Swimming Through the School of Hard Knocks
How Social Bonds Can Rejig the Outcome of Chronic Disease
When Sylvie La Fontaine was diagnosed with breast cancer in April 1999, she had just competed with her team in the Canadian Masters national swimming championships. Five foot ten, with rectangular tortoiseshell glasses and pixie-cut hair, Sylvie favored snug wraparound tops she sewed herself, worn over leggings and boots; she hardly looked the part of a grandmother of three. A real estate agent and interior designer, she was the de facto hub of several intense face-to-face social networks, including her swim team. Its president for seven years by that time, she fielded a multitude of personal and training questions from its 150 members, including but not limited to their health issues, reproductive concerns and sports injuries, marital flare-ups and child-rearing doubts, thoughts on the pool's water quality and the coach's latest endurance workout. She was even a shoulder to cry on when a member's beloved pet had to be put down. She sustained this role with bemused equanimity until a teammate blasted her—and not for the first time—about some insignificant mishap at a competition. The attack penetrated her usual defenses and really stung. Given her recent cancer diagnosis, Sylvie wondered whether she should pull back from the team in order to conserve her emotional resources.
But she found that it wasn't that simple for her to withdraw. Not only did people keep seeking her out for advice, Sylvie couldn't resist getting involved when there was work to be done. Along with being swim team president, she was also president of a rural homeowners association that had recently planted sixty thousand trees to naturalize communally owned farmland (she had planted fifteen thousand of them herself). She unwittingly drew confidences from people she barely knew—which puzzled her, as she tended to keep her own counsel. I was just one of what seemed like several hundred swim buddies, colleagues, and neighbors who considered Sylvie a friend. And that was just her middle social layer: she had many closer friends too.
Sylvie and her husband had formed strong bonds with several navy couples while he was enlisted and their kids were young. Closer still were three couples she had met through the swim team; they now dined and traveled together whenever they got the chance. When Gary, one of these close swim friends, found out he had colon cancer, the same week Sylvie received her diagnosis, she competed alongside him at the national championships, then threw herself into his care, organizing tag teams to drive him to the hospital and helping to coordinate his treatment regimen. Supporting Gary as he fought his six-month survival estimate became her most pressing project. "I wasn't sick. He was," she flatly retorted when I asked why she talked about Gary when I asked about her own health. (Gary outlived his initial prognosis by three and half years.) "I didn't really need anything at the time. Breast cancer is not something that hurts, you know. It's very mental."
Not everyone would agree with this assessment. What's indisputable is that despite her vow to withdraw, Sylvie continued to be deeply immersed in several face-to-face social networks that involved taking care of other people. Though cancer did prompt her to give up her leadership roles for a while, she still swam with the team, entertained family and friends, and took care of people in her circle she thought needed her help. Few see looking after others as therapeutic for the person who does the caretaking, or consider community involvement as therapeutic as drugs. Yet there is mounting evidence that a rich network of face-to-face relationships creates a biological force field against disease.
What Is Social Contact, Really?
As is true of many women, Sylvie's social connections were so deftly woven into the fabric of her daily life that she didn't see them as remarkable. Yet even if she was blind to the benefits, her social entanglements would stand her in good stead as she faced down her own cancer. That's a handy side benefit of social interaction. Unlike a placebo, which requires you to believe you are receiving medical attention, face-to-face social bonds bolster our immune responses by stealth. No needles pierce the skin. Nothing gets swallowed, inserted, or inhaled. Outside Latin cultures, most social contact doesn't even involve the laying on of hands. So how does social contact exert its effects?
To begin with, the right kind of social contact (hostility doesn't work) instructs the body to secrete more endogenous opiates, which act as local painkillers, and fewer hormones such as adrenaline, noradrenaline, and corticosteroids—the body's often destructive answer to immediate stressors—which can wage an ongoing war on our tissues and our physical resilience. More and more proof is emerging that in many cases, full social lives can slow down, if not halt, an existing cancer's progress. How a complex, interwoven social life can bolster survival in the face of a grave illness is the story I'll tell in this chapter. I'm not referring here to the number of Facebook friends or Twitter followers you've accumulated simply by clicking "invite" or "accept," but to something more concrete.
Think of social contact as having three prongs or arms of support. One is a route to timely information that's uniquely valuable to you. In the case of breast cancer, these are the friends and family—and the people they know—who refer you to surgeons and oncologists with good track records, to clinical trials and experimental drugs, and to reliable facts while you sojourn in the disorienting land of chronic illness. When Sylvie was diagnosed, she asked a swim buddy who was a medical researcher for the name of a good surgeon. Seven years later, when a suspicious mass was found in my right breast, I asked Sylvie if she could help and she passed that name on to me. I was three connections away from information critical to my health, and her word-of-mouth testimonial damped down my anxiety as I considered my next step. (As you read on, you'll see that the number three keeps resurfacing as I describe how information and trends get transmitted within social groups.)
Lifts to the doctor's office, sitting with the patient while there, babysitting, and preparing meals comprise that second arm of social support: material assistance. One husband I read about in The New York Times perfected the "ask" when coordinating crucial social support for his wife, Alexandra Bloom, a forty-one-year-old psychologist and mother of their four-year-old twins. Describing himself as highly organized, Tom Nishioka swung into action when his wife learned she had breast cancer:
Within days, Mr. Nishioka and three friends designed a website for people to sign up to help them. It's hard to ask people things like, "Who's comfortable sitting through chemo with you, or who likes to cook?" said Dr. Bloom. Ten team captains signed up to organize researching oncologists and health-insurance options, making home-cooked meals, shopping for groceries, going on doctor visits, taking the girls to and from school, and tidying up the apartment each day. More than 150 friends signed on. Three are honorary grandmas, Dr. Bloom said. "Each of them visits once a week. They read books to the girls, they bring the girls their favorite foods, like string cheese, strawberries and blueberries. They see their role as spoiling them."
This extraordinary couple recognized that their face-to-face social networks were a critical factor in Dr. Bloom's recovery. The Internet was a part of their communication plan, to be sure. Their friends signed up to help on a dedicated website. But when it came to pitching in, the members of their village had to show up; they had to be there, in person. And of course, providing food, rides, and other favors is not all that close friends and family have to offer. They also encourage you to eat, to take your medication, to see the doctor—and perhaps come along to ask probing questions while you're there.
Along with this concrete support is the mood- and health-bolstering effect of having loved ones nearby—the third arm of support. Perhaps this is why people without such social buttressing are more than twice as likely to die prematurely than those with active face-to-face social lives. In fact, neglecting to keep in close contact with people who are important to you is at least as dangerous to your health as a pack-a-day cigarette habit, hypertension, or obesity. And while the first benefit of social contact I described—access to timely information—has been beautifully streamlined by Google searches, the last two benefits—concrete and emotional support—work most powerfully if those people are near enough to see, hear, and touch you.
Social Contact and the Shape-Shifting Disease
Proving the link between social contact and cancer survival is not just complex from a scientific point of view, it's also controversial. On the complex side, your genes, history of pregnancy and childbirth (or childlessness), hormone levels, menopause, hormone replacement therapy and its timing, diet, exercise, alcohol and cigarette habits, radiation exposure, where you live and the nature of the social and work life you lead there are just some of the factors that combine to create the toxic brew that causes cancer cells to proliferate .?.?. or not. The sheer number of causes and the way they shift and interact over time make for a seemingly impenetrable tangle. To add to the mess, cancer seems to be not one disease but several hundred that share a common process—that of unchecked hegemonic growth—one reason why the oncologist and author Siddhartha Mukherjee refers to cancer in his book, The Emperor of All Maladies, as "a shape-shifting disease of colossal diversity." Still, when researchers attempt to isolate each of these factors and hold them constant, the link between consistent social contact and breast cancer survival remains.
But what does this mean exactly? Social contact can be a grab bag of connections. There's the intimate encouragement and support offered by your life partner or best friend, the day-to-day contact with colleagues, neighbors, or teammates; the loose affiliations to people you meet in your professional networks or at church. Compare these types of contact to what you experience when you meet strangers in a cancer support group or on Facebook. Though evidence tells us that social connections are as protective as regular exercise—those with the most face-to-face connections have a two-and-a-half-year survival advantage over those with the same disease who are isolated—not all types of social contact are created equal.
Some cancers are the body's terrorists: they're rare, swift, and indiscriminate killers. In contrast, breast cancer's growth patterns are usually lazier. Given its longer horizon, the vast numbers of people affected, and the political will (and the research budgets that follow suit), breast cancer survival rates are a good way to examine whether social bonds can slow or halt the march of this disease. And as of the 1990s, multiple studies have shown that women with breast cancer who feel supported by caring friends and family—and who actively seek out such social contact—have a more favorable response to the disease and ultimately a better prognosis. More than any other factor, a woman's network of active social contacts and her perception of social support predict her blood levels of lymphocytes and natural killer cells, both of which eradicate cancer cells. Though she is just one case, this was certainly true of Sylvie. She thinks of herself as an introvert. But she surrounded herself with people who mattered, and as a result she not only felt supported but survived.
The question is how. Two types of studies do a good job of connecting the dots between our social bonds and our health. The first are demographic sweeps that probe the social lives of thousands of people at a time and then follow them into the future—as they get older and start to fall apart. The scientists at the helm of these studies, neck-deep in data for decades, draw lines between the number and types of get-togethers with friends, colleagues, kids, cousins, and fellow parishioners penciled in on their calendars and what kind of health problems hit these people, and when.
In the seventies, Harvard epidemiologist Lisa Berkman was the first to conduct population studies that made the link between our social lives and our "best by" dates. She lived in northern California at the time, and her study of every single Alameda County resident (a total of 6,928) showed that, among other surprising findings, the women who were socially isolated had an elevated risk of dying of cancer, and isolated men who already had cancer were more likely to die prematurely.
The sheer volume of participants in studies like Berkman's makes certain links indisputable. We know that the connection between social involvement and robust physical and mental health is no fluke, and that the benefits of regular social contact are at least as powerful as regular exercise and a healthy diet. But the downside of such large-scale population studies is that, though they prove that two factors are connected, they can't tell us which one comes first. Do people with lots of friends and family live longer because their active social lives protect them from cardiovascular events and cancer? Or are the type of people who seek out lots of interaction with friends, children, parents, cousins, neighbors, and colleagues simply the type of folks who are also biologically destined to live long, healthy lives, come what may? If people who are less healthy in general have a hard time developing and maintaining connections with other people, then it may not be their social isolation that's at the heart of the matter, but their poor health.
The way to solve this chicken-and-egg dilemma is to randomly assign people to one of two groups. In the first they are surrounded by solicitous buddies and loving kin, and in the second they live a monastic life. Meanwhile, everything else stays the same. They start out healthy and cancer free; they have similar genetic, lifestyle, and health backgrounds; they're the same sex and age; and they're similarly privileged, deprived, or addicted in the food, drink, and comfort departments. Then you watch what happens as time passes. Does social contact affect the growth of cancerous tumors?
We can't try this sort of experiment with human beings, of course. Even if it were possible, it's not ethical to deprive people of social contact just to see what might go wrong. But you can try it with rats, which despite their serious image problem share almost all the genes linked to human diseases and like us, are also highly social animals. When research psychologist Martha McClintock, her oncologist collaborator Suzanne Conzen, and their colleagues tried isolating red-eyed albino rats bred for research purposes, the team made a remarkable discovery. Socially isolated female lab rats developed eighty-four times as many breast cancer tumors as female rats who lived in groups. Eighty-four times! Published at the end of 2009, their study drily relates this extraordinary finding: "Isolation increased the number of discrete tumor masses by 135%. Among isolates, tumors were more widespread, developing in three if not all four mammary quadrants." The researchers go on to report that 50 percent of the isolated female rats developed malignant breast cancer, while the incidence among their group-housed mates was only 15 percent. Compared to the party animals, the solitary females' tumors were not only more numerous but bigger. Clearly, if you're a female mammal, having little contact with a close circle of family members and friends not only causes psychic pain in the short term but increases your risk of developing breast tumors in the long term.