Like us all, I have questions.
But first, I am not an immunology or epidemiology expert, or a public policymaker for that matter. I appreciate the efforts all of those who are the above. I respect them deeply. I don’t want to go on a rant. What I do want to do is get us all thinking more broadly in this crisis. Because we are creating another crisis.
My area of expertise is physical therapy. With a doctorate, I have worked hard to acquire a comprehensive understanding of the musculoskeletal, neurological, and cardiopulmonary systems’ effect on movement and function, as well as mental and physical well-being. I have worked with all age groups, from pediatrics to geriatrics over my 30-year career. Many of them have been what we categorize as At-Risk. The CDC names those at high risk as being 65 years or older, people living in a skilled nursing or long-term care facility, and all individuals with underlying medical conditions, particularly if these conditions are not controlled. Those underlying health conditions pertain to disorders of any of your primary systems. Interestingly, the medical community also acknowledges ethnicity and social isolation as at-risk factors. Latino and African-Americans are more at risk. And now, we are beginning to create a new crisis with our social isolation measures.
Question 1 is do we understand the lethal implications of our Social Isolation measures?
Social isolation has tremendous health consequences. First, it leads to loneliness, which opens the gate. Then significant functional decline follows, leading to death. (1) The reduction of social interaction is a known killer particularly for men. (2), (3). Interesting that we are also seeing that more men are dying from COVID than women. If anything, we probably don’t want too much isolation inflicted on them.
For the At-Risk group, particularly seniors, isolation has known deadly implications on health. Isolation either enhances underlying comorbidities and hastens death, or it leads to comorbidities for those who were previously healthy. And once sick with these comorbidities at an advanced age, it is difficult to recover. The subsequently prescribed medications, which beget adverse reactions, lead to more medications, which reduce the effectiveness of a previously robust immune system.
The social distancing rules that are in place sound nice and helpful. For many of us who are mostly healthy, able to zoom with our family, friends, and co-workers, get outside with proper social distancing practices, this is true. But for those who are at risk, who aren’t as tech-savvy, who aren’t able to get around as much, or who are being forbidden to have any visitors even at the prescribed six-foot social distance as is found in hundreds of facilities across the United States, the prolonged measures are isolating. Isolation, pure and simple, is incarceration. Whether it is imposed by others or inflicted on ourselves, prisons are places where we can’t find our way out, and no one can get in to help us.
Unsolicited isolation is detrimental to the psyche. Essentially, this is imprisonment. When we are not allowed to conduct normal social interactions because the management says so, that dramatically changes the relationship between the individuals. Power and dominance are given to management, for example, stripping the residents of any say in the matter. The induced sense of helplessness further negatively impacts mental health and consequently impacts physical health.
This leads me to my next question.
Question 2 is how can we address this in a more holistic way? Or put another way: how can we achieve our goal of protecting those at-risk without having to say at the end of their miserable lives, “Well at least you didn’t die from COVID”?
Actually, it is more of a plea. We need to address this NOW.
Let me give you a real-life example or two. My friend’s 80-year-old mother was happily living in an independent living facility. Not one to exercise, she did enjoy her walks with her friends and meeting up with them for meals and the other organized activities. She was thriving, independent, albeit perhaps skirting the edges of dementia as a residual from a stroke she had recovered from several years prior. But she was relatively healthy and happy.
Until COVID came knocking. Isolated to her room, with no one checking on her physically, she remained in her recliner for days on end. Poor hydration and no exercise, lying in soiled clothing for days, she landed in the hospital with a urinary tract infection, exhibiting severe dementia, and unable to walk. And of course, my friend is not being allowed to visit her mother in the hospital.
Or, there’s my dear friend who is a kick in the pants 80-year-old (or so) lady. She described the past 8 weeks of her life at her senior retirement home. This is not a skilled nursing facility. She and her “inmates” are strongly encouraged to “volunteer their isolation” which looks like the following. They are allowed outside of their apartments for 1 hour every day, but not all together. She has the 1–2 PM shift, and so doesn’t get to see her friends. All meals are in her room. She is not allowed to do her laundry, but the personnel does it for her. She is not allowed to have any visitors unless it is essential. Since she is independent, she has no “essential needs,” so she has no visitors. Her form of exercise is walking her 15 ft balcony back and forth in the fresh air.
Any visitors like myself who wish to bring her flowers or any little gift, must ring the bell of the facility and leave it at the door of the facility. Someone picks it up and takes it to her. If anyone of them has an “essential appointment” out in the community, when they return, they are required to be quarantined for 2 more weeks.
One resident contracted COVID and died on April 2. Since then, they have been negative for COVID cases. But they are still not allowed to socialize with each other. They are not allowed out of their apartments. This after nine weeks.
Does this sound like a good quality of life? Her answer? “Let our immune systems do what they are supposed to do. If we die, then it’s our time to die. We’ve lived full lives.” Evidently, that is becoming the consensus in her circle.
From a practical health aspect as a physical therapist, I and many of my colleagues are particularly concerned with this prolonged approach of trying to safeguard our seniors. We predict it will have the opposite effect.
Humans are not designed for prolonged isolation and activity reduction, and these attempts of “protection” will have significant unintended negative fallout. This fallout could be potentially worse than the chance of them dying from COVID.
As a colleague pointed out, “ The consequences of inactivity for the elderly are increases in falls, pneumonia, and a myriad of other complications that can be life-ending.” Increases in falls mean painful fractures of hips, pelvis, and spine, which most likely will incur hospitalizations, potential surgeries, long exposure to anesthesia, which also further induces the onset of dementia and a further significant reduction in mobility.
We know that two weeks of a sedentary lifestyle (walking less than 2.2 miles) significantly increases insulin and blood glucose levels, hypertension, cardiometabolic disorders, and weight gain. (4) Can you imagine what eight weeks with the added insult of social isolation does? It will take three months of a concerted exercise program for them to return to previous levels. Even then, the weight gain they acquired most likely will remain.
In light of the above, I believe the unrest you are hearing among many of the isolated, is a result of a perception of the reduction in their mental and physical health. Depression and anxiety can’t help but begin to take a foothold.
We must develop a broader perspective of health and well-being, and begin addressing this aspect of their overall health, not simply protecting them from a virus. Otherwise, they will become more unstable and less able to fight a virus. That defeats the purpose of protecting them. What if our attempts to protect them were actually creating more deaths, rather than preventing them?
Another at-risk group to consider is our teens. I know, I know. They are healthy. But mentally, they are a fragile lot. Much of their identity is tied up in their friendships and activities. All of which have been banned. What happens to them if their mental health takes a dive?
A friend of mine who is a high school teacher told me today that many of his bright and shining students are severely depressed. They don’t see the point of studying. “What does the future have for me? Why bother?” They are giving up. I predict suicide rates will be increasing.
Social distancing will need to be continued, but social isolation must be eradicated. It is deadly and we must transition from this into a healthier approach as soon as possible. Perhaps this means we will be better about aggressive sanitation in all facilities. Perhaps we will be screening visitors better. Perhaps we’ll all be wearing some sort of PPE. There are solutions out there if we begin the difficult dialogue now. Surely we can do better for our vulnerable populations. If we truly care, then we must introduce more reasonable social contact for them.
1. Perissinotto CM, Cenzer IS, and Covisnky KE. Loneliness in older persons: A predictor of functional decline and death. Arch Intern Med 2012; 172;14:1078–1083
2. Kawachi I, Colditz GA, Rimm EB, Giovannucci E, Stampfer MJ, and Willett WC. A prospective study of social networks in relation to total and cardiovascular disease in men in the USA. J Epidemiology and Community Health 1996; 50:245–51
3. Eng PM, Rimm EB, Fitzmaurice G, Kawachi I. Social ties and changes in social ties in relation to subsequent total and cause-specific mortality and coronary heart disease incidence in men. Am J Epidemiology 2002; 155:8:700–709