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The Milbank Memorial Fund is an endowed operating foundation that aims to improve population health by connecting leaders and decision makers with the best available evidence and experience. It does this work by:
The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
November 16, 2020
The Health of Aging Populations Social Determinants of Health COVID-19
Carrie Henning-Smith Read Bio
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The COVID-19 pandemic has exacerbated risks for isolation and loneliness, especially for older adults who face heightened risks from the virus and who are more likely to live alone. Loneliness and social isolation were already widespread and are associated with poorer health and greater mortality risk. Isolation and loneliness are also associated with preventable health care expenditures, costing Medicare alone an estimated $6.7 billion annually.
To date, most efforts to counter isolation and loneliness for older adults have centered on bolstering interpersonal interactions (e.g., “social prescribing,” friendly visitors, phone calls). Many interventions also focus on increasing screening for loneliness and isolation in clinical encounters — ideally coupled with referrals to programs designed to boost social connections one person at a time. Such interpersonal interactions are essential to countering loneliness and isolation. But, they are not enough.
Truly preventing and addressing social isolation and loneliness among older adults requires broader changes in policy and society, above and beyond interpersonal interventions. There is also a need to address the equity issues that place some older adults at greater risk than others, including those related to geography, structural racism, functional ability, and socioeconomic status.
First, ensure accessibility and inclusivity in the built environment. For example, federal, state, and municipal government — as well as private institutions — can require that universal design principles be incorporated into buildings to allow for inclusive environments. Universal design refers to the process of making spaces accessible and inviting to “all people who wish to use it,” regardless of physical ability or age. Connectedness can also be improved by focusing on sidewalks, curb cuts, crosswalks, and shared outdoor spaces. For older adults with changing health or functional limitations, such efforts are essential to ensuring that they can fully participate in community life.
Second, expand transportation infrastructure, allowing older adults better access to connect with one another in person. In urban areas, this may involve addressing the affordability, accessibility, and acceptability of public transportation. In rural areas, more creativity may be needed to overcome persistent transportation challenges, but examples abound of successful models, including rural public transportation, volunteer drivers, and shared community resources to connect individuals with one another.
Third, policies should ensure that everyone has access to a livable income and time away from work. This is important for the millions of older adults still in the workforce, as well as for building community more generally. Too few people have access to paid sick time and paid leave, parental, caregiving, medical, vacation, and otherwise. Further, poverty is linked to social isolation and job losses from COVID-19 will only make things worse. Altogether, in the United States, work (and the pursuit of work) plays an outsized role, often leaving too little time or too few resources to tend to other aspects of life. For older adults, these issues may impact their own employment and economic security, as well as the availability of friends, family, and loved ones to spend time together.
Fourth, serious investment should be made in places where people of all ages can come together. During the COVID-19 pandemic, this includes addressing the digital divide, expanding access to broadband Internet, cellular connectivity, and technological devices to ensure equitable access to virtual gathering spaces. Post-pandemic, this should include expanding funding, programming, and staff for social infrastructure and shared gathering spaces, including libraries, parks, community centers, and public schools. Places that are safe, welcoming, accessible, and freely open to all community members are indispensable to any effort to address loneliness and isolation and are instrumental in creating safe gathering spaces for older adults and for intergenerational interactions.
Finally, truly addressing social isolation and loneliness among older adults requires urgent action on some of our most pernicious challenges, namely structural racism and climate change. Structural racism has historically and continues to divide us; from neighborhood segregation and opportunities for education and employment to the ways in which we encounter and interact with one another. Both structural and interpersonal racism create barriers to social connectedness. The long and shameful history of racist policies in the United States, including redlining and disinvestment in communities of color has perpetuated health inequities and isolated Black, Indigenous, and other people of color economically, physically, and socially. Truly preventing isolation and loneliness requires dismantling systems of white supremacy, including inequitable access to housing, education, and economic opportunities, ensuring that all people are able to have safe, meaningful engagement with their immediate and broader communities.
Similarly, as more places experience natural disasters or become inhabitable, the emotional and social needs of climate refugees, people fleeing their homes and communities in search of safer ground, will become more pressing. Such social upheaval has the potential to exacerbate rates of isolation and loneliness among people of all ages. Further, older adults who are isolated already are among the most likely to suffer the health consequences — including mortality — of increasingly common natural disasters. Increasing connection and slowing climate change would both reduce preventable death.
Addressing social isolation and loneliness among older adults will be neither inexpensive nor easy. However, there are already enormous costs — financially and societally — to the status quo. Emerging from the COVID-19 pandemic presents an opportunity to reimagine the structures that guide social interactions for older adults and people of all ages, and public health should be a leader in this work.
Nov 16, 2020
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