The preceding discussion reflects the early state of the art regarding the role of social isolation in disease. Because of this limited understanding, a precise assessment of the burden occasioned by this risk factor and the potential for prevention is, of necessity, tenuous. An examination of theoretical and empirical work is essential to begin increasing the accuracy of burden assessment. This approach will serve as well as a background for the discussion of preventability that follows.

The role in health of such phenomena as social support and social isolation has its roots in early consideration and theoretical formulation of the mind/body controversy. Despite the hazy and at times unscientific approaches to this area of human functioning, the role of psychosocial concepts in disease and health demands attention. Eastwood described the beginnings of "psychosomatic medicine," which addressed the mind/body paradox, as an attempt to identify psychological variables that promote diseases.15 This early "psychosomatics" movement was reflected in a 1964 WHO report,49 which concluded that the relationship of mind and body was a dynamic one and that the human system can be affected by either psychological or physiological insult and stress. Over the years, and particularly during the 1960s and 1970s, a significant corpus of work emerged in this area.13,20,44

This early, pioneering approach evolved into later large-scale studies to test the role of social supports in mortality and morbidity. This trend began in the mid-1970s and is typified by the studies of House and colleagues,22 Berkman and Syme,3 and Blazer.4 Later research examined prevention strategies designed to delay the onset of disease, affect the early detection of disease, contain the course of functional impairment in the presence of disease, and maintain the highest quality of life in the face of impairments and disability as the result of disease. (This approach clearly addresses all of the stages of the WHO classification and the framework of the Health Objectives for the Nation working group.) The three prospective cohort studies noted above3,4,22 showed higher rates of mortality from all causes for socially deprived older persons. These studies used different measures of social support and varying time intervals over which the effect took place. Yet the analysis in each is convincing in linking the absence of social support to higher mortality rates.

Berkman and Syme3 reported on a nine-year follow-up study of a random sample of 6,928 adults in Alameda County, California. They found that people who lacked social and community ties were more likely to die in the follow-up period than those with more extensive contacts. Their findings also indicated that the "association between

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