EP. 90: HEALING OUR CRISIS OF DISCONNECTION

WITH JEREMY NOBEL

Nov 28

WITH JEREMY NOBEL, MD

A physician and founder of the Foundation for Art & Healing shares how storytelling and creativity can foster connection and help heal our crisis of loneliness.

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Episode Summary

In recent years, loneliness has transformed from a private, personal experience into a full blown public health crisis. Studies have repeatedly shown that loneliness and social isolation increase the risk of premature death, dementia, and all sorts of mental illnesses. In this episode, Jeremy Noble, MD shares how he is combating our national crisis of loneliness by fostering connection through art and storytelling. Dr. Noble is the founder of the Foundation for Arts and Healing, a lecturer at Harvard Medical School, and the author of the 2023 book Project UnLonely: Healing Our Crisis of Disconnection.

Over the course of our conversation, we discuss Dr. Noble's unique path to arts and medicine, the three types of loneliness—social, emotional, and existential, what meaningful social connection looks like, and the healing power of creativity.

Jeremy Nobel, M.D., MPH, is a primary-care physician, public health practitioner, and award-winning poet with faculty appointments at the Harvard T.H. Chan School of Public Health and the Harvard Medical School. He is the founder and president of The Foundation for Art & Healing, whose signature initiative, Project UnLonely, addressing the personal and public health challenges of loneliness and social isolation, has gained national visibility.
In this episode, you will hear about:
• 2:08 - Dr. Nobel’s journey to becoming a “public health practitioner” and the personal meaning that the has found in his work
• 5:44 - The issues that Dr. Nobel is most interested in addressing within public health
• 7:03 - How Dr. Nobel found his way to the arts and humanities
• 14:21 - The benefits available at the intersection of the arts and medicine
• 16:09 - The mission of the Foundation for Art and Healing and Project UnLonely
• 22:26 - The definition of “loneliness” and the importance of loneliness literacy
• 24:19 - The “pyramid of vulnerability” for loneliness
• 27:10 - Evolutionary reasons for loneliness and how those are exacerbated today
• 34:19 - The three types of loneliness
• 38:20 - How we can cultivate a culture of connection in a society that has grown to distrust people and institutions
• 42:24 - What public health agencies should do to better prepare our society to reckon with loneliness
• 44:11 - The importance of addressing the loneliness inherent in medical training
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine, we will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] In recent years, loneliness has transformed from a private personal experience into a full blown public health crisis. Studies have repeatedly shown that loneliness and social isolation increase the risk of premature death, dementia and all sorts of mental illnesses. In this episode, Dr. Jeremy Noble shares how he is combating our national crisis of loneliness by fostering connection through art and storytelling. Dr. Noble is the founder of the Foundation for Arts and Healing, a lecturer at Harvard Medical School, and the author of the 2023 book "Project UnLonely: Healing Our Crisis of Disconnection". Over the course of our conversation, we discussed Dr. Noble's unique path to arts and medicine, the three types of loneliness social, emotional, and existential, what meaningful social connection looks like, and the healing power of creativity.
Henry Bair: [00:02:01] Jeremy, thank you so much for taking the time to join us and welcome to the show.
Dr. Jeremy Noble: [00:02:06] Thanks, Henry. It's a real pleasure to be here with you.
Henry Bair: [00:02:08] So over the course of your career you have been, at various times a practicing clinician, an expert on health systems management, a health policy analyst, a founder of digital health companies, and an artist to set the stage. Can you share with us what initially drew you to medicine?
Dr. Jeremy Noble: [00:02:26] I'm very fortunate that I get to focus my energies and attention in a broad array of things. Henry, as you mentioned, I've had the again, the good fortune of exploring a lot of avenues in medicine. I don't currently see patients. I worked as a primary care physician for a number of years, about 10 or 15 years, you know, after residency. And then I also got boarded in occupational medicine, which gave me an additional way to have clinical engagement in the workplace setting. Right now, I've really transitioned in what I have an academic base at Harvard, at both the medical school and the public health school.
Dr. Jeremy Noble: [00:03:03] But when you actually say, well, what do you do? I like the term public health practitioner. You know, someone who is really sensitive to the broad goals and challenges of public health that public health addresses, and health is more than the absence of illness. And that's really led me to an awareness of the complexity of the ecosystem. We depend on all of us to really have health, and that that's really become my focus.
Henry Bair: [00:03:30] Okay. And in what way is this work meaningful to you? Like, why does it resonate with you personally?
Dr. Jeremy Noble: [00:03:38] How it's resonated to me just really honestly has changed over the years. You know, early on in my career, I started off, both my parents were chemists. I was very interested in science and started off in the Md-phd program in immunology at the University of Pennsylvania. I was so intrigued. It was before we knew much about T cells. Other than that they were important. So it was like, how do how do we find, you know, what is the T-cell receptor? And these kinds of questions and how it could relate to autoimmunity and diseases like diabetes. It was really early in those investigations. But along the way, as I started doing clinical rotations, my attention shifted towards the complexity and opportunity of dealing with real patients with real diseases. And I found that increasingly compelling and meaningful to explore. And so through the course of my residency and then practice that was meaningful, I had a sense that I could put what I had learned in medical school. And then in the actual experience of caring for patients, put that knowledge to work in a way that I thought mattered. And then as my work expanded into the public health realm again, I had this great fortune in a sense that my work really mattered. It gave me a sense of meaning and purpose in my life, and a way to make sense of the world in kind of a larger model of human experience. And that continues in the work I'm doing now in humanism. And so I feel very fortunate that although the precise way that my work has been meaningful has shifted over the decades, it always has been incredibly personal and meaningful work for me. And I think a career in medicine and public health still offers that opportunity to anyone starting off, even right now, because of the complexity of the challenges, the many ways you can address human suffering at the molecular level, at the individual level, at the group level, community level and the global level, all of it matters.
Henry Bair: [00:05:44] So within the realm of public health, what are some of the issues that you're most interested in addressing?
Dr. Jeremy Noble: [00:05:48] Again, over the years? Different things. At one point, I was very interested in access and quality. And how do you measure that? And then how do you do population health and how do you identify people who could benefit from early interventions? You know, this is more of a public health issue than an actual health care issue, although they're starting to blend, as you're probably aware. But 20 years or so ago, I started getting interested in all the factors and the bigger social world, you know, that influence health. Again, recognizing health is more than the absence of illness, as the World Health Organization says, it's achieving our full potential in mental, physical and social domains. I found that really required we look at many of the shortfalls in social activities. Sometimes this is reviewed as social determinants of health. I imagine that may be familiar to many of your listeners. Some of the classic social determinants are really often viewed as what's missing. So it's often viewed as food insecurity, housing insecurity, income insecurity. And along the way, the one that got really compelling attention for me was social isolation and loneliness, the insecurity or lack of the social connections. We need to be healthy and well.
Henry Bair: [00:07:03] We're going to talk a lot about loneliness. But before we circle back to that, I'd like to explore this other significant component of your career, which is in the arts and humanities. Can you share with us what prompted you to begin exploring the arts?
Dr. Jeremy Noble: [00:07:18] You know, it's interesting. I think every human being has a creative imagination. And I think all of us, you know, explore that. And, you know, look at kids, you know, you can't stop them from being creatively imaginative. You know, give them any kind of art supplies, making supplies. They just go to work. That's their job. Let's go make something right. But I think for a variety of reasons, people often either feel intimidated by that kind of joyful, celebratory, playful making, or they feel judged and so on. Now, some people, of course, feel incredibly nurtured and excited by that. They often go on and explore that in creative ways and becomes big parts of their professional and personal life. But for me, I was very fortunate early on to discover the pleasure of two things language. And even in high school, I found poetry very helpful in navigating my personal world and then in college, image making photography as a way to make sense of the world. But it never really occurred to me then that this could in any way become part of my professional work. But it was clearly something energized me, gave me, as I said, a way of making sense of myself, sharing thoughts and feelings often difficult to have in ways that I thought could make sense to other people. It invited me to be more connected during very lonely times. I remember early on in my college experience how sharing creative work formed kind of surprisingly close bonds with people, and so I always had that, that basis of personal experience. In fact, in college, I got so interested in the creative work that I left college, deciding after two years that I would go to art school.
Henry Bair: [00:08:57] What did you want to do in art school?
Dr. Jeremy Noble: [00:09:00] Well, you know, I had I was so fortunate again, at every step along the way, I had the good fortune of working with a remarkable photographer, Emmet Gowin. So Emmet is still living. He made beautiful images, captured my attention, I think, since has captured the world's attention. He's quite well known in photography circles, and that was so inspiring to me that as I did that work mostly in my sophomore year, I said, this is really what I want to do. I want to go out in the world and make images and, you know, and I had done well, you know, in classes both in science and humanities, history, philosophy and so on. But I was just compelled I had to go do it.
Henry Bair: [00:09:39] At this point. Did you have a major were you was there a course of study, or were you early on enough that you were sort of undifferentiated as a college kid?
Dr. Jeremy Noble: [00:09:45] I was just at the point where I guess I had to make that choice, you know? And so maybe that's what made me decide I would seek kind of a school that focused on creative arts. And so while arts were available where I went, I went to Princeton as an undergraduate, and they take the arts very seriously. They teach arts there. But I thought I wanted to really focus on it. And so I left Princeton and was on my way to interview at an art school in Kentucky. How did I pick Kentucky, you might ask? Because in my work with Emmet Gowin, I had discovered the work of an amazing photographer not well known except to historians of photography photography, Ralph Eugene Meatyard. What a great name. And he had done amazing, amazing images of people, often with masks and costumes. And and I was at the stage in my life where I was trying to understand who am I? And something in me. Yard's work really resonated. And he lived in Kentucky. He worked as an optician actually, for most of his professional career, but made images on the side, and he was teaching at an art school in Kentucky. And I thought, I'm going to go there and, you know, study. I had it all in my head.
Dr. Jeremy Noble: [00:10:58] So this is where the narrative gets kind of interesting. So I lived in Pittsburgh. That's where I grew up. That's about a ten hour drive to Kentucky and Louisville. And I talked my mother into lending me her car, and I talked my best friend into driving with me. So we leave at around 6 p.m. thinking we'll drive all night. I would do the interview, drive back, no problem. We didn't have to stay at a hotel or nothing like that. So it was a great plan until around 5:00 in the morning when he fell asleep on the interstate just outside of Cincinnati, drove off the highway at 65 miles an hour. He wasn't injured. I was seriously injured. Internal injuries, other things. I was taken to a local suburban hospital outside of Cincinnati. My life was saved by a very diligent general surgeon. Had to go to the O.R. several times. I was septic. I had broken a lot of bones, too, but he'd done a wonderful, wonderful job. And even as a 20 year old, you know, it occurred to me, wow, this is fantastic. This guy's got this skill. He could keep people alive or keep them from dying. And it was just so practical to me. I thought, well, why don't I go back and learn this skill and I can do art on the side? This is the logic of a 20 year old, but it was compelling enough. It got me through rehab.
Dr. Jeremy Noble: [00:12:13] I had to... I had some pretty serious rehab for the rest of that year because the accident was early in the fall. I went back into Princeton. They did an amazing job. I told them I want to pursue the arts, but I also want to go to medical school. And they were very supportive of me crafting a set of courses I could take that allowed me. I became a chemistry major, had a fantastic time, wrote a thesis, had a remarkable mentor and chemistry at the same time, Dr. Tom Spiro, an incredibly imaginative, compelling guy, has become really the leading chemist for climate chemistry, interestingly. But he knew I wouldn't be a chemist. But he also was totally committed to me being whatever I needed to be, which I'll be always thankful for. And so I was able to also take classes from the amazing poet Galway Kinnell. And so I was also quite fortunate to get into the University of Pennsylvania medical school, where I continued what then became very diligent studies in medicine.
Dr. Jeremy Noble: [00:13:12] But I never lost my interest in the arts. And in fact, some of the poems I think are still my best work. I wrote while I was in medical school because of the intensity of that experience, you know? But I never thought that would be my career. And then now, ironically, 40 years later, my professional work intertwines creative arts creative expression as a functional interventional modality to change our brains, our minds, and our behaviors with what we need to be healthy and well.
Henry Bair: [00:13:47] That's a really fascinating story. So it sounds like, in a twist of fate, your decision to go to art school was thwarted even before you physically made it to the art school. Is that right?
Dr. Jeremy Noble: [00:13:58] That's exactly right. And I only sorry for subjecting you in the audience that very long story, but just to reinforce how little is really what we plan it to be. I mean, there's the old, old thing, you know, man proposes, God disposes. You know, it's like we imagine and it's good that we imagine we need to, but we also need to have a bit of a sense of humor about what really gets us down the road.
Henry Bair: [00:14:21] Yeah. Yeah. Amazing. So in terms of your your interest in the intersection of arts and medicine, is it more arts as therapy or is it more the value of the arts in helping clinicians think about health? Or is it the arts more generally in helping people live well, or is it all of them?
Dr. Jeremy Noble: [00:14:40] It's all of them. And what is really exciting is over the last 20 years, there's a much deeper evidentiary base for all of it. I got interested explicitly in the arts as a public health intervention after 9/11, when I saw the art work done by kids in the five boroughs as they were struggling with acute stress disorder and very simple creative expression exercises. Draw what's on your mind? Let's talk. Yeah, had incredible impact across race and class, meaning something was going on in the brain. I thought that was incredibly exciting. I decided, you know, it didn't wasn't really a fit for what I was doing on the traditional academic work with digital therapeutics and so on, although with with AI and generative AI, I think it may come back to digital creative making. Maybe we'll talk about that downstream. But it just really was early. And now, 20 years later, there's an incredible evidentiary base on how art interacts with neurophysiologic structures at the hormonal level, at the vasovagal level, at a whole range of humoral outputs, but also in the actual functional interaction of art as stimulus to certain regions in the brain that identify social cognition, the so-called social connection, that the arts literally change how we make sense of the social world around us.
Henry Bair: [00:16:09] Yeah. That's amazing. You ended up creating this Foundation for Art and Healing, which has been going on for over a decade. Right? What is this foundation and what is its mission?
Dr. Jeremy Noble: [00:16:18] Yeah, so almost 20 years. As I said, we started after 9/11, and when I first started, I said some of the most ignorant things in my life. I've said a lot of ignorant things, but this is right up there with the worst of them, which is "I'll start a non profit. How hard could this be?" Well, it turns out it's very hard to start a nonprofit, having done for a very practical reason, by the way, because I've started for profit initiatives in digital health and other things. And while they're always challenging, right, you have to have a good idea. You have to nurture it. You have to build teams. You have to demonstrate things. You have to do that in both for profit and nonprofit. It's very hard to capitalize non profits. It's very hard to get the full resources you need to build prototypes to demonstrate that something works. So you're out there trying to do it on a shoestring. Now we've been successful, we've gotten through it. We've demonstrated efficacy in the arts to make some significant improvements in key parameters for health and well being. But it took a struggle. Now, fortunately, now arts and the brain. Arts and health. Is getting the attention broadly. We're starting to see the emergence of much better capitalized entities, really pushing forward on how the arts are not just entertainment, not just a distraction, but fundamental to how we make sense of the world and also to how our brains function. And because of that, how our bodies function.
Henry Bair: [00:17:38] So what are the specific initiatives, research questions, projects that the Foundation engages in? When you talk about collecting enough capital, I suppose, to be able to implement your products, your solutions, your experiments, whatever you want to call it. Like, what exactly are you talking about?
Dr. Jeremy Noble: [00:17:54] So we've worked in various areas, right? So right after 9/11, our major focus was on trauma, using the arts to reduce trauma. And it turns out they're very effective. In retrospect, a lot of what we were doing then was the foreshadowing to what we're doing now, which is using the arts to address loneliness as a fundamental kind of emotional construct. It turns out there's quite a bit of loneliness associated with trauma. And so I think much of the positive results we were getting early on in our trauma programs, although we weren't aware and measuring it at the time, was the benefits of the arts in post traumatic stress to give people other ways they can feel connected to themselves and the world without being triggered into a fear response. But we eventually sorted it out that what we were doing was addressing loneliness, because the participants in our programs told us this was an incredible stroke of good fortune. I mean, anyone who's been in the discovery world understands they plan to discover certain things, hope to discover certain things, but certain times there's serendipity involved. And that's the way it was with with us and loneliness. We were running our programs for trauma, and recognizing trauma occurs in a lot of settings. This was in the trauma of having a significant chronic illness, in this case diabetes. If you were in a marginalized community, low income and a marginalized gender. So we ran this program with black, middle aged, low income women with diabetes and poor control A1c's over nine and in just six creative making and mindfulness sessions.
Dr. Jeremy Noble: [00:19:33] We increased mental health statistically. But in the testimonials, the women told us they felt less lonely, more connected, much more motivated to self care, measuring their blood sugars, this kind of thing, and exhibited those behaviors. We weren't expecting that result. It was fantastically interesting to us. And as a primary care physician, I knew that engagement with self care was critical to managing chronic illness, which is 70% of the illness burden in the country, 70% of the cost in the country. It starts with serious chronic illness, hypertension, diabetes, musculoskeletal disorders. If we could address those by increasing people's engagement and motivation and self care in collaboration with their care teams, this could be a game changer.
Dr. Jeremy Noble: [00:20:19] So we've started down that road. It's called Project UnLonely. We started at about ten years ago, but it formally got launched in 2016 with three goals. First, increase awareness of loneliness and its toxicities. This was before the pandemic. That's gotten a lot easier. Our Surgeon General, Vivek Murthy, has made it even easier with his advisory from HHS on loneliness that came out in May 2023. So awareness that loneliness won't just make you miserable, but it can kill you. That's the first goal, the second reduce the stigma around it. People still find it very difficult to say out loud the words I'm lonely. I often ask that by a show of hands who would find it difficult. I don't ask people who's lonely, just who would find it lonely. All who would find it difficult to say it. All the hands go up. So we work to normalize loneliness, using creative arts to tell stories of loneliness through short films. So people see, see loneliness represented in these beautiful, creative, artistic ways, in aging, in LGBT communities, in illness, in trauma. And then they can talk about it, and then suddenly they realize that loneliness is just a biological signal that there's something you need. Just like thirst is a signal, you need hydration. Why be ashamed of being lonely? We're not ashamed of being thirsty. And it turns out, as you probably know, it's a social construction in our culture. We shame people and we shame ourselves around loneliness. So that's why we focus on stigma. And then the third goal, which we are really very proud of, is we've built and tested a variety of programs that use creative arts as a modality and intrinsic modality in these, in programs that can be delivered in community based organizations, replicating the ones we tested in very simple models so it can scale quickly, you know, organizations. Like community centers, libraries, schools, faith based groups, health care, workplaces. So that's that's the model and that's Project UnLonely.
Henry Bair: [00:22:26] Great. So so we're going to go definitely into more detail about what exactly those initiatives look like on the ground. But you know, we've been using the word lonely a lot. And I guess it's easy to take it for granted that we all know what it feels like, because I think we kind of all intuitively know what it is, or at least what it feels like. But guess just just for clarity's sake, like what do you mean by loneliness, from your experiences, your personal experiences, from talking to patients, from doing all this community work? What exactly is loneliness?
Dr. Jeremy Noble: [00:22:53] It's really important, you know, it's what I call loneliness literacy. This is what we need to do more loneliness literacy. Because while everyone has, if you say, do you know what loneliness is? Everyone says yes. Just like they say yes if you know what love is or sadness is, right. Because it's very personal and we know we learn what it is. But even now there's still a lot of confusion about loneliness and being alone. So being alone, which is an objective state that there's no social contacts in your world, is different than being lonely, which is actually, by definition, for the last 40 years or so. The gap. This is the social psychology formal definition of loneliness by Peplau and others about 40 years ago, that it's the gap between the social connections we want to have. We imagine we aspire to and what we truly believe we do have. So it's totally it's 100% subjective, which means it's both a personal construction and a societal construction. The good news is it means it can be reconstructed, which is a big part of what the arts can do. But that's loneliness being alone. Isolation can be quite toxic. It can, and it does drive up risk for early mortality, for instance. But it could also be a source of of insight. It could be such a high class experience. We have a fancy word for it. We call it solitude.
Henry Bair: [00:24:15] And that could be a good thing. Right? That's not necessarily undesirable.
Dr. Jeremy Noble: [00:24:19] Absolutely. And just like and I think this is the complexity. I think everyone is lonely from time to time. I think it's the most human feeling, just like thirst, that we need human connection where it becomes problematic, Henry, is when it starts spiraling, because this is what our brains do. If you feel a little bit of loneliness and don't attend to it, it's uncomfortable. It's painful. Social scenarios are painful, so you withdraw and you become lonelier. So you try. But then if people don't welcome you, you have a bad experience. Then it reinforces your sense of self adequacy or that you're flawed. And then sometimes people get into distracting toxic behaviors, whether it's drinking or other kinds of distractions, and they become lonelier and lonelier. So this is something called spiraling. It's common in a lot of emotional disorders, but it's a serious problem in loneliness. So part of what we educate people are is to recognize the pyramid of vulnerability for loneliness. Bottom tier of the pyramid is everybody. We're all at risk for being lonely sometime. And in that tier we should educate ourselves about loneliness, pay attention to it. Learn to trust our intuition on how and when to connect to others and to ourselves to become resilient. That's the bottom tier.
Dr. Jeremy Noble: [00:25:36] Second tier is when usually because of some trigger or traumatic event, could be a loss of a loved one, it could be a new onset illness, it could be domestic violence, it can be meteorologic violence like your home is blown away. So then you go into that middle tier. That's the trickiest and most important tier. That's where if you intervene effectively, often with something as simple as peer to peer conversations that are led in ways that you can then feel more connected, you don't go to the top tier of serious disconnection. That's when people spiral to be much higher risk. For instance, American Heart Association, that's when they publish 30% risk of heart attack, stroke or death from either. This is where the correlation is of loneliness being as toxic as smoking 15 cigarets a day. That's all in that top tier. So you want to avoid that. As a public health and personal health strategy, you want to recognize early forms of loneliness as it begins to spiral for you, or your friends, or your kids or your neighbors, and do what you can through kindness, through connection. Again, at that middle tier, they're not in serious physiologic trouble yet to welcome them back to human connection by doing what you can.
Henry Bair: [00:26:54] Okay. Thanks for laying the tiers out for us. Now, I'd be curious to know, do you think that we have always as a society, loneliness has always been there, and it's only now that we're finally awakening to it. Or do you think we actually, as a society, we are getting lonelier?
Dr. Jeremy Noble: [00:27:10] I think loneliness has always been part of the human condition. Think about it from evolutionary biology. It's 20,000 years ago. You hear a rustling in the bushes and you want to. And you think it's a saber toothed tiger, and you want to defend yourself, and you go to pick up a stick. Don't you want to have ten people around you also picking up sticks? Of course you do. Right. So there's something in our brains that says if you want to survive, you better have access to other people who can help you in a pinch. I think that's evolutionary. So it's always been there, but I think it is growing in our society for a variety of reasons. Some of them are structural. More people are choosing to live alone. Some have to do with cultural phenomenology. People are choosing not to be part of faith based groups, which for quite a bit of time offered a kind of connection to people. I think the two cornerstones, as Freud put it, of our psyches, work and love, have become, for many people, vast gamified marketplaces where they're not sure where they stand or how to succeed. Online dating and so forth. But then also other online things like QAnon and other groups that offer a way to be part of a group, but often at a very high price, but then also the workplace with the gig economy.
Dr. Jeremy Noble: [00:28:31] But even in a traditional job, like in health care. You know, I don't practice anymore, but a lot of my friends are practitioners. And what used to be the convivial lunchtime and the kind of a clinician corner of, say, the hospital dining area, you know, they're eating a peanut butter jelly sandwich while they're finishing their their notes on epoch and feeling behind all the time. And so there are a variety of things, I think, making us lonelier. And to the extent there's a silver lining about the pandemic, I think two things happened. One is it gave everybody more of an experience, almost everybody of at least social isolation, if not loneliness, usually both, but also for a short window of time. It's made it okay to talk about loneliness because it's not loneliness, because I'm not attractive or people don't like my haircut, or I'm not smart enough to have a conversation with people. We were lonely because we were facing a common enemy, the virus. Right? And had the social isolation so we could talk about it because their loneliness was almost a courageous badge of heroic social collaboration. Right? Yes. I'm lonely, but I'm lonely because I'm doing what needs to be done, just like you.
Dr. Jeremy Noble: [00:29:47] And we connected around that. So I'm hoping we can learn from that. That it's okay to talk about loneliness even when you know it's not tied to such a commonly held cause. Because I think many of the causes for loneliness are commonly encountered. What I call the territories of loneliness. And I just published a book on this topic called "Project UNLonely: Healing Our Crisis of Disconnection". And in the book I point out five territories of social experience where loneliness is often encountered. And I call these the territories of loneliness. In the first one is trauma, which almost everyone experiences to certain degree, and I talk about adverse childhood events and other kind of military domestic meteorologic trauma scenarios, but also the micro traumas of racism and so on. So that's a territory. Aging is a significant territory. Illness, serious chronic illness, catastrophic illness, rare illnesses. They all separate and isolate people. I saw that as a primary care practitioner. I still see it in friends who are dealing with illness. The fourth is the world of difference of being of a different race gender, not conforming even to the conventional beauty myth. So people think you're funny looking, you know, lots of ways people, disabilities of all sorts. People get excluded systematically, which is a different kind of loneliness than psychological.
Dr. Jeremy Noble: [00:31:13] And then the fifth territory which we're all navigating is modernity. This is social media often being very isolating for people because it forces them or it invites them to create an artificial persona that's not who they truly are. That's all almost like a highlights reel of what they think other people would find admirable in them. The huge amounts of divisiveness in our culture and political world right now, everything from what's going on in the Middle East and people on different sides of deeply held beliefs, the red and blue political divisiveness, the wealth divide. I mean, we're divided, I think, increasingly and more toxically as a country than ever before. And so this is all modernity. These are the territories. What the book then tries to point out is the power of connecting to each other and to ourselves through narratives, shared stories, many of them that can be built through. Creative expression, whether it's a poem, a drawing, a play, a piece of ceramics, a collage. That's why I think while loneliness, I think is worse now than it's ever been in recorded history. Our awareness of it, of its toxicity and what to do about it is actually greater than ever in history. And I'm just encouraged by the mobilization of energy and attention in multiple sectors to addressing loneliness worldwide.
Tyler Johnson: [00:32:40] Yeah. You know, there was a wonderful book that was written. I mean, it's now probably 20 or 25 years old. That was called The American Paradox, which I think it was an apt title, although arguably too narrowly drawn, because I actually think it's a paradox for many places in the so-called Western developed world. But the thesis of the book was that we were entering a time of unparalleled material prosperity, and yet great metaphysical or spiritual or whatever you want to call it, emptiness, right? That there was there was almost a sort of a sickness. And I feel like a similar paradox obtains over the last, especially 15 years with the digital revolution and the onslaught of the internet age, in the sense that we have never been more quote unquote connected, and yet we have never been more alone. Right? I think Sherry Turkle's book Alone Together is an aptly titled work. Right, because it's so striking that we have all of these supposed connections through all different forms of social media and through all of these ways that we can, you know, I, I can have a sibling on a different continent and have a real time video conversation with them. And it doesn't even cost any money. I mean, you know, except for my normal whatever cell phone bill. And yet I agree with you that it really does strike me as a crisis of loneliness. And I think that that's one facet of a deeper and broader crisis of meaning. Right. It's like we've never known. We have never been able to run as fast, so to speak, as we can now. We've never been able to do as much, achieve as much as we can now. And yet there is this great sort of echoing hollowness at the center of everything, where a sense of shared meaning used to be.
Dr. Jeremy Noble: [00:34:19] I totally agree. And and it was my curiosity about that paradox that had me respond to the research signal we were getting in our group work. And I teach in Boston. I know Sherry and I've been reading her work and I thought, wow, she's really on to something. How can we be so connected in a kind of technical sense worldwide for nothing, for pennies, right? You can be on WhatsApp and I can have a video with my sister on the other side of the world, or with a complete stranger on the other side of the world. And yet, despite 6,000 people following us on Instagram, who brings you lunch tomorrow if you're sick? Yeah, and the answer is you have no confidence anyone will. So this got me involved in loneliness, which has been a great adventure. And one thing I found you might find this particularly interesting is there are different types of loneliness, just like there are different types of love, right? There's love of family, romantic love, patriotic love. So in loneliness, it's, first of all psychological loneliness. Do I have a friend, a confidant? The second is societal loneliness. Am I being systematically excluded because of race or color or disability? And the third is a kind of existential or spiritual loneliness. Does my life have meaning and purpose? What was on the planet before I arrived? What will be on this planet when I depart? How do I make sure my life has consequence? How do I have an identity that I care about? And I think there's tremendous despair if you don't have the answers to those questions.
Tyler Johnson: [00:35:51] Yeah, there are so many things in life, right, that you and I should know this probably as a cancer doctor, but so many things that you can't appreciate until they're taken away. And I felt like that was poignantly and devastatingly true in terms of the need for community in the setting of the pandemic. Right. Like, I remember when the vaccines finally became available and we felt like we were allowed to sort of start approaching other people who weren't in our household again, running into a friend in the elevator of the hospital. This was about a year into the pandemic, and we live in Northern California, so the pandemic was taken very seriously here, right? We were virtually on quarantine. And I just remember we had little stickers on our badges if we had been vaccinated. Right. And so I looked at her and saw her sticker, and she looked at me and saw my sticker, and we just embraced in the elevator. But this was like the first time in a year that I felt like I had had a direct, personal, face to face connection with a person who was not in my own household. Right. And as a person who's enmeshed in a lot of very sort of thick, meaningful communities, right? Social communities, work communities, religious communities, everything else, it was so devastating to have those communities completely stripped away. And that one moment of embracing in the elevator was just, for me, summed up so much of what connection means and why it matters and how it enriches our lives.
Dr. Jeremy Noble: [00:37:16] Yeah. Well said. And then now it's the old country western line. You don't miss the water till the well runs dry, you know. But now that we have some sense of it, how do we make it more available to everyone? And that's where I admire the work that Vivek Murthy, our Surgeon General, is doing to create visibility on this. And in the wonderful report, I think. He identifies six pillars you know, smarter use of technology, better, better research, all these wonderful things. But the sixth pillar is the one that I think offers the most promise, which is to build a culture of connection, to actually talk about loneliness, but then also build opportunities, particularly for marginalized people. I mean, the loneliest demographic is an adult demographic is 18 to 28 right now. Suicide is now the second leading cause of death in ages 10 to 35. I mean, it's expanded, and I know that while loneliness isn't the only cause of suicidality, it may be the most preventable one.
Tyler Johnson: [00:38:20] You know, it's been really striking to me. Right. So Robert Putnam, now probably 30 years ago, wrote Bowling Alone, which is a book that was sort of the canary in the coal mine, about sort of the harbinger of this problem. Right? That people we have become a very anti institutionalist country. Right. We don't like belonging to things in the way that we used to. Right? 100 years ago. People belonged to the Rotary Club. They belonged to their church. They belonged to the lions and the masons and the, you know whatever. And now many of us belong to nothing and are very quick. As soon as we feel friction with an organization to disassociate from the organization. I cite that only to say, given those broader demographic trends, and also given the steep decline in trust of other people and of institutions in the United States, how do we cultivate a culture of connection? Because that seems like a really tall order, like it seems like a nice thing to say and write in a book, but like, how do we actually do that?
Dr. Jeremy Noble: [00:39:19] Great question. It's the central question, I think, right now in public health, because, you know, one of the central questions in public health, because if you look at the social determinants of health, food insecurity, housing insecurity, and of course, isolation is often viewed as one of those many of those are all other ways of saying that poverty is the biggest social determinant of health. And I think, you know, in our culture, we're not comfortable saying that out loud, but it's still the truth. And one of the challenges is to address all those other social determinants of health. We need to have significant wealth redistribution, which, if it's ever going to happen in our society, is going to happen slowly. However, social isolation and addressing loneliness is the only social determinant of health that does not require massive wealth transfer. But it does require the thoughtful redesign and reengineering of civic infrastructure, which we can do because many of the civic organizations actually want to be better engaged, faith based groups, for sure. Community center groups, for sure, but then also libraries, museums, schools. And I actually I think health care, which has been kind of quite siloed in many cities and so on, you know, the traditional health care delivery systems, you know, almost their moats around them in many places, even, they are saying, oh, no, we want to be we want to be interactive with the community based organizations. Social prescribing obviously in its infancy, but a structure, I think we can make meaningful inroads into loneliness and social isolation. But it has to be a kind of a declared, not an accidental wandering towards it, but declared. And what I've chosen to focus on is the importance of human connection through creative expression, storytelling, the arts. Because I think it's incredibly powerful for a lot of reasons, both at the individual and the group level, and people enjoy it. It's fun. And it's been it's probably been what's holding culture together since the beginning of culture.
Henry Bair: [00:41:24] So now that you've shared with us, like the big picture changes we need to make in your mind, like ideally in concrete terms, what should public health agencies do? What should hospitals do to better prepare our society to reckon with this problem of loneliness?
Dr. Jeremy Noble: [00:41:42] I think every I talk about kind of nodes or community based organizations, they have different roles to play and can do it in different ways. I actually just came back from the Milken Institute Future of Health conference, and there was a lot of understandable dismay about the health systems. Many of them are in very difficult financial straits. Fortunately, some of the biggest ones have developed large balance sheets because there were some better years for health systems, so they have some basis of going forward. But I think while health systems have a role to play to address loneliness, I think the biggest role is acknowledging its importance, educating our patients about loneliness and its toxicities, encouraging them to be more interactive, and so on. I think where loneliness really happens is out in the community, in our homes. I mean, you've heard you've heard this language before. You know, where we live, love, work, play, learn. That's where we socially connect to. I think the health system has an enormous role as a mentor, guide, prescriber of things in the community. I think that can be their role as well as do the research, to look at the relationship between high levels of social isolation and loneliness and accelerating use of health care resources, because if you can show, as has been done in some studies, that significant difference in cost in lonely versus non lonely populations, you know, just one study AARP did it thousand hundred dollars difference in annual cost in lonely versus non lonely Medicare beneficiaries.
Dr. Jeremy Noble: [00:43:20] All kinds of challenges in the methodology. I'm not saying we know everything we need to know about it yet. So when health systems I'm also talking about health system driven research. Collaborative research because we have a society that would value the science and find that motivating. Certainly the health economics of addressing loneliness could be compelling to health system leaders, certainly to others who are at risk for delivering health care to populations, whether it's an at risk Medicare Advantage plan or some other at risk model. So I'm not saying health systems don't have a role, but I don't think they can own the answer. I think community and what is community that's like multifactorial, too, has enormous opportunity and ways to benefit by being more focused on connecting to the communities they serve.
Tyler Johnson: [00:44:11] I just feel like this is really essential to point out, because many of our listeners, from what we gather, are medical students or medical trainees, residents, fellows, that kind of thing. And I think it is just important, as you were saying, it's important to surface the crisis of loneliness in general. I think it's also important to recognize that medical training, which can often last a decade or more, is almost by definition, an atomizing experience, right? You may feel very deeply alone, and I think it's just important to point out to medical trainees that seeking a sense of connection and trying to foster a sense of community, even if it's just within your class of residents or fellows or whatever it is that is deeply, deeply important. It's not like a little peripheral side thing that you do. If you have time. It is absolutely vital to maintaining your mental and physical health, and to making the rigor of training something that you can get through with your sanity and health intact.
Dr. Jeremy Noble: [00:45:04] I totally agree. I you know, when I went through medical residency, I experienced devastating levels of loneliness. I'm actually surprised. I'm surprised I made it through. I mean, it was really awful. And we most of us did make it through, but not Unscarred. Yeah, it was a traumatizing experience. I got through it in part by writing poetry. I found that very helpful. I still write and I and I have some poems from those days. There's one of them that's actually ended up in anthologies. It's called Pain Workup, and I didn't realize it at the time. I thought I was writing about the pain my patients were having. I was writing about my own pain. So we can we can do better. We owe we owe that to the trainees. In medicine, it.
Tyler Johnson: [00:45:45] Is its own unrecognized form of trauma. The isolation and deep psychological pain of training can be very difficult.
Henry Bair: [00:45:52] I want to say that I'm seeing more and more efforts trying to address this just through reflective practice sessions, through storytelling in medicine sessions, which it seems to me more and more medical schools are recognizing how important it is to prepare students ahead of time for this loneliness by getting them interested and engaging in creative pursuits. To your point earlier. Yeah, absolutely.
Dr. Jeremy Noble: [00:46:15] So we've formalized some of that. We have the Arts and Humanities Initiative at Harvard Medical School. I know Stanford has initiatives very similar and it's multi threaded. You know, it's about storytelling. It's about techniques. How you could you could be better in touch with yourself and others as you're going through this inevitably demanding experience about kind of being with other people in these incredibly emotional times of their life, times of great need. We're. You're struggling with your own capabilities and adequacy to address those needs. Maybe the experience has some essentially challenging elements, just like. Life has necessary challenges to it so you can grow and learn what you need to learn. But I think there's more we can do to support each other going through it. And I think it is being recognized, which is terrific. I know it's being continually talked, talked about in my medical school and I suspect more broadly, and I think that's very timely. The other benefit of humanizing the medical training experience is it reduces the trauma that then often holds clinicians back from connecting with patients in ways that could be helpful to the patients.
Henry Bair: [00:47:28] Well, on that optimistic note, thank you so much, Jeremy, for taking the time to share your insights, your personal stories, and all the important work that you've been doing through your foundation and through this project. So honestly, this is this couldn't have been a more important time for us to be talking about this. So again, yeah, thank you for all your work.
Dr. Jeremy Noble: [00:47:47] Thank you for the work you both are doing to bring these podcasts out to people. We can have conversations that are vital, essential and lead to even more conversation. So I'm very grateful.
Tyler Johnson: [00:47:58] We really appreciate your work and your time. Thank you so much.
Henry Bair: [00:48:05] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:48:24] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:48:38] I'm Henry Bair
Tyler Johnson: [00:48:39] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.