxiety—and exacerbates them in people unlucky enough to have both a genetic propensity toward social anxiety and a painful social history. Whether conscious of it or not, they’re always on guard in social situations, assessing the trustworthiness of people around them, trying to distinguish potential friends from foes. “If I’m the kind of person who’s had a rough upbringing,” Cole says, “when I go into new social settings, I am not going to come up to the first person I see and be immediately friendly to them.” Instead, the first response is caution and wariness, which may appear to others like reserve, standoffishness, or even arrogance. People who are naturally friendly may take offense and back away, and before you know it, the fear of social threat becomes a self-fulfilling prophecy of rejection.

Loneliness only occurs when you want to connect and be accepted, but can’t, in this case because life has trained you to be afraid of being exploited or hurt by other people. That, Cole says, creates the “classic paradox of loneliness in a room full of people.”

When I began my rotations in the hospital as a third-year medical student, I was struck by the distinctions we typically made between emotional pain and physical pain. When we encountered physical pain in our patients, we would rush to determine the origin of the pain, asking questions, performing exams, and obtaining laboratory and imaging studies. And we would be aggressive about monitoring and treating the pain. When we discovered someone was experiencing emotional pain, we reacted with concern and compassion, but there was an underlying assumption that this was less of a concern and less consequential than physical pain. What few of us understood at the time was that, within the brain, there’s less difference between the two than we think. The sensory fibers that register emotional and physical pain overlap in the brain. This proximity means that loneliness, loss, or disappointment can produce symptoms similar to those caused by physical blows or wounds.24 If you feel shunned, researchers have found, you’re likely to flinch the same way you would if slapped. If the shunning and slapping occur during an fMRI, the same region of the brain (the dorsal anterior cingulate cortex) will light up in both events.25

These studies and others like them have confirmed something most people suspected: rejection hurts. But they also showed that emotional and physical pain are both processed by the brain in very similar ways. The overlap between physical and emotional pain in the brain sheds light on why people may reach for more powerful and dangerous substances—like opioid painkillers and alcohol—when they experience emotional pain from loneliness. With the opioid epidemic, in particular, we have increasingly appreciated the role emotional pain plays in driving use and overuse. Opioid deaths have been labeled deaths of despair for good reason. While we recognize loneliness and other sources of emotional pain as risk factors for misuse and addiction, we don’t make the connection often enough. I have found the opposite also to be true: social connection is an essential part of the addiction recovery process. In caring for patients over the years and during my time as surgeon general, I met thousands of people who struggled with addiction to opioids, alcohol, and other substances, and when I reflect on those who made it through that dark tunnel and emerged in recovery, nearly all of them described a trusted relationship or a trusted group of close family or friends who had made their recovery possible. While loneliness has the potential to kill, connection has even more potential to heal.

Loneliness is a built-in reminder that we are stronger together, not just as clans and tribes or family and friends, but also as caring communities that form the foundation of a healthy culture.

Let there be no purpose in friendship save the deepening of the spirit. —Kahlil Gibran, The Prophet

our Uber driver, a young man originally from Addis Ababa, Ethiopia. He said what he missed most about Addis was that people around you there took care of you, and you did the same. He added, “You can just leave your kids with your neighbor and go away for four or five days and they will take care of them. It’s what we do. We cook for each other, we take care of each other’s kids, and we spend time together.” As working parents raising our two small children far from our extended families, Alice and I were quite taken by this last remark and wanted to know more. He then told us that his own wife and children were still in Addis. I asked if he felt lonely without them. “Of course, I miss them,” he remarked, “but I met other Ethiopian families in the DC area, and we have built a smaller version of what we had in Ethiopia. We have each other so we’re not lonely.” Alice and I looked at each other. The world he was describing felt so different from the one we lived in. When it comes to our day-to-day life, we resort to modern stopgap solutions just like many of our friends. We hire a nanny to help us balance work and child care. We use reputable online sites to find babysitters when we travel for work with the kids. We think about how to attach tracking devices to our children for security and peace of mind when they go around town with various caregivers, and we have spent countless hours in the middle of the night between diaper changes searching for parenting advice on everyt...

Looking back I realize these Ethiopian traditions are not so different from traditional Indian practices. My parents described equally close-knit community networks when they told me about growing up in India. And when I used to stay at my great-grandmother’s house in Bangalore as a child, spontaneous drop-in visits from friends and extended family were daily occurrences. Most of the visitors lived nearby and, whether or not we were related to them, my sister and I were encouraged to call everyone “uncle” and “aunty.” This made it seem as if we were all part of one enormous family. Later, as an honorary uncle myself, I discovered that this practice has a reciprocal bonding effect; whenever a child calls me uncle today, I feel both more connected to and more responsible for that child. Also like Mrs. Bekele’s family, my relatives often fall silent for long pauses during group conversations. Even as a child, I noticed that they didn’t feel an urgency to fill each moment with talk. What mattered was simply being together.

Growing up, I was aware that the world of my parents’ childhood was different from mine. Traditional households in India (and in the Indian American community in South Florida) seemed messy and complicated, with everyone always around and deeply immersed in one another’s business. No one seemed bothered about privacy. That had its share of drawbacks, to be sure, but we also enjoyed, even counted on being intertwined with one another. The nuclear families I saw around me in Miami seemed, in many ways, the exact opposite, with privacy and independence placed in high regard.

The shift from extended to nuclear family networks had swept across the industrialized world in tandem with the shift toward speed, efficiency, and competition as the dominant terms of progress. As much as I accepted these norms while growing up, after becoming a doctor and confronting widespread loneliness among my patients, I began to suspect we’d lost something more valuable than we realized in this transition to modern culture. On the rare occasions when large extended families like Mrs. Bekele’s appeared in the hospital, their presence was almost always a net benefit, as they brought with them compassion, hope, support—and love.