In 2023, upon being reappointed as the U.S. Surgeon General, now for the Biden administration, Dr. Vivek Murthy worked with his team at the Department of Health & Human Services (HHS) to craft an official document partially inspired by his own 2020 book, the New York Times best-seller Together: The Healing Power of Human Connection in a Sometimes Lonely World. Ultimately, Murthy and HHS released the report Our Epidemic of Loneliness and Isolation (Office of the Surgeon General, 2023).
Even prior to the pandemic, loneliness was being experienced deeply and painfully across the United States of America. While many potential causes have been considered – issues with modernity, the breakdown of the local community, the decentralization of religion in everyday life, the dominance of digital communication and socialization – the pandemic only exacerbated the problem. Clinicians and researchers had been finally looking at loneliness as a health issue, and “their data demonstrates that pronounced loneliness corresponds to “a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death” (Office of the Surgeon General, 2023, p. 4). Loneliness, in short, is on par with smoking over a dozen cigarettes daily. More quantifiably: “Loneliness and social isolation increase the risk for premature death by 26% and 29% respectively. […] poor or insufficient social connection is associated with increased risk of disease, including a 29% increased risk of heart disease and a 32% increased risk of stroke” (Office of the Surgeon General, 2023, p. 8).
What precisely do we mean when we speak of loneliness? It’s not isolation or solitude; it’s not the occasional Fear of Missing Out (FOMO) one might feel or that lone evening of canceled plans. Rather, HHS defines loneliness as “A subjective distressing experience that results from perceived isolation or inadequate meaningful connections, where inadequate refers to the discrepancy or unmet need between an individual’s preferred and actual experience” (Office of the Surgeon General, 2023, p. 7). Along with being pernicious, it is also pervasive; “recent surveys have found that approximately half of U.S. adults report experiencing loneliness, with some of the highest rates among young adults” (Office of the Surgeon General, 2023, p. 9). While the focus here is on the U.S. population, I should note that this is not exclusively a domestic American issue. In fact, both The Irish Times (Duggan, 2023) and The Irish Independent (Mulgrew, 2023) have each published articles within the last year about Ireland purportedly being the “loneliest country in Europe.”
Japan is also among the many nations where extreme loneliness has been identified. And we have here, I feel, the opportunity to consider both loneliness and its health effects in the manga of cartoonist Nagata Kabi, starting with her debut work, My Lesbian Experience with Loneliness. First published online in 2016 and produced in English translation by Seven Seas Entertainment in 2017, the comic documents Kabi’s desperation to, at age thirty, make some connection, particularly a romantic or sexual one, outside her extremely insular life. Subsequent volumes chronicle her estrangement from her family (My Solo Exchange Diary), her mounting alcoholism (My Alcoholic Escape from Reality), and her resulting hospitalizations due to acute pancreatitis (My Pancreas Are Broken but My Life Got Better). With her story broken into separate volumes, it is easy to miss the connection between Kabi’s acute loneliness – anguishingly explored in her earlier comics – and her further medical conditions. As an aside, I should say that any salacious aspects of her initial foray hiring companionship at a “love hotel” fall quickly to the background of her growing health complications.
By 2021, Kabi was detailing, in addition to her loneliness, the numerous health problems she had started experiencing, particularly alcohol abuse. In John T. Cacioppo and William Patrick’s highly influential Loneliness: Human Nature and the Need for Social Connection (2009), the authors describe Kabi’s situation almost exactly: “[P]roblems in self-regulation specifically attributable to loneliness have turned up in measures of alcohol abuse” and eating disorders (p. 37). These can build and introduce other comorbidities for an individual struggling through a difficult period.
(Of course, Kabi’s are not the only comics to address this. The comics medium offers many examples on the mental health toll of loneliness, e.g. It’s Lonely at the Centre of the Earth by Zoe Thorogood (2022), The Loneliness of the Long-Distance Cartoonist by Adrian Tomine (2020), and arguably Peep Show (1992) by Joe Matt or, Jimmy Corrigan: The World’s Smartest Kid by Chris Ware (2003), etc. But Kabi’s non-fiction reflections detail the physical ramifications of it in her diary as well as its subversiveness – how it infiltrates her whole life.)
Much like Binky Brown Meets the Wholly Virgin Mary by Justin Green (2009) offered insights into Obsessive-Compulsive Disorder, Kabi’s series acts as a case study in the health impacts of loneliness, from depression and alcohol abuse to acute pancreatitis and eating disorders. The impacts gradually accumulate, as Kabi relates:
I don’t usually get it when my body and mind are yelling at me that we’re sick. / But that many symptoms were too hard to ignore. ‘Lonely. Lonely. Lonely. Lonely.’ My heart and body were screaming at me that we were lonely, that everything was too much. / I’d ignored the negative consequences of pushing myself and enduring the hard stuff, but now the invoice was coming due. Would I have to pay the negative consequences plus interest? / It wasn’t just for stuff I’d ignored the past few weeks, either—this was interest on my entire past. ‘What have you done?!’ Current me got the bill. (2018, p. 20) (See Figure 1).
Figure 1
How does loneliness affect health, exactly? In his book Project Unlonely, Dr. Jeremy Noble (2023) suggests several ways that loneliness has been observed to impact overall wellness. “Physiologically, the stress of loneliness increases cortisol levels, impairs the immune system’s capabilities, and increases inflammation, all of which directly raise the risk of premature death from cardiovascular illness, cancer, dementia, and diabetes” (2023, p. 26). Working off a 2015 study by social connectedness-expert Julianne Holt-Lunstad, Noble and his team found that “people without strong social relationships were roughly 30 percent more likely to die prematurely than socially connected people” (2023, p. 27). These may be due to “the well-known physiological effects of loneliness—elevated blood pressure, increased inflammation, reduced immune response” (p. 97).
Perhaps the most effective way to view Kabi’s loneliness is, as historian Fay Bound Alberti suggests in her 2019 book A Biography of Loneliness, “as an emotion ‘cluster,’ a blend of different emotions that might range from anger, resentment, and sorrow to jealousy, shame, and self-pity” (p. 6). I believe elements of this are easily observed in a number of Kabi’s accounts, for example why the workplace was so unfulfilling for her:
Now, though, I totally get it. ‘Excuse me!’ / At that part-time job, I was looking for a place that would accept me unconditionally. ‘I’m sorry. Could I please leave early…?’ / But, of course, a part-time job isn’t the place for that. ‘!!!’ It’s a place for receiving wages in compensation for labor. / There’s no room for someone who can’t work their wages’ worth. I would have to look elsewhere for unconditional acceptance. (2017, p. 11)
Other aspects of this cluster can be seen in her longing for a place where there were no expectations upon her. When she is discovered cutting and engaging in self-harm, she imagines—incorrectly, as she’ll later admit—that the hospital might be the ideal place to alleviate this cluster of inner pain.
Getting hurt absolved me of something. I thought it would lower the bar for other people to accept me… And then I could find a place where I belonged. / But I still wasn’t anywhere close to…the welcoming kindness of a hospital bed. / Years later…I read about a person who hurt herself. She said… “I don’t really understand the pain in my heart. It doesn’t have any real form. But it’s easy to understand the pain when it’s my body that’s being hurt. It calms me down.” And I totally got it. / Putting the invisible pain in my heart into words was a process that took time and effort, and more than that…You can see it; the cause is very clear. Creating and seeing the dummy pain calms you down. You feel better right away. (Kabi, 2017, p.13)
If she cannot be free of such expectations—whether that’s society’s or her own—then she imagines an understanding partner being the solution to her mix of emotions.
Ahh...at last. I’m going to be saved… / I’m so, so ready for someone to comfort me. To melt away my years of loneliness. I want her to hold me – and not just for a few seconds.’ / I was really, really lonely. I didn’t know why I was hurting. I just had this longing, and it was finally going to be fulfilled. / But I felt like I had to open my heart…or my loneliness would never go away. ‘I’m so alone… . (Kabi, 2017, p. 74) (See Figure 2).
Figure 2
Kabi suggests that her sense of loneliness emerged fully after her school days. “The last time I’d lived a proper life, in my high school days…my sweet nectar had been my friends and their compliments” (2017, p. 126). With that “sweet nectar” long gone, recognition through her art becomes the main sustenance for Kabi. In Kristen Radtke’s 2021 comic Seek You: A Journey through American Loneliness, the author observes that loneliness can plant its deepest roots in youth.
A hallmark of loneliness is shame: since childhood, there are few things more humiliating than being left out. Loneliness implies a flaw in us like no other longing or sadness does. ‘I’m lonely’ translates to ‘I’m unlovable’ or ‘Nobody likes me.’ It says that you’re a loser. / But loneliness isn’t necessarily tied to whether you have a partner or a best friend or an aspirationally active social like in which you’re laughing all the time. It’s a variance that rests in the space between the relationships you have and the relationships you want. Loneliness lives in the gap. (Radtke, 2021, p. 70-71)
Specific to Kabi’s drinking problem and, later, pancreatitis, Nobel notes, “Loneliness arising from the sense of deliberate exclusion by others has significant risk for depression, addiction, or even suicide” (2023, p. 165).
There are additional elements of Kabi’s experience with loneliness as well as the larger healthcare issue it might indicate. First, Kabi remains convinced, even after her misadventures with lesbian escorts, that the solution for all her woes is a true romantic partner, someone with whom she can connect fully; her earlier obsession with death is gradually replaced “toward a thirst for love” (Kabi, 2018, p. 106). “But there are things that, surprisingly, haven’t changed. / Like the fact that I can still feel so sad, miserable, and lonely that I sometimes burst into tears. / I’ve cried mainly because… ‘I’ve been alive for twenty-nine years, and I’ve never had a single love!!’” (p. 103) (See Figure 3). She wants to be able to say, a la Jerry Maguire, “You complete me,” but that notion, dating back to the time of at least Aristophanes (Alberti, 2019, p. 64), comes with its own complexities: “The idea what there is a special someone for everyone, and that wholeness is dependent on finding that person, is incredibly limiting,” reminds Alberti (p. 66). Noble adds, “For many lonely people, a primary source of their disconnection from others is their broken connection with their inner selves” (Nobel, 2023, p. 29), and “This disconnection from self can be the first determinative tear in the fabric of connection” (p. 44). While this falls outside the scope of this [writing], it could be asked if the sexual assault Kabi suffered as a child – disclosed only late in her narrative – contributed to her self-isolation as an adult. Even so, the art of My Lesbian Experience with Loneliness frequently depicts Nagata in isolation, often surrounded by her speech and thoughts. This, I feel, visually conveys Radtke’s sentiment that “The problem isn’t so much in the time one spends alone, but in how one feels about that loneliness” (2021, p. 68).
Figure 3
It may be helpful to view Kabi under a particular lens – as experiencing hikikomori, a documented Japanese phenomenon of acute social withdrawal. “Japan has unique terms for two specific conditions related to loneliness. One is Hikikomori, or the acute social withdrawal of adolescents and young adults, and the other is Kodokishi, which refers to the concept of dying alone,” says DiJulio et al., of the Kaiser Family Foundation (2018, p. 15). As of 2020, over 1 million individuals meet the official government definition of hikikomori and suffer from associated physical illnesses.
The term – which “derives from the Japanese verbs hiki and komoru, which means ‘withdraw’ and ‘come into’ respectively” (Castelpietra, Nictora, & De Leo, 2021, p. 47) – may be especially useful in considering expressions of the loneliness epidemic internationally. A growing body of research shows that hikikomori occurs not only in Japan, but also in neighboring South Korea and China, as well as in countries as diverse as Oman, India, Spain, France, Italy, the United Kingdom, Canada, Australia and the United States (Castelpietra, Nictora, & De Leo, 2021, p. 49).
The Kaiser Family Foundation team sees hikikomori “as a coping strategy to survive a stressful and high-pressure society in which youths fall at the bottom of the social pyramid” (Castelpietra, Nictora, & De Leo, 2021, p. 53). A study of documented hikikomori in Japan found half of the participants were shown to carry comorbid affective, anxiety, and substance use disorders (Koyama et al., 2010). Interestingly, as Kabi’s health deteriorates, she refers less and less to her loneliness as the root of her distress and more to the guilt she feels concerning her lifestyle, her parents, and her limitations. Again, this is an “emotion cluster.” “But I keep drinking… to sorta escape the ugly thoughts and stuff, to avoid the guilt. / I’m drinking to get through my work and emails—I can’t without it” (Kabi, 2021, p. 124). The titular Loneliness of her first volume has become obscured by the palimpsest of illness, guilt, and shame.
Kabi’s manga will extend into 2026 with the English translation of My Wandering Warrior Eating Disorder. Further, the trajectory of loneliness’s effects on her appear to continue their arc. As she mulls in 2023’s My Pancreas Are Broken by My Life Got Better:
‘Were my poor communication skills…a large part of why I got into drinking?’ was my thought. / Being treated like an adult might have been the start of my drinking. / But I really feel like the reason it became a full-blown addiction was because of my inability to communicate, and how terrible I am at saying what I actually want. ‘I can’t!! I’m scared!! I can’t make them understand anythiiing!!’ / If I don’t fix this…I think I run the risk of getting addicted to something else or escaping into alcohol again” (p. 132).
That risk is echoed by Cacioppo and Patrick (2009), warning that issues with self-regulation brought on by extreme loneliness may also include eating disorders (p. 37).
Taken as a whole, Kabi’s comics track the medical ramifications of intense loneliness, serving as a keen example of the epidemic’s effects and an comics exploration of its healthcare impacts. All this, however, is not to doom Kabi necessarily, especially as she uses her art to investigate the sources and effects of her loneliness. The U.S. Surgeon General and his HHS team detail a number of possible, personal remedies for combatting loneliness and taking back one’s life. In some of her concluding words from Seek You, Radtke envisions a way to create community and engender discussion as we share the loneliness we may each experience, “I want to use loneliness—yours, and mine—to find our way back to each other” (2021, p. 340).
References
Alberti, F. B. (2019). A biography of loneliness: The history of an emotion. Oxford University Press.
Cacioppo, J. T., & Patrick, W. (2009). Loneliness: Human nature and the need for social connection. W. W. Norton.
Castelpietra, G., Nicotra, A., McGiffin, E., & Leo, D. D. (2021). The hikikomori phenomenon: Could loneliness be a choice of self-restriction from society? Open Journal of Psychiatry, 11(01), 47–62. https://doi.org/10.4236/ojpsych.2021.111005
DiJulio, B., Hamel, L., Muñana, C., & Brodie, M. (2018). Loneliness and social isolation in the United States, the United Kingdom, and Japan: An international survey. Henry J. Kaiser Family Foundation.
Duggan, K. (2023, November 18). Why is Ireland, the land of a thousand welcomes, the loneliest country in Europe? The Irish Times. https://www.irishtimes.com/health/your-wellness/2023/11/18/ireland-lonely-country-europe-survey/
Green, J. (2009). Binky Brown Meets the Holy Virgin Mary. McSweeney's.
Kabi, N. (2017). My lesbian experience with loneliness. Seven Seas.
Kabi, N. (2018). My solo exchange diary, volume 1. Seven Seas.
Kabi, N. (2019). My solo exchange diary, volume 2. Seven Seas.
Kabi, N. (2021). My alcoholic escape from reality. Seven Seas.
Kabi, N. (2022). My wandering warrior existence. Seven Seas.
Kabi, N. (2023). My pancreas broke but my life got better. Seven Seas.
Matt, J. (1992). Peep Show (Issues 1-15). Drawn and Quarterly.
Mulgrew, S. (2023, June 7). Ireland has the highest levels of loneliness in Europe, new study finds. Irish Independent. https://www.independent.ie/irish-news/ireland-has-the-highest-levels-of-loneliness-in-europe-new-study-finds/a1717927937.html
Noble, J. (2023). Project unlonely: Healing our crisis of disconnection. Avery.
Office of the Surgeon General (OSG). (2023). Our epidemic of loneliness and isolation: The U.S. Surgeon General’s Advisory on the healing effects of social connection and community. US Department of Health and Human Services. http://www.ncbi.nlm.nih.gov/books/NBK595227/
Radtke, K. (2021). Seek you: A journey through American loneliness. Pantheon.
Thorogood, Z. (2022). It’s Lonely at the Centre of the Earth. Image Comics.
Tomine, A. (2020). The Loneliness of the Long-Distance Cartoonist. Drawn and Quarterly.
Ware, C. (2003). Jimmy Corrigan: The World’s Smartest Kid. Pantheon.
