The absence of friendship in the COVID-19 pandemic

  • A friendly environment can trigger healing effects in our bodies, while a stressful one can cause harmful reactions and suppress immunity.
  • Terence Ryan, Emeritus Professor of Dermatology, University of Oxford, suggests that restricting opportunities for friendship could have done significant harm to the mental health of COVID-19 patients.
  • He explains the critical importance of adopting a ‘care attitude’ alongside scientific approaches to medicine.
  • Using his own experience of treating leprosy, Ryan highlights the harmful effects of isolation on the body’s immune system in man and animals.
  • Ryan asks us to consider how reducing isolation and embracing more friendliness could change the cause and outcome of any future pandemic.

In the coming years, society will reflect on how we dealt with the COVID-19 pandemic and look for lessons to learn. Positives will be the isolation and analysis of the causative virus and the development of effective vaccines. However, treating the factors that make humans and animals likely to transmit the virus were given too little attention. These include the lowered immunity of those bereaved or affected by loneliness or, in animals, of those affected by cruelty such as caging. The positive influence on wellbeing of friendly volunteers in vaccine centres was not studied. And although we realised that mental illness was far more common during the pandemic, the effect of isolation and social distancing from friendship was not taken into account.

The importance of ‘friendliness’ in the cold precision of science has significant precedence. The provision by ‘modern medicine’ of health and wellbeing is characterised by the ‘personal touch’ of medical staff as well as the support of family and community. And yet, it all but disappeared during the pandemic, replaced by treatment at a safe distance, smiles hidden behind masks, and family and friends separated by closed windows. Terence Ryan, Emeritus Professor of Dermatology, University of Oxford, believes we should explore how isolation when needed can be supplemented by what he calls ‘care attitude’ – a mix of sympathy, empathy, compassion, kindness, preserving dignity, and bringing joy, cheer, and friendship. ‘Friendship is the single most important factor influencing our health, wellbeing, and happiness,’ says Ryan, quoting from the recent studies of the Department of Experimental Psychology at the University of Oxford.

Beyond being a renowned specialist in dermatology with a particular interest in leprosy, Ryan is also the curator of the Oxford home of Sir William Osler, the father of modern medicine. Osler pioneered the instruction of medical interns at the bedside and believed students should connect directly with the patients they were learning to treat. Notably, that connection must be more than compassion. For Osler, compassion meant taking on another’s sadness. Rather it was friendliness that helped heal. In his words, ‘It is an unpardonable mistake to go about with a long face’: he always began an examination with a friendly greeting using the patient’s name, and with a smile.

‘It is an unpardonable mistake to go about with a long face.’ William Osler.

The psychological and physiological effects of friendliness

Ryan has seen the injurious effects of the absence of friendliness in his research worldwide into leprosy. The disease is still seriously stigmatised and those infected were, for a thousand years, usually treated in the same way as seriously ill COVID-19 patients – by isolation. But Ryan has seen cases where expressions of genuine friendliness helped generate remarkable results in leprosy patients, as well as those with other disfiguring conditions that may cause onlookers to recoil in fear and disgust – a response that further reduces our ability to confront and treat infectious diseases.

A lack of friendship affects more than humans. A dog in a rusty cage, it is pressing its nose through a space in the cage. It appears sad.
Suppression of the immune system increases susceptibility to, and makes us more inclined to transmit, infection. It has been written that caged animals suffer and consequently have lower immunity, causing them to be susceptible to viruses and transmit them more easily. Isolation has been a policy over a thousand years for leprosy and recently for COVID-19. This results in impairment of health, wellbeing, and happiness, a potent therapy for which is friendship.

The secret to the healing effects of friendliness lies in how our brain reacts to its visible expression in others. We are neurologically wired to respond to visual cues, human, animal, and environmental, and not only from humans – the wide eyes of a helpless puppy, or for children a rag doll or teddy bear, trigger an immediate sympathetic and protective reaction. The brain registers such cues in the frontal cortex and forwards them to its emotional centre, the amygdala, which then releases powerful chemicals to balance our nervous and endocrine systems, which regulate our bodily function. Ryan has studied psychosomatic disorders, inducing pain and bleeding, and suppression of inflammation in Asian body piercers and firewalkers. He believes from his experience as a dermatologist that psychological stress, an evolutionary adaptation to the fight-or-flight response to threat, can sometimes impact not only our mental health but also our physical health, triggering harmful physiological reactions such as rashes and other skin disorders. Ryan also knows the opposite is true: a caring attitude, hypnotism, acupuncture, and mindfulness, which create a pain-free response, can trigger physiological responses that heal.

‘Friendship is the single most important factor for influencing our health, wellbeing and happiness.’ RJM Dunbar.

COVID-19 and the absence of friendliness

For Ryan, pure science is not enough to care for disability following burns and trauma, or the effects of caging on animals and solitary confinement in humans. Doctors, nurses, and community health workers should acquire the skills of care technology applied with care attitudes – revisiting Osler’s teachings. These skills would also help trigger the neurological reactions, both central and peripheral, to flood our body with the chemicals we need to complement and accelerate the healing process.

Social distancing may have helped limit the spread of COVID-19, but it also kept people isolated and lonely. Ryan points to research that shows how physical and mental isolation and caging of animals depresses the body’s immune response thereby making it more susceptible to infections. The friendly interactions that are important for social bonding are also vital in protecting our health. Ryan makes the same appeal for our interactions with animals and the environment. As with humans, friendship and kindness can counter effects like immune suppression in animals arising from anxiety, cruelty, or loneliness, which medical intervention alone cannot resolve.

A holistic care attitude can help us avoid mistakes made by purely scientific practices, develop better approaches to resolving loneliness, and perhaps even tackling poverty by cross-class friendship in youth organisations. And as we start to review the way we tackled COVID-19, it’s worth asking if more lives could have been saved and depression avoided had patients not had to suffer isolation as well as the disease. In September 2022, the UK press cited several international studies that found loneliness triggers inflammation and ageing and is more harmful than smoking. ‘Such studies add to the evidence for the therapeutic value of friendship,’ says Ryan, ‘and are relevant to my arguments against social distancing in my mentoring of tropical disorders such as leprosy, podoconiosis, and lymphatic filariasis. It’s equally important for global epidemics such as COVID-19 and for the prevention of transmission of diseases by caged wild animals in Asia.’

‘Friendship,’ Ryan concludes, ‘is deserving of further research.’

If Sir William Osler were alive today, how do you think he would rate the typical modern hospital for friendliness?
He would have been horrified by some of the worrying reports on lack of care. He would have lectured on best practice and would be speaking on webinars worldwide, commenting on over-reliance on technology scans and blood tests, as well as there being too little detailed history-taking or thorough examination of patients.If isolating COVID-19 patients was both a sound hygiene solution and a care mistake, how could we have done things differently?
It was correct to recognise the need to prevent infection of hospital staff and spread of the virus throughout hospitals and care homes, but Osler might have predicted that too much social distancing might lead to depression and impaired mental health. He would have offered suggestions on how to avoid prolonged separation from loved ones.Overworked health practitioners may argue they have little time and energy to expend on ‘care attitude’; what advice would you give them?
Care attitude is a therapeutic priority and ways to prevent loneliness are worthy of more thought and research.

Could you say a bit more about how a care attitude can help our relationship with animals and the environment?
Many animals suffer pain and fright from human technology. Humane education should teach ways of reducing fear to prevent it suppressing immunity and leading to increased transmission of infection. Friendship encompasses the full range of emotional responses listed in care attitude – sympathy, empathy, compassion, kindness, preservation of dignity, bringing joy and cheer. Both humans and animals want to be liked and enjoy the company of those they do not fear and who bring benefit. Similarly, the environment needs contact with those who bring benefit such as curtailment of pollution and destruction, and of those who work to manage climate change. I am a trustee of Actasia,, an organisation that takes ‘humane education’ and the principles of a care attitude into primary schools in Asia, where wild and domestic animals routinely die in cages in its markets and pets die in postal packages. Actasia also discourages the fashionable use of fur from caged wild animals. In Asia, fear of dogs as pets in areas of high prevalence of rabies is counteracted by Actasia’s delivery of an intensive vaccination programme for stray dogs.

How would you design a research study to further demonstrate the holistic benefits of friendship for our wellbeing?
I would seek the advice of those who have already published in these fields. I would add to the exploration of viruses and vaccination against them, more research into the transmission between species encouraged by factors that reduce immunity. I would teach humane education and include friendship as an antidote to factors such as fear, pain, and loneliness in all educational establishments from primary schools to universities.


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