PDF Summary:Together, by Vivek H. Murthy

In an age where digital connection has never been easier, an invisible epidemic of isolation threatens our well-being. In Together, former US Surgeon General Vivek Murthy reveals that loneliness is a public health crisis with consequences as deadly as smoking 15 cigarettes daily. Through research and personal narratives, he demonstrates how our evolutionary need for connection shapes our biology and society, and he offers practical solutions for rebuilding meaningful relationships.

In this guide, we'll explore Murthy's framework for understanding the loneliness epidemic, from its definition and prevalence to its biological foundations and health consequences. We'll also discuss Murthy's multi-level strategies for fostering deeper connections in your life and community. Throughout this guide, we'll supplement Murthy's analysis with commentary exploring neuroplasticity research on social brain development, cultural differences in experiencing loneliness, and innovative models for combating the loneliness epidemic. We'll also incorporate insights from experts in other fields including anthropologist Robin Dunbar, Jan Gehl (Cities for People), and Robert Putnam (Bowling Alone).

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On the flip side, our brains process social rejection in the same areas that register physical pain. When we feel lonely or excluded, our bodies produce stress hormones and inflammatory responses similar to those triggered by physical threats. This shared neural circuitry creates a powerful drive to reconnect with others, as our biology treats social isolation as a danger to our survival—a mechanism that evolved to protect us by ensuring we maintain the connections necessary for safety and well-being.

(Shortform note: The shared neural circuitry between physical and social pain opens opportunities for treating disconnection with established pain management approaches. Research shows acetaminophen alleviates the brain’s response to social rejection, suggesting that treatments developed for physical pain could help address social suffering.)

Part 3: The Consequences of Loneliness

Our evolutionary hardwiring for connection explains why lacking meaningful relationships profoundly affects our well-being. Murthy explains that when we’re socially disconnected, our bodies and minds respond as though facing a survival threat. (Shortform note: While loneliness may no longer pose the same physical threat it did to early humans, it continues to be a survival threat—social isolation increases the risk of premature death by 29%.)

In this section, we'll examine both the immediate neurobiological effects of disconnection and the long-term consequences of chronic loneliness on physical health, mental well-being, and broader social structures.

The Physiological Response to Loneliness

Loneliness leads to harmful physical changes: Your brain interprets prolonged social isolation as a threat, which triggers the release of cortisol and other stress hormones. These stress hormones are bad for your health in a number of ways—for example, they suppress immune function, increase inflammation, and raise blood pressure.

(Shortform note: Studies show that mindfulness-based stress reduction programs help relieve the physical health effects of loneliness. This may be because mindfulness calms the body’s stress response, helping your brain learn to not respond so severely to loneliness. Mindfulness also encourages self-awareness without judgment, which helps you perceive moments of loneliness more neutrally, further dampening your body’s response to lonely feelings. Furthermore, as psychologist David Richo argues in How to Be an Adult in Relationships, mindfulness promotes relationship health, which may help break the cycles of disconnection that cause loneliness and related physical health outcomes in the first place.)

The Long-Term Health Impacts of Loneliness

According to Murthy, loneliness strongly predicts poor health outcomes and earlier death. Studies show that lonely people experience worse sleep, faster cognitive decline, and reduced stress resilience. Research suggests chronic loneliness is as harmful as smoking 15 cigarettes daily—more dangerous than obesity, alcoholism, or physical inactivity. People who are chronically lonely face a 26-32% higher risk of dying early compared to those with strong social connections, even when accounting for other health factors.

(Shortform note: While many countries have established public health campaigns against smoking, loneliness remains largely unaddressed despite carrying similar mortality risks. Anti-smoking campaigns have dramatically reduced smoking rates through public awareness, policy changes, and support programs. A similar campaign for loneliness could be equally effective. The UK has pioneered this approach with its Ministry of Loneliness, established in 2018. This government body funds community spaces, outreach programs, and education initiatives to reduce stigma around loneliness, demonstrating how addressing social disconnection can be elevated from individual concern to systematic public health strategy.)

Loneliness also worsens or causes many mental health problems, with studies linking chronic loneliness to higher rates of depression, anxiety, and suicidal thoughts. The relationship works both ways—loneliness can trigger mental health issues, while mental health conditions can further isolate people, creating a harmful cycle.

(Shortform note: The bidirectional relationship between loneliness and poor mental health makes recovery more difficult for those with mental health conditions. Depression diminishes the ability to enjoy social connections, while anxiety heightens fear of rejection, both leading to withdrawal. These internal barriers combine with external factors like mental health stigma and limited treatment access to deepen isolation. The result is a self-reinforcing cycle where loneliness and mental health problems continuously intensify each other, making intervention essential to break this pattern and restore health.)

The Impacts of Loneliness on Social Structures

Murthy says that the collective economic burden of loneliness extends far beyond personal suffering, creating substantial costs for health care systems and workplaces. Research shows that people who are lonely stay 64% longer at hospitals, visit the emergency room 29% more often, and are more likely to be placed in nursing homes when compared to more socially connected peers with similar health conditions. In the workplace, chronic loneliness manifests through higher absenteeism, decreased engagement and productivity, increased disability claims, and earlier retirement.

(Shortform note: Economic arguments have shifted loneliness from a “soft” issue to a policy priority. Loneliness costs Medicare $6.7 billion annually, and the costs of loneliness in the workplace exceed $154 billion. These figures help policymakers secure funding for community-building programs, which show strong returns on investment by reducing healthcare use and improving employee engagement and retention. However, the economic benefits of loneliness interventions are only one piece of the puzzle. While cost savings may influence policy decisions, the emotional and social value of belonging is just as important—even if it's harder to measure.)

Part 4: Strategies for Reconnection

According to Murthy, the mental and physical health consequences of chronic loneliness, coupled with its economic implications, make loneliness a public health crisis that requires multiple levels of intervention—from the personal to the institutional. In this section, we’ll discuss strategies to address the crisis of chronic loneliness.

Individual Strategies

To break through loneliness, you need strong connections with others and yourself. Let’s explore some of Murthy’s strategies for building authentic relationships—moving from internal awareness to community engagement.

Get to Know Yourself and Practice Self-Compassion

According to Murthy, understanding yourself helps you connect with others. He recommends asking yourself questions about your values and interests, considering what causes you stress, and reflecting on how you respond to challenges. He also suggests examining where you fall on the introversion-extroversion spectrum to better understand your social interaction preferences. Murthy believes that recognizing these preferences allows you to meet your needs as you maintain meaningful connections with others.

(Shortform note: There are several tools that can facilitate the self-reflection Murthy recommends. One tool is the Big Five personality assessment, which measures five dimensions of personality: Extraversion (energy from social interaction), Agreeableness (concern for social harmony), Conscientiousness (organization and reliability), Neuroticism (emotional stability), and Openness (curiosity). This assessment places people on continuous scales for each trait, acknowledging that most people fall somewhere in between extremes. For example, someone scoring moderately on extraversion might need both social engagement and solitude.)

Murthy argues that as you get to know yourself better, you also need to be gentle with yourself because self-criticism can undermine your confidence and ability to connect with others. He offers metta meditation (or loving-kindness meditation) as a strategy to develop self-compassion. Murthy suggests that by treating yourself with the same kindness you would offer a friend, you practice the empathy necessary for developing and sustaining meaningful connections.

(Shortform note: To practice loving-kindness meditation, sit quietly focusing on your breath, then direct positive phrases toward yourself: "May I be happy. May I be healthy. May I be safe." Gradually extend these wishes to loved ones, acquaintances, difficult relationships, and all beings. As you say these words, try to genuinely feel the intention behind them—this makes your practice more impactful. Also, practice regularly—research suggests that brief daily practice (even 10 minutes) can significantly reduce habits of self-criticism and improve overall well-being.)

Make Time for Solitude and Experience Awe

According to Murthy, self-knowledge and self-compassion require moments of solitude, which can be as simple as a walk, brief meditation, or quiet time before bed. This intentional alone time allows you to process thoughts and emotions without distraction. Murthy also encourages finding opportunities to experience awe, citing psychologist Dacher Keltner's research. In Awe, Keltner explains how feeling awe when we encounter magnificent works of art, nature, or communal experiences shifts our focus from self-interest to our place within something larger. Both practices enhance your capacity for connection: Solitude helps you understand yourself better, while awe reminds you of your shared humanity with others.

(Shortform note: These complementary practices address different aspects of loneliness. Solitude helps counter what researchers call "internal loneliness"—the disconnection from oneself that manifests in low self-esteem and often precedes social isolation. Meanwhile, awe combats "existential loneliness" by giving you the sense that you belong to something larger and more meaningful than any single human can be. In other words, as Keltner explains, awe diminishes the self so you can key into greater unity—and this happens not only on a cognitive-emotional level, but also on a neurobiological level)

Prioritize Quality Over Quantity

Research shows that when it comes to personal relationships, quality matters more than quantity. Murthy recommends strengthening your inner circle (which usually consists of 5-15 people) through regular face-to-face interactions, vulnerability, and physical activities that release bonding hormones. While these close relationships require the most time, they provide the strongest protection against intimate loneliness.

How Many Meaningful Connections Can You Realistically Have?

Anthropologist Robin Dunbar's research on friendship patterns provides evolutionary context for Murthy's emphasis on relationship quality over quantity. According to Dunbar, humans naturally organize social connections in concentric circles: 1-2 special friends, 5 intimate friends, 15 best friends, and beyond. We allocate two-thirds of our social energy to just 15 people—40% to our closest five and 20% to the next 10. Dunbar argues that we do this because our brains have a limited capacity for managing social relationships, both cognitively and emotionally. This means we’re wired to invest deeply in a small number of meaningful connections rather than spreading ourselves thin.

While technology expands our superficial connections, Dunbar argues our cognitive architecture still limits us to 150 meaningful relationships regardless of social media. By prioritizing face-to-face interactions with our closest connections as Murthy suggests, we're optimizing our limited social resources according to patterns established through human evolution.

While you may focus first on your inner circle, don't neglect your middle circle (casual friends) and outer circle (acquaintances). Murthy says you can strengthen these connections by joining groups centered around shared interests like singing, dancing, or team sports, which create social bonds. In your workplace and community, practice kindness in brief interactions to foster belonging and prevent collective loneliness, whether by greeting neighbors by name or engaging with service workers. Throughout all these relationships, remember personal details, show genuine interest, and participate in the give-and-take of help and support to build reciprocity and trust.

(Shortform note: Why are casual friendships and acquaintances important? According to sociologist Mark Granovetter, they offer unique advantages that close relationships often don’t. His “strength of weak ties” theory shows that loose connections—like coworkers, neighbors, or distant friends—can provide access to new information, job opportunities, and diverse perspectives, making them a valuable part of a healthy social network.)

Build Routines That Build Connections

According to Murthy, establishing a routine can help you keep your relationships intact when life gets hectic—so you don’t regress into loneliness just because you’re busy. He recommends technology-free family meals, scheduled check-ins with distant loved ones, and community groups with consistent meetings. These consistent connection points provide stability during difficult times and build the trust that makes asking for support feel natural rather than burdensome.

(Shortform note: Murthy's recommendation for structured relationship routines directly addresses what the Berkeley Economic Review identifies as the fundamental challenge of our era: In an "attention economy" that constantly competes for our focus, our mental resources are truly scarce. This makes it difficult to prioritize relationships, especially during busy or stressful periods. By building regular, intentional moments of connection—like tech-free meals or scheduled check-ins—Murthy offers a way to protect our most important relationships from being pushed aside by everyday demands.)

Community-Based Strategies

While personal relationships are one part of our social health, Murthy emphasizes that broader community connections play an equally vital role in combating loneliness. Now, we’ll outline strategies to weave stronger social fabrics that benefit both individuals and broader communities.

Gather in Community Spaces and Honor Traditions

Murthy encourages people to frequent what sociologist Ray Oldenburg calls “third places”—locations outside home and work where people gather informally, like cafes, libraries, and parks. These venues provide neutral ground for casual interactions that are often the starting point for closer relationships. (Shortform note: According to Oldenburg, third places foster community through accessibility, neutrality, and minimal social requirements. They succeed when they offer comfortable, conversation-oriented seating, neighborhood accessibility, and welcoming atmospheres without pressure to purchase or linger. The best third places have distinctive character while maintaining easy visibility and entry from public spaces.)

Additionally, Murthy highlights the importance of cultural celebrations, seasonal events, and community traditions. These gatherings typically bring together multiple generations, feature shared activities like music and meals, and create opportunities to form shared memories and stories that shape a community's identity. (Shortform note: Cultural celebrations and community traditions create what sociologist Émile Durkheim identified as "collective effervescence"—the powerful emotional synchronization that occurs during shared rituals. These gatherings create transformative group experiences where individual consciousness temporarily merges with collective identity.)

Be of Service

Murthy emphasizes that contributing to community well-being through volunteering, neighborhood associations, and civic participation is an antidote to loneliness. He cites research showing that service activities not only benefit recipients but also significantly reduce feelings of isolation among participants by shifting their focus to others and creating opportunities to collaborate on shared goals. Murthy advocates interventions like neighborhood clean-up days, community gardens, and local political engagement that bring people together around common concerns.

(Shortform note: Some forms of volunteering are better than others at addressing loneliness. Structured and sustained volunteer activities, especially those involving direct interpersonal connection, are the most effective at reducing loneliness, particularly when individuals volunteer for at least two hours per week or more than 100 hours per year.)

According to Murthy, these activities help create what sociologists call “weak ties”—casual acquaintances who contribute significantly to one's sense of belonging—while building “social capital” (the networks, relationships, and shared values that help communities function effectively). Murthy suggests that the most impactful service opportunities involve regular contact with the same people over time, allowing relationships to develop naturally.

(Shortform note: In Bowling Alone, political scientist Robert D. Putnam describes social capital as the inherent worth of interpersonal bonds, relationships, and networks. Putnam documented how Americans have become increasingly disconnected from community organizations and social structures since the 1950s, undermining civic engagement and weakening the social fabric that helps communities function effectively. To replenish social capital, he recommends community-building efforts like involving students in generating ideas for programs that instill civic values more strongly and having inclusive churches that are tolerant of religious differences.)

Bridge Demographic Divides

Murthy emphasizes the critical role of programs that bridge age, cultural, and socioeconomic divides. Intergenerational initiatives offer a particularly powerful solution to social isolation. By connecting retirement communities with schools, these programs create mutually beneficial relationships where elders can mentor young people while receiving the vitality and fresh perspectives of youth.

(Shortform note: A prime example of successful intergenerational programming is Providence Mount St. Vincent in Seattle, known as "The Mount," which houses both a senior care facility and a preschool for children ages 6 weeks to 5 years. Since its establishment in 1991, the program has fostered daily intergenerational interactions through activities like music, dance, art, storytelling, and meal preparation, with documented benefits including reduced isolation for seniors and positive aging perspectives for children. The program has gained international recognition as a model for intergenerational care.)

Murthy also discusses how technology can facilitate local, face-to-face connections across demographic divides when used as a bridge to real-world interaction rather than a substitute for it. These bridging programs help address the increasing segregation by age, income, and background that characterizes many modern communities.

(Shortform note: Some platforms are designed to facilitate, rather than replace, face-to-face connections within communities. For example, Meetup fosters interest-based gatherings where most participants are explicitly open to making friends. Meanwhile, Nextdoor focuses on hyperlocal neighborhood connections, with research showing that 53% of users globally report feeling they can rely more on their neighbors and local community since using the platform. However, both services have limitations—Meetup struggles with attendance consistency and Nextdoor faces challenges with content moderation and privacy concerns.)

Institutional and Policy-Level Strategies

While individual and community efforts are crucial, Murthy argues that addressing the epidemic of loneliness requires coordinated action at institutional and policy levels. Governments, organizations, and institutions can implement evidence-based interventions to create environments where meaningful connections naturally flourish.

(Shortform note: How do institutions know whether their interventions are effective? Traditional public health metrics poorly capture the qualitative aspects of social connection. Harvard's Human Flourishing Program has developed more holistic measurement frameworks that integrate subjective well-being with objective indicators, potentially offering more meaningful ways to evaluate policy effectiveness in this domain. Without such nuanced assessment tools, institutional responses risk focusing on superficial metrics rather than meaningful change.)

Confront the Problem

Murthy advocates comprehensive government strategies to address social isolation, with policy recommendations including funding community organizations that create connection opportunities, supporting public spaces as social infrastructure, and developing campaigns to reduce loneliness stigma—approaches showing promise in the UK, Japan, and Denmark. He points to the UK's 2018 appointment of a Minister for Loneliness as a pivotal example of institutional recognition.

(Shortform note: The UK has invested over £20 million in loneliness initiatives as of 2020, funding charities, tech firms, and community groups, but evaluation remains limited. Pilot programs like the Royal Mail initiative (where postal workers check on elderly residents during delivery rounds and refer them to support services) show promise—three-quarters of participants valued these postal worker visits. However, substantial work remains to achieve measurable reductions in loneliness levels. Despite including loneliness measures in 11 government surveys, these initiatives have yet to be assessed for their actual impact on nationwide loneliness rates.)

Additionally, Murthy challenges digital companies to redesign their products to prioritize meaningful connection rather than maximizing engagement through addictive features. While he acknowledges technology's potential to connect people across distances, he warns that current usage often drives us apart rather than bringing us together, and he suggests tools that facilitate in-person meetups, features that help users monitor screen time, and algorithms that promote quality interactions over endless scrolling.

The Stalled Fight to Regular Social Media

In 2024, Murthy intensified pressure on tech companies, urging Congress to require warning labels on social media platforms—similar to those on tobacco products—due to the "significant mental health harms" associated with adolescent use. However, despite growing concerns and Murthy’s public advocacy, his call for federally mandated warnings has not yet resulted in any legislation, and state-level proposals are also stalled. The Stop the Scroll Act (which would introduce warning labels and restrict addictive platform features) and similar proposals have faced delays due to a combination of strong industry lobbying, concerns about infringing on free speech, and disagreement over the appropriate level of government intervention.

While some technology companies have implemented features like Apple’s Screen Time and Google’s Digital Wellbeing as self-regulatory steps, many health experts and advocates argue these measures don’t address the underlying problem: engagement-driven algorithms designed to maximize user attention. Without broader, systemic reforms that target these core design choices, critics believe current industry responses remain largely superficial and insufficient to counteract social media’s potential harms.

Treat for Loneliness

Murthy proposes treating social connection as a critical vital sign, transforming healthcare approaches to patient well-being. Drawing on his experience as Surgeon General, he advocates training providers to screen for loneliness during routine visits, establishing referral systems to community resources, and developing support groups for patients with chronic conditions. The UK's "social prescribing" programs, where physicians prescribe community activities alongside medication, offer a promising model for this approach.

The Value of Social Prescribing

Social prescribing offers a way to use healthcare resources more effectively. Redirecting patients with non-clinical needs—such as loneliness-driven anxiety or social isolation—to community-based interventions preserves clinical resources for acute and chronic medical conditions.

This approach addresses the mismatch between patient needs and medical expertise, as studies estimate up to 20% of primary care visits in the UK involve primarily social issues that community resources are better equipped to handle. By systematically connecting patients to services like social groups, financial support programs, or arts activities, social prescribing reduces unnecessary medical visits, lowers emergency department use, and alleviates provider burnout.

To make these changes sustainable, Murthy recommends restructuring healthcare economics by creating billing codes for loneliness screening, establishing insurance coverage for group medical appointments, and developing financial incentives for preventive social connection interventions. He argues that by integrating social connection into healthcare and aligning medical practice with economic realities, we can address a fundamental but long-overlooked determinant of health.

(Shortform note: Healthcare systems face several barriers when trying to address loneliness through reforms like social prescribing and screening. These include outdated systems that don't work well, resistance from established medical hierarchies, and payment structures that reward treating illness rather than preventing it. Additionally, some argue that reforms are likely to fail if doctors and patients aren't involved in designing the new methods.)

Design for Connection

Finally, Murthy emphasizes that physical environments and organizational cultures significantly impact our opportunities for social connection. He argues that intentional design across multiple settings can either facilitate or hinder meaningful interaction. By prioritizing connection in the design of shared spaces, institutions can create environments that naturally encourage connection without demanding extraordinary individual effort.

In the Workplace

Murthy argues that organizations must implement structured approaches to foster connection among employees through both physical and cultural means. He emphasizes how redesigning office spaces to include communal areas, establishing formal mentorship programs, and creating policies that prioritize relationship-building can combat workplace isolation. In his research, Murthy found that more progressive companies increasingly recognize that social connection drives innovation, productivity, and retention, leading them to incorporate team-building activities into regular work hours rather than treating them as optional add-ons.

(Shortform note: Maintaining connection will likely look different for remote teams. Virtual team-building activities and video calls can help maintain the human element that office interactions naturally provide. Dedicated channels on platforms like Slack for personal interests create spaces for casual conversation beyond work tasks. Meanwhile, clear communication protocols, collaborative tools, and regular check-ins prevent isolation.)

In Schools

According to Murthy, schools and universities can embed connection-building into their core mission through curriculum design, physical spaces, and institutional policies. He points to research showing that implementing social-emotional learning programs from early childhood through higher education helps students develop the foundations for healthy connections. He advocates redesigning classrooms to facilitate collaboration, creating peer mentoring systems across grade levels, and ensuring extracurricular activities are accessible to all students regardless of ability or resources.

(Shortform note: While Murthy emphasizes collaboration in education, many institutions prioritize individual achievement over cooperative learning. Research shows schools often remain structured around competitive metrics, standardized testing, and individual performance. Education expert Vicki Abeles documents in Beyond Measure how this emphasis on competition not only creates unhealthy stress but also fails to help students develop the collaborative skills they need for real-world challenges.)

In Urban Design

Murthy contends that urban planners, architects, and local governments can intentionally create physical environments that naturally foster social interaction. He cites research showing that developing mixed-use neighborhoods with walkable streets, accessible public spaces, and community gathering spots can counteract isolation in modern urban environments. He references successful examples of communities that have revitalized town centers, created community gardens, and transformed libraries into social hubs with diverse programming to demonstrate how physical infrastructure shapes social behavior.

(Shortform note: In Cities for People (2010), urban design expert Jan Gehl demonstrates how car-centric development and architectural choices have systematically eliminated traditional gathering spaces. Restructuring institutions to facilitate genuine connection—through collaborative learning models, communal workspaces with private areas, and human-scale urban design—might better align our environment with our biological needs, potentially addressing rising loneliness while enhancing both well-being and productivity.)

Hope for the Future

Murthy acknowledges that addressing the loneliness epidemic can feel like a daunting task, but he argues that the future is hopeful. The human drive to connect is fundamentally resilient, deeply ingrained in our nature. Despite the challenges of modern life—technological isolation, changing social structures, and increasingly fragmented communities—our innate capacity for empathy, compassion, and meaningful relationships remains undiminished. According to Murthy, our emerging awareness of loneliness as a critical public health issue is itself a source of optimism. By recognizing social connection as essential to individual and collective well-being, were taking the first steps toward meaningful change.

(Shortform note: Murthy's optimism is supported by historical adaptation patterns. Past technological disruptions—from the Industrial Revolution to television—initially fragmented communities, yet society responded by creating new connection points. For example, factory work disrupted rural communities but sparked new civic organizations and educational institutions. Similarly, television initially isolated viewers but eventually inspired shared viewing experiences and cultural discussions. Today's grassroots efforts—community gardens, digital detox movements, and intergenerational programs—suggest we're already developing creative responses to digital isolation, continuing this cycle of disruption followed by social innovation.)

Ultimately, says Murthy, combating loneliness is not about returning to an idealized past, but about consciously creating new ways of connecting that reflect our current realities. Each small action—whether reaching out to a neighbor, participating in community service, or simply being more intentional about our social interactions—contributes to a larger movement of reconnection.

(Shortform note: Murthy's emphasis on small, cumulative actions is supported by research on social contagion in human networks. Research shows that behaviors like cooperation and social engagement can spread through networks in "social cascades”: When one person increases their social engagement, they affect both direct contacts and the wider community. This suggests that even small groups can use the contagious nature of social behaviors to make bigger changes in community connection patterns.)