U.S. Surgeon General Dr. Vivek Murthy: Efforts & Challenges in Promoting Public Health

26:07And they are to managing the crisis messages. But I think that their equally is important. But I do think that what you're pointing out is an infrastructure piece that that needs to be built, which is a way for, you know, health authorities to reach people, you know, with information quickly and comprehensively. I'll just tell you that in the 1980s, when Sea Ever Coop was the Surgeon General, one thing that he had done, which was interesting is he had actually sent a letter, a physical letter, to all households in America about HIV. A physical letter. A physical letter. Some of our listeners won't know what that is.

26:41Yeah. So, you read about the history books. There's some shows up in your mailbox and you open it and hopefully something you want to read. But in this case, this case, he was worried about HIV about the fact that people didn't know about it. So he worked through and, with, as I understand it with a member of Congress, found, you know, a way to do this from a funding perspective. But it was a very unusual move. And one that was never replicated since, and there was never infrastructure funding to do that again. When I was Surgeon General last, you know, some years ago, and then this time around, one of the things I did do is I was able to send a physical letter to the medical community.

27:22The first time it was about the opioid use crisis and about changing our prescribing practices in medicine so that we expose fewer patients to the harm of opioids while making sure people who needed them actually got them. And the second time it was about COVID therapeutics. It was about making sure that when we had data about medicines that actually worked like Paxlevid that we may actually offered them to patients, made them available to patients because we were realizing that many people weren't getting offered, life -saving medications, even though they were in high risk groups. So we were able to find, you know, and we, again, there too, it was sort of creatively cobbled together resources funding.

27:57This is all sort of, you know, sort of behind the scenes government stuff. But the bottom line is that you want an in emergency. And what you want, I think, in the long term, is a simple, clear, comprehensive way that public health messages can get out to people. And to this day, what we still have to rely on are one traditional channels, like, you know, traditional media to cover the initiatives we put out, whether it's on social media, and youth mental health, or on loneliness, or on youth mental health more broadly, we have to rely on online channels, which we do as well. Or we have to look to creative partnerships that we build with people who reach different audiences.

28:35And then together, we try to get our messages. Our office does all three of these, but it's a patchwork. And, and, you know, and it's not always ideal, but it's what we do now. I think part of what this reflects is a broader challenge, like in government, but also in society more broadly, which is that we have valued historically prevention and health communication very little. We put the mass majority of our resources into treatment strategies, into getting medications to people, into diagnosis. And that's very important. Don't get me wrong. But we are now seeing with mental health diseases, one example that if we only focus on expanding treatment and deepening our well of knowledge there, and we don't do anything to help people stay well, but we just can't keep up.

29:27Right. Because one problem feeds the other. Exactly. The kids that are stay listening, if I would grown up in today's era, I'd be on my phone and tablet late at night, because I was up reading magazines and talking friends on the phone late at night. So it's not a criticism, but, but, you know, disruptions in sleep, disruptions in circadian rhythm, disruptions lack of physical activity, poor nutrition, social isolation. I mean, these are all piling the sand much higher on this, in this other side of what you do in terms of, and here I'm obviously stating the obvious. You know, so it's just going to create a mountain of issues on the other side, which presumably has a larger budget is what I'm sensing, but doesn't, but there's no way that budget is large enough to deal with that.

30:09I mean, if somebody's kid, for instance, is trying to address the issue of whether or not to go on prescription medications and or, by the way, folks and or change their dietary intake because they feel they might have ADHD, for instance. I mean, what are they going to do? They're going to Google. They're going to listen to podcasts that they should be able to write first to your organization and say, you know, what is the highest level stringency data say about these issues and AI should be able to tell them accurately. Yeah. And maybe you have somebody chime in for them. I mean, we all pay taxes.

30:49I pay federal and state taxes. And to some extent, happily so, right? Because it pays for public works and many, many important things, police officers, firefighters, et cetera. But if you don't have a channel to communicate with people about what they and their kids and their relatives can do, then to some extent, it feels like it's a cul -de -sac. It's like how in the world can we get healthy again or healthier as a country? The part that keeps me up at night is, and one of some of the hardest decisions I have to make in the office are putting aside issues that we know deserve a lot more time and attention.

31:36But we just really don't have the resources to deal with. The issues that we have dealt with, I'm certainly proud of my team that we've worked hard to try to raise awareness of the issues we have taken on, whether it's around social media and youth and mental health or whether it's around isolation or clinical clinician burnout or other issues like that. But the truth is that there's more that needs to be done. More issues that need to be tackled. And we have to get to a place where we can talk about what I think of as a core pillars of a healthy life, which are sleep, our nutrition, our physical activity, our social relationships.

32:10Like these are all vital elements to living a healthy life. Right now, we're not teaching kids about this in school, right? But if you think about education and school as a place and a force that should prep, prep kids for the rest of their lives, it should lay a foundation for a healthy life going forward. These absolutely are important elements for kids to learn about. I think it's as important for kids to learn about how to build and maintain healthy relationships in their life as it is, frankly, for them to learn how to read and write. And I know that's a strong statement to make, but it is true in terms of its contribution to their happiness or fulfillment, their health and their success.

32:51I could not agree more. We have a series that's out now with a psychiatrist, a Paul Conti, about mental health, not mental illness, about self -inquiry and how to use self -inquiry and practices that do not require a therapist in order to bolster mental health. Of course, therapists can be very useful, but not everyone has access. And not everyone feels comfortable doing that. But we are, but one channel, I mean, you are the governing body for this. You're the army, Navy and Marines, so to speak, of health. I'd like to take a quick break and acknowledge one of our sponsors, Athletic Greens. Athletic Greens, now called AG1, is a vitamin mineral probiotic drink that covers all of your foundational nutritional needs.

33:38I've been taking athletic greens since 2012, so I'm delighted that they're sponsoring the podcast. The reason I started taking athletic greens and the reason I still take athletic greens once or usually twice is that it gets to be the probiotics that I need for gut health. Our gut is very important. It's populated by gut microbiota that communicate with the brain, the immune system, and basically all the biological systems of our body to strongly impact our immediate and long -term health. And those probiotics and Athletic Greens are optimal and vital for microbiotic health. In addition, athletic greens contains a number of adaptogens, vitamins and minerals that make sure that all of my foundational nutritional needs are met.

34:16And it tastes great. If you'd like to try athletic greens, you can go to AthleticGreens .com slash Huberman. And they'll give you five free travel packs that make it really easy to mix up athletic greens while you're on the road and the car on the plane, et cetera. And they'll give you a year supply of vitamin D3K2. Again, that's AthleticGreens .com slash Huberman to get the five free travel packs and the year supply of vitamin D3K2. There's a lot more to explore there. We may have to do several of these together, but to touch on all of them. But maybe we could talk about a few of the things that our listeners asked about when I solicited for questions.

34:58And I got more than 10 ,000 responses across social media in a very short amount of time. But there was some redundancy. One of the things that I'm very curious. Can I just say on that point? One, I'm really glad that you asked folks to submit questions. And it was really excited to see how many people actually wrote in. But I think it's also just a testament to how you've done such an incredible job of building a channel to the public, to let people know about these topics that are so vital to our health and well -being, whether it's sleep or physical activity or mental health. And so I just want to thank you for all the work you're doing trying to help people understand more about health.

35:35And clearly the fact that folks are engaging, they're sending questions and they're sending comments to you means that you're building a relationship there with a lot of folks. So just kudos to you for doing that. Well, thank you. The audience of the Hubert and Lab podcast is the only reason we do it. I mean, I love learning and teaching, but that's the truth. So they are the podcast. The podcast is them. So thank you for that. There were a lot of questions. And I also wonder about, why is it that many food additives and preservatives and dyes and things of that sort that are not allowed in Europe or allowed in US food products?

36:19So really good question. And decisions around food and food safety in particular are made by the Food and Drug Administration. So that's the FDA. It's not it's a separate agent independent agency. It's not one that our office is involved in and sort of directing in any way. And so we're not involved in those decisions and don't have insight into how they're making their drawing their conclusions. But they do it in a process that's you know guided by science just like they do and with medications with devices, etc. With that said, you know, I am concerned that dietary practices, the food that many Americans are consuming are in fact not supporting their health and well -being and in many ways are detracting from it.

37:07When we look at highly processed foods, one of the concerns I have there is we often see sodium content is very high. We see the sugar content is very high. And you know, there are certainly additives in there as well that I think we I would love to have more data on the actual health impacts of those. But the bottom line is that a significant portion of our diet is comprised of highly processed foods in America. And that worries me. The also other piece of this that worries me are just how much you know, refined sugars are being added to so much of our foods. And most people think that sugars are only added to things like desserts, etc.

37:48But you look at spaghetti sauces, salad dressings, salad dressings. A lot of these things which we think of as savory products have sugar added to them as well. And so we are consuming, I think unhealthy levels of sugar in our diet. We're consuming a fair amount of additives given the process food composition in our diet. And I think part of the reason this is happening and there won't be very clear. I don't fault individuals out there for the composition of their diet necessarily because we have also made certain decisions in our country about what we subsidize about what's cheaper and more expensive for people.

38:27And the cheapest foods unfortunately are often the most unhealthy foods, the most highly processed foods. If you are somebody who lives in the low income neighborhood, number of these neighborhoods don't even have grocery stores in them, which is a tragedy because you can't get fresh produce, etc. A lot of times you're shopping, you're grocery shopping may be done at a local convenience store at a 7 -11 or somewhere else that may not have like the array of fresh fruits and vegetables that you and your family need. I don't even think they have vegetables. I think they occasionally have some lemons or apples or oranges of bananas.

39:04But when I walk into a convenience store, what I see is a pharmacy. I really do. I see alcohol, caffeine, energy drinks that have a number of different things in them designed to stimulate different neuromodulators, like dopamine and serotonin. I see nicotine products. I see high sugar, high highly processed foods. And keep in mind, I was a teenager. I mean, I drank my slurpees. I had my butter fingers. You know, I wasn't you know, Bart Simpson like in my level of butter fingers, but I liked them. But it was it was a smaller fraction of what we ate. And when we were at home, those foods were either not available or we weren't we certainly weren't allowed to eat them and add libdom.

39:44You know, okay, so what's clear to me is that the FDA makes decisions about what is safe, what's not safe. But for instance, okay, this last year there were several papers published in high quality journals showing that if people eat just high, just sweet and savory foods combined, that neural circuits in the brain rewire through process of neuroplasticity that drives increased appetite and changes the response to healthier food so that they don't taste as as satiating. Okay, that's sort of a duh to a lot of people. But I think it was an important set of findings because it said the brain actually changes in response to the very rich flavorful foods that are associated with highly processed or even moderately processed foods.

40:33Okay, I mean, that's just a couple of studies. There was nothing in those studies that said, if you eat these foods, you're going to develop cancer. But you know, at some point one has to as a citizen, a tax -paying citizen, speaking on behalf of many other tax -paying citizens, I have to sort of take a step back and say, how long do we wait? Do we have to get a randomized clinical trial about the 500 ,000 sick kids that grow into sick adults and then run a trial where they go on an elimination diet where they're eating only on processed vegan or unprocessed meat and vegetable or unprocessed starch and vegetable.

41:15I mean, then we're talking about a 30 -year health crisis before we intervene. Why not, I mean, if I were in charge, which I'm not, and clearly I wouldn't survive in a government organization because, well, I got the uniform down. I always wear the same thing, but a uniform. But I wouldn't because I would want to say, wait, you know, why not air on the side of caution? Why not send out this AI -generated text message that tells everybody in all the languages that Americans speak and can understand? Hey, you get to make choices about what you eat, but you should be aware that making your diet comprised of more than 15 to 20 percent of these foods is potentially going to lead to serious issues down the road.

41:57And those serious issues are extremely serious. I mean, the obesity crisis is really a crisis of both body and brain metabolic challenge that we can talk about. So, you know, who sets the thresholds? You know, in other words, why is it that in this country we have to wait until people start to get really sick and dying and really struggling before something is done in the direction of their health? And I'm not blaming you. I just want to understand because the wealthy people I know care a lot about their food sources, and they pay a lot of attention to it. And why aren't we allowing everyone the opportunity to make better choices?

42:36So, this is the right question, and this is something I think about a lot, because I'm conscious about what I eat, but I also talk to folks around the country and realize a lot of people don't have either the information or the resources to actually purchase healthy food, right? And to know like what's going to be good for them and for their families. This is why, you know, I mentioned we have a list of issues that, you know, we would work on, you know, if we had more resources, this is actually one of them, because to me, one of the most common questions people ask is, what should I eat? That's simple, but it's it's a vaccine, it's complicated, and it's incredibly confusing.

43:11If you go online and just try to search for information. And it's a classic example of where it's important to have an objective, scientific authority that can come and then speak on broad principles around diet that can talk about what we know and don't know. So, here's an important thing. I think a lot of times people may see something as, you know, on the market, they might really list of ingredients, they don't recognize half of them because they're additives, but they figure, well, if it's there, then it must have been studied for 30, 40 years, and there must be no harmful consequences, right?

43:44But sometimes things are put out there because we have short -term data that says that they're okay, and there might be, but there may be a need for more long -term data. Helping people understand what do we know, what do we not know is important, so that people can make decisions for themselves based on how much risk they want to take. The other thing that the concerns me, Andrew, is I, look, I'll tell you, I have a bias here, and my bias is that I am worried about the, you know, additives and other products we have in food, they don't have long -term data that's clear in terms of health risk.

44:17And so, because of that, like my bias is generally to think, how can we get people, you know, minimally or less processed foods, and how can we get the more fruits and vegetables? How can we make sure that they have that more available to them? But we've got to not only meet the information available, but we have to make it accessible from a cost perspective. If you don't have a grocery store in your community, if vegetables and fruits cost 3x, what other foods do, that's going to be a problem, right, to change diet. The other thing we have to keep in mind is that, you know, food companies, you know, a lot of them do a great job of actually trying to get healthy nutritious food out to people, you know, and kudos to them.

44:52But I worry also that there's an incentive also to just try to sell more and more and more of your product. And one of the ways to do that is to try to hack the body to kind of figure out, okay, well, what kind of synthetic additives could I put together here or what kind of combination of nutrients could I put together that will get people coming back for more and more and more? And we saw this in the nicotine industry. You saw the nicotine industry, you also, I would say another in parallels, you see it in social media as well, where the business model of the social media platforms is built on volume of use, right?

45:26How much time am I spending on the platforms? It's not quality of time. It's quantity of time, right? So if that's the business model, then you're going to design your platform to maximize how much time someone spends on them, regardless of whether it's detecting from sleep, interacting from in -person interaction, detracting from anything else that's healthy, regardless of whether that may be causing certain harms, right? Like the business model dictates, you know, in many ways how these things are designed, and that applies, I think, to food as well. So which is why I think it's incumbent upon us to be particularly cautious with highly processed foods, foods that have additives, and to understand how is this impacting our brain?

46:03How is that impacting our satiety? How is it leading potentially to greater ingestion that is healthy and leading to things like obesity, which have a whole host of other medical conditions from cancer to arthritis, to diabetes, and heart disease associated with it? Those are the questions as a citizen, as a father, of two young kids who's trying to bring them up at the healthy lifestyle. Those are the questions that I would want to know the answers to, and it's one of the reasons I think these kind of objective reports are so important for the public. I'm just trying to see the scope of the problem and the mechanics involved in trying to alleviate these issues are complex.

46:42I see that. They aren't also to one of the things that's important to do that, though, is you need to have authorities that can speak to these issues, better insulated from political retribution. They explain this. I mean, listen to that. Listen to somebody, forgive me for interrupting me, somebody who from time to time will make not recommendations, but will offer information about potential actionable items, things that people could do or not do according to a couple of studies that have come out. I mean, they have come under intense scrutiny from my colleagues who are like, wait, that's not a randomized controlled trial.

47:22How can you do that? Yet, I know from being in this field for a long time that, for instance, the emerging therapies for PTSD and depression that are now based on federal funding for things like, and I'm not recommending this, by the way, for children or for everybody. For instance, the macrodose psilocybin therapeutically supported legal use of psilocybin for major depression. The data there are not perfect, but they're pretty darn good compared to the major SSRIs. But for years, if an academic said, the words I just said, they've lose their job almost instantaneously because they're controlled substances.

48:00That's a to -do, but then there are a number of things that we're talking about here that are just about making better choices about things to avoid. If people understood, I think that it's sugar poison, well, some of my audience will say sugar is poison. It's as addictive as cocaine. Look, it is not as addictive as cocaine or heroin. It is not. However, if a child or adult is eating very sweet or very savory foods of any kind, consistently, if those are not healthy foods or if they contain unhealthy additives, over time, the brain will rewire so that healthy foods don't taste as good. They won't be the choices that people make, and you're going to end up with a sick individual period.

48:41And I don't think we need one more clinical trial funded by federal tax dollars to support that statement. What I'm starting to gather is that you're a very rational, grounded, broad thinking individual. I'm not just saying that because you're sitting here, and you're trained in medicine, and you understand the science, but that you don't have the means at your disposal to put out a call that says, hey, folks, having some sugar every once in a while, it's reading the kids to ice cream great. But if 80 % or more of the diet of our kids isn't made up of minimally or non -processed foods, their brains are going to be rewired in unhealthy ways, and you can almost expect that they're going to have some health challenge in the future that may not be autism or schizophrenia, but is going to be a major health challenge of a, and that is serious, and now's the time to intervene by avoiding certain things.

49:37And if you don't want to do it, look, it's a free country at that level, you're welcome to do it. But you'd be better off spending X number of dollars on these healthier foods, because there's also, and we know this from my colleague, Ali Krum's laboratory at Stanford, that even the mere knowledge that certain foods are nutritious can lead to more satiety from eating those foods at the level of hormone release, not just psychologically you're telling yourself, whether the orange is as tasty and filling as a candy bar, but the understanding of the fact that it is nutritious actually leads to shifts in patterns of, you know, grill and secretion, etc.

50:13So people can be feel better on a healthier, slightly lower calorie, nutrient and rich diet of healthy proteins and fruits and vegetables, and it's not a mind trick, it's physiology. Yeah. Anyway, I think I feel your pain for frankly. And I'll tell you, look, sometimes people ask, hey, why don't you just go and say a couple of statements that you just said, would that be fine? Like, why, why is time needed to prep someone that why are we sourcing it, etc.? Here's actually why. Like, I know in today's day, it's easy to just go and like, rattle off off, you know, off the cuff statements or shoot from the head.

50:50My social media channels and really to get their word out to millions. I appreciate that. And that may take you up on that. But I'll tell you that one of the reasons, one of the things we always do, recognizing that when we put out statements that people, people, one, they trust it's coming from a scientific authority and that it's been vetted, right? So we put the effort and time into vetting this thoroughly. We check sources, we look at the data, we talk to experts, we think about how to communicate this in the right way. That's the work behind the scenes work that we do before we put out sort of reports and initiatives.

51:24Because we want people to have confidence, you know, in what they're hearing. We also know that when we put out initiatives that other people build on them, philanthropists, you know, and foundations will then think about should I fund work in this area, you know, schools and workplaces will think about shifting some of their practice policy makers will also think about legislation that they may want to design based on that. So we want to make sure it's really solid. But the point I was making when I said also that we have to make sure that not just our office, but folks who are, you know, in public health and who are in medicine who are trying to speak to the public about their health that they are protected from retribution and attacks is this is what I meant, which is that is saying things about diet, saying things about tobacco.

52:09These can be challenging for some folks because their industry is built around these, right? Which may not always like what you have to say if it hurts their business model or their bottom line. And they may then lean on political leaders, elected leaders, others to then try to silence you or shut you up. And I'll tell you I've experienced this in the past, you know, then I was surgeon general during my first term. I had issued two key reports. One was on alcohol drugs and health about the addiction crisis. And the other was about the e -cigarette crisis among youth. I will tell you that they were plenty of people who were very unhappy that I was issuing the first federal report on e -cigarettes.

52:51Folks who felt that hey, this is going to make folks unhappy. It's going to create political pressure. It's going to create a lot of problems. Similarly with alcohol drugs and health, there are many folks who said hey, if you do this, you're really going to upset the alcohol industry. Do you really need to have alcohol in the report? Why don't you just focus on other drugs? Why don't you take alcohol out of the title? You know, all of these sort of, you know, concerns are erasing you this. So, so are people who get paid by the alcohol industry? These are people in government who are reading the tea leaves and who are supportive of the work we're doing, but everything.

53:23Hey, like you're going to really upset a lot of people. And industry and you're also going to help a lot of people. Yeah. Well, this is what it comes onto. They say, well, and if you upset folks, then they're going to try to fire you. They're going to try to do all these things to which honestly, like my my response to a lot of these and the reason we just put them out anyway was because I said, well, the worst thing that can happen is I get fired. And that's okay. You know, if I go out knowing I did the right thing here, then I'm fine with that. I'm not looking to build a lifelong career in government.

53:52I'm not doing this job to like, you know, get to the next thing on the ladder. Like this is about serving for the time I can. I wanted me to be able to go to sleep at night, look myself in the mirror. I know I did so with integrity. So that was an easy decision for me. But but my point is that like we have to be thoughtful that in these issues that they're going to be headwinds, right? I'm sure in your case, for example, you probably gotten pushed back from folks about talking about certain things that may have wrinkled folks who may have had an interest in those issues. And that's okay. You keep talking about them as you should.

54:23And I'm grateful for that. But this is especially especially important at a time where I think public trust in our institutions more broadly and in science and in medicine have taken a hit over the last few years. And I think it's a time where we have to be even more vigilant. Those of us in medicine and public health to make sure that what we do is based on data that we're transparent about why we're saying what we're saying that we're also clear about what we know and what we don't know so that if recommendations change over time, people recognize that this isn't necessarily flip -flopping, you should change your recommendations if the data changes, if the circumstances change.

55:05So anyway, this is all part of the work that we've got to do. But to me, this is a really important part of the work. The integrity behind our work in public health is not just about the issue we're taking on today. It's about the trust that we need to rebuild in the field more broadly. So if I understand correctly, if you were to, for instance, put out a call that says, look, you know, there are food additives that are allowed in the US that are not allowed in Europe that may be of risk. We don't have enough data at present to avoid these things, but here's a kind of a yellow zone. You know, your green known to be safe, red, clearly known to be unsafe, yellow, we just don't know yet, not enough data.

55:45So here's what my recommendation would be for my children. It's free country, you know, people that argue it's not, but at least at the level of which foods you want to buy with your own budget, it's a free country. So you're saying that you get messages that warnings about certain things could lead to push back. But if I have to imagine that there's something, and I'm not a conspiracy theorist, but there has to be either the people that are saying, look, there could be problems are just friction averse. They just don't like anyone to be angry at anyone. Or there must be some incentive for things to remain quiet.

56:29I mean, surely the government has not had problems saying to do things or to not do things that had that upset companies or shut down companies or elevated companies and their success. So I'd like to know more about the back contour of this. Well, look, I think and this is not too dissimilar for I think what happens in other industries. But it's, you know, whenever you do something in whether it's in the private sector and government, people weigh what are the pros cons? What's a pushback? I'm going to get how do I deal with that pushback? Right. And pushback isn't always a bad thing, right? If you get pushed back from the public, people, hey, that doesn't make sense.

57:04It makes sense. That's you should listen to that and then use it to inform your approach. But that's the public whose your job is to serve. I'm talking about pushback from companies is different. Right. So when pushback comes from people who have a financial interest in the product, that you may be commenting on, then you've got to be you need to know about that number one so that you know how to how to mitigate it. And while people may take different approaches to this, my approach as a public official as surgeon general has been to say at the end of the day, like I'm happy to to hear from anyone in terms of their concerns or pushback.

57:36But the end of the day, what's going to guide my decisions about what we issues we take on, what decisions we make, and what we say to the public is going to be what is in driven by science and the public interest. And if that means it's politically inconvenient, that's okay. If that means that you know, something happens, you know, to my job, that's okay too. You know, like we look, the bottom line is life is short. We don't know how much time we have here. We may as well make the time we have count. We as a do the things that are right and that are going to serve people. That's my simple philosophy, my parents taught me when I was growing up.

58:06So that's the approach I bring to this. And that's why if we were to do let's say an initiative on diet, I have no doubt that some of the things that we would say would be perturbing to folks who had a financial interest in industry because I don't think that the current setup in the industry is serving the public well. I think we have made unhealthy foods cheap. That's a problem. We've made healthy foods expensive. That's a problem. We put health from a dietary perspective out of reach for millions of Americans. That is a fundamental problem. And we've also disempowered people with that by not giving them the information that they need to make decisions.

58:41So even if you have resources, I guarantee that there are people listening to this podcast and many more people out there who go to the grocery store and just feel confused. What on earth should I buy? What's healthy? What's okay anymore? It's just hard to know. And so I think we've done a disservice by not doing more to help the public understand and access healthy foods. And again, it's why it's an issue that was on our list of issues that we would want to work on because I think that the public health need here is immense. I have a question about trust in big institutions and public health initiatives in general.

59:17The question is about masks. Early in the pandemic, as I recall, we were told that masks were not necessary. Then we were told they are necessary. And I think for a lot of people that flip in messaging and they were told that they were not doing anything. Landed like a parent telling their teenage kid to always wear a seatbelt. But then you look into the front seat and how my dad aren't wearing seatbelts. And as anyone who's been around teenagers, there has been one. You make that mistake once. You're not making it again. And you may never recover from that particular example. In other words, the public felt like there was a switch of messaging.

59:59But what I don't recall happening was a like, hey, we got that one wrong. So sorry on us. You know what? The new data say blank. What I recall was a message of don't and then do. But there wasn't a lot of kind of acknowledgement of how challenging the situation was. It was just a lot of top down mandates. And in my opinion, and this is just my opinion, I think that led to a pretty rapid distrust of subsequent messages from which we still haven't really recovered. And so why do you think it's so challenging for public facing officials to just say, look, doing the best we can at the moment, screwed up before changing the message.

1:00:49Now it may change again. We're navigating this in real time. It's dynamic. Yeah. Please stay with us because you know, goes without saying there's been a huge chasm around this and related issues. Yeah. And look, it's a important question. And look, I, I'm always, I want to be thoughtful about, you know, how I comment on what was done in the first year of the pandemic. I was, I was a citizen as outside government. And I don't know what was happening inside government in terms of the the decisions that were made there. But I do know sometimes from my experience in Ebola and in Zika during those experiences we had as a country that in the, you know, in the fog of war when everything's coming at you, sometimes it's hard to make the right decision all the time, right?

1:01:31So I want to give some of those folks who were there, you know, in the first year of the pandemic, you know, some benefit of the doubt. But I do think that the important thing, the principle I I certainly try to follow, but when I think that, and you know, we can all do better, I can do better certainly too. But I think an important principle for us in public health communication has to be that we're clear, that we're transparent about what we know and what we don't know. And then we explain the why to people. So if we're telling someone to do something, why is it because there's a lot of data behind it, is it because it's a sort of expert agreement best practice?

1:02:11Because sometimes in medicine, sometimes when we don't have enough data to guide us on a therapeutic approach, but when the problem is imminent, then sometimes experts will get together and put together expert informed guidelines to say, okay, look, based on our best judgment and the limited data we have, here's what we would recommend. And as the data evolves, we will change, you know, and modify those recommendations. We do that with hypertension, right? New evolve and update recommendations.

1:02:41We do I think one of the challenges that I saw many public health officials encounter was even when they went out with comprehensive messages like that, which are hard to fit into a sound bite or into simple posts on social media, often a lot of that wasn't covered. What gets covered is the top line. You know, this is what's really recommended. That's what's being required, etc. All the explanation is lost. It's missing, right? And I think we also are living in a time where people are reading headlines, like they're living busy lives, right? They're not necessarily, you know, always hearing all of the nuance, you know, that's being explained.

1:03:15But I think that that's a challenge, right? It's like, I think I know many public officials struggled with how do you deliver nuanced information at a time when there isn't a clear, black and white answer to things. But I think the last piece around this is, I think something I was taught early in medical school is to approach your patients with humility, recognizing that even though you have more training than they do, you don't aren't living their life. You don't necessarily know what they're going through. And you shouldn't assume things about them, right? And so approaching with humility means that you've got to recognize that not everyone's going to be able to follow your guidance.

1:03:52And if they aren't able to, that doesn't mean you criticize them. It also means recognizing that people may have ideas or suggestions for you that may actually improve your recommendations or how you communicate. And so these are the principles I think that are important in public communication. But I think that both the challenge of translating nuanced arguments into what's actually covered, that was tough for many public health officials. I think the other thing honestly, just on a human level that became hard for many of them. And I am thinking particularly about local and state public health officials who are on the front lines that I talked to a lot, was they ended up getting attacked a lot and abused a lot during the pandemic.

1:04:31And I don't just mean like attacked online. I mean, people showing up at their houses, people harassing their children, people threatening their safety. And this is often people who were upset about some of the requirements that were being put down from local departments of health. And you can understand what COVID was as stressful a time as we've seen recently, people lost their jobs before losing loved ones. I mean, talk about a stressful time. But I think at a human level, public health officials who were exposed to that kind of abuse and who started to worry about their children's safety, many of them stepped out of the arena and said, is this really worth it?

1:05:08To put my family at risk. And that was hard because we lost a lot of good public health people in that respect. So I think in addition to having sort of these core principles of public health communication in place, then what we also need to restore is an environment where we, of frankly, a humility and civility where we don't attack people, who maybe have different views or are coming out of recommendations that are not palatable to us. And I think it's also incumbent upon our leaders in society to not stoke that kind of resentment and violence as well. Because that happened during the pandemic as COVID got increasingly politicized.

1:05:47And while that may have been at times done for political reasons here and there, the people who suffered were both the public health leaders who are trying to do the right thing for their communities and the public themselves who weren't able to have a clear direct channel to and a dialogue with their public health officials because a lot of that ended up getting closed off. Yeah, I feel like there was a lot of talking down to the dissenters in the general public. Yeah. And I totally agree that, you know, getting violent or harassing people with whom you disagree is totally inappropriate. And you're the one thing just to say about the humility piece.

1:06:25And I'll give you an example here of where I think this could have been should have been done better. Isn't an effort, for example, around masks to recommend that people wear masks. And one important thing just to know is that when it comes to like schools requiring masks, like those are decisions that are made on local levels, right? The federal government doesn't mandate masks in schools. It doesn't have the authority to do that. So those are local, local decisions. But at the end of the day, they were people who did not want their children to wear masks, right? For a variety of reasons, some worried about their development, social development, some worried dead.

1:06:59It was adding stress to their kids. Like people had met in different reasons why they may or may not have wanted their children to wear masks. And one of the things I think that was not helpful was that when they were to keep parents who made the decision, they didn't want their kids to wear masks. I think some of them received a lot of criticism without people necessarily stopping to understand why they may have been making that decision. Because I'll say as a parent whose children were in school, my kids are five and seven. And in the first year of the pandemic, they were doing preschool virtually, which was a nightmare.

1:07:30It was incredibly hard for us. Even when they got back to school and the fall of 2021, it was a really tough adjustment for them. And I could understand like some of the concerns that parents were having wondering about, hey, how are these precautions affecting my child's experience and social development? So on the whole, this recommendation may still be, hey, improve ventilation in your classrooms, recommend masking, recommend testing, et cetera. But those recommendations, I think, have to be made in a way that acknowledges like the humanity of people who are may have a different point of view or may make a different decision for their child.

1:08:08And I know that when local localities made the decision, in many cases, to require schools and their kids in their district to wear a mask, that puts some parents who didn't want that. I put them in a hard place, right? And but I think that our failure to actually have an open, honest, respectful conversation about this, where we didn't feel like we were each being attacked, you know, as parents for our decisions or as community members for the decisions we were making, I think that not only hindered, I think the response, but I think it actually contributed to this division, the sense of black and whiteness that, hey, it's us against them.

1:08:45And then suddenly, if I was against one measure, then I was against all of them, you know, or if I was for one measure, I was for all of them, because we just started segregating into sites. And this became a polarized, you know, experience at a time where really it should have been a crisis that brought us together as messy as it was. And that, honestly, Andrew, is what I worry about most for the next pandemic, right? Like, I think we've learned a lot from this pandemic about how to manufacture vaccines and how to develop them quickly, how to distribute them efficiently. And you know, we had one, I want to lose one of the, I think most historic and effective vaccine distribution efforts in this country, even though certainly could have been better, but it vaccines therapeutics, a lot of the nuts and bolts of a pandemic response well.

1:09:37But I worry what we are still struggling with is how we build trust, how we communicate with the public, and how we stay together as a country in the face of adversity. Because if we're going to, if we're divided the way we were during COVID during the next pandemic or the next, you know, for a thought that may come from a foreign adversary, that's a huge national security issue for us. And so that's what keeps me up at night when I think about the next pandemic that may come. Two questions related to what you just said. First of all, as it relates to vaccines, in my opinion, and I think the opinion of many people out there that the response to the next pandemic will be heavily contingent on at least some sort of acknowledgement that there are people who at least feel that there have been vaccine injuries, right?

1:10:33To simply say, okay, the previous round with COVID went this way. And now there's now virus X, right? Let's hope not. God forbid, but sounds like it's coming at some point. And people are going to think to the last time, and they're going to immediately say, well, the last time we were told to, you know, take a vaccine, some people had a good experience with that. Other people didn't. And in this empathy model of acknowledging and, you know, you're letting your moral compass guide and understanding the why behind what people are doing and how they're reacting, it seems to me that now would be the time to at least try and understand where they're coming from, even if one disagrees, maybe even especially if one disagrees.

1:11:24And try and get people aligned now before the next pandemic. And so what efforts are being made if any to try and acknowledge that some people really do feel as if they were harmed? I'm not saying they were or not, but clearly there are people who feel that they or people they know were harmed. Is there an effort to present them with data, to have discussions with them, to try and get people aligned so that the next time around we can be more of a unified front, whatever the necessary response happens to be? Yeah, no, it's a really important question. And to me, I always go back to sort of first principles from practicing medicine, right?

1:12:06Which is if there is a medicine, you give a patient, and even if it helps 99 .99 percent of patients, but this one particular patient happened to be harmed by it. You go in, you acknowledge it, you talk about it, and you together try to try to path for how you want to move forward. And the path forward might be, yes, let's get rid of that medication, but let's use an alternative, let's try it. Or we can't use that medication anymore, hear the risks you may sustain, but we'll find other ways to protect you, right? So that's what we would do in medicine, right? That's what I've done with patients over the years.

1:12:36I think here too similarly, when I think when it comes to tracking adverse events from vaccines, this is an area where the CDC and the FDA track and collaborate. And tracking means not just not only collecting reports from the public and from clinicians when they see an effect that may be related to a vaccine, but it also involves analyzing those to see where they correlate it or where there's actual causation there, right? Because if today, for example, I felt unwell and I traced back what happened yesterday and it turns out, hey, I ate this burrito that was out in the sun for way too long. The question is, am I feeling sick because of the burrito or did the burrito just happen to be something that happened that it's independent of how I'm feeling?

1:13:24Maybe it turns out somebody was actually sick with a GI bug around me and that's the reason that I'm feeling the way I am today. So the analysis that needs to be done on cases that are reported is important and it's something that the CDC and the FDA do together. Now that analysis I think is essential to communicate clearly to the public and whenever I engage with folks in the public which we do often and people will talk to me about their experiences with vaccines, I do think it's important to acknowledge what people have gone through. Like some people, for example, when I got vaccinated for COVID, for example, I felt like I had mild flu -like symptoms for a couple of days.

1:14:01It wasn't great. I would have preferred I didn't have those feelings and then I felt better a couple of days later and then I moved on but I acknowledged it didn't feel good to feel that way. There are other people who may have had experiences where they felt that they had more serious side effects and there may be a question that was that related to the vaccine or not. So I think we have to both hear and acknowledge those. I certainly try to do that. I know I think it's important to keep doing that across all of government but I also think it's important for us to help people understand the process that we have to go through to understand whether those are related or not.

1:14:34If you go online and the CDC's site where they collect a lot of this information and you just purely look at reports that are given of potential adverse effects that you can't sort of take that and say, ah, those are all related to the vaccine. Look at this rate of harm. It's extraordinarily high because we don't actually do that with any other vaccine or medicine. Sure. We start there. We do the analysis and we try to understand what's actually related or not. So I think that's what we've got to do here too. One last thing I'll say is that it's important I think also for us to help put this in context of other vaccines and medicines and interventions that we use.

1:15:13So for example, just take Tylenol, for example, like most people think, oh, well Tylenol, it's safe. There's nothing bad happens if you take Tylenol, etc. But people who track the data know that Tylenol by and large is generally speaking as safe medication but there are people who experience adverse effects from Tylenol, liver damage, you know, and other adverse effects. And you know, that data is available. But what has happened in the case of that medication is that the risks and benefits are both analyzed and then a recommendation is put forward about a generally safe way to use it. And then there's data put out about the the side effects common or rare, right?

1:15:53But I think sometimes we also forget that a lot of the medicines that we have come to take and just see as a normal part of our life, just like any other vaccine, like there's some rate of rare side effects that will happen. I say that because what I worry about in the black and white environment that we're living in is sometimes people will take an anecdote about a potential adverse effect and will portray that as the rule, right? And we'll say, well, look, I know somebody who had this side effect. So nobody should take this because this is what's going to happen to you. If we did that, nobody would ever take Tylenol, no one would ever take ibuprofen, no one would take NICWILM, like no one would take any of the common medications that we pick up at the drug store and that we commonly use.

1:16:35So that's how I think we have to approach this with a combination of clear communication and pathical listening and data and context. Again, that isn't fit neatly in a social media post per se, but I think part of what we're, what we need to do as a country is rebuild the relationship, honestly, between the medical and public health establishment and the public. And I think it starts with this kind of communication. The other question I had about the next pandemic and the one we just had is, why not have committees of people of diverse backgrounds, socioeconomic diversity, racial diversity, every aspect of diversity rather than individuals standing there telling us what to do for several reasons.

1:17:21One is we are a country of many different people. I think there are dozens, if not hundreds of scientific papers showing that patients follow the advice of doctors that look like them and sound like them or to whom they would aspire to be like. We know this. And yet public health officials typically are unitary. One person telling us do this, don't do that. This is a good idea. That's a bad idea. I'm one citizen, but I'm putting up both hands, both feet, and all toes and saying committees, small, but diverse committees that people can relate to and feel as if the messages that they're getting are vetted through a common understanding.

1:18:08Yeah, so it's a really good suggestion. And I couldn't agree with you more that a diversity of voices is really important to get a message out. And during COVID, actually, that's one of the things that our office actually was always helping to build with something called the community core, where we actually, we recognize it's very clearly, and this is something I came to see as a doctor. Sometimes I was a right person, a message to patients. Sometimes I wasn't. Sometimes it was the nurse, sometimes it was the medical student, sometimes it was an administrator or the social worker with different background, different life experiences.

1:18:40So part of this work is when one to step up, when to step back. But the community core that we were building was a really diverse group of people. And a lot of them had public health backgrounds, but a lot of more community leaders who understood health, even though they didn't have formal training. But they're people who knew their communities, right? And they had the trust of their communities, and they understood what was going on. They wanted to be helpful. So we brought them together to say, okay, look, here's what the science is telling us. Here are the general recommendations. Here's what we would provide.

1:19:11You ask us any questions you have, like if there's something we don't know, we'll go back and look it up. But you're the leaders in your community. They should be hearing from you, you know, about about these messages. And then those folks went out and actually we work closely with them, collaborated with them. They would design the messages for their community based on what they thought made sense. They weren't taking what we said word for word. And we didn't want them to. But to me, like that kind of diverse approach is what we need more of. Now, you know, I'll say what I would have liked. I would have liked if more media networks put those folks on TV and got them on the radio, right?

1:19:44Because it's important that many of them were showing up in their communities. We're knocking on doors, we're doing local podcasts, et cetera. And that was great. But I would have liked more of their faces, I carried on TV, right? So that's a place where when when we talk to media and when I talk to folks in media, one of the things I encourage them and push them to do also is to say, look, if you can take more of these diverse faces and voices and put them out there, that's actually good for the community. And it also helps people see that it's not like one or two people who are sort of pushing an agenda here.

1:20:15This is like the public health community's big. It's broad, it's diverse. That has a lot of voices. And the more voices we can hear from as public, I think the better off we are. Yeah, here, here, I, I, you know, again, I genuinely hope and pray that we don't have another pandemic. But if and when we do, I hope there will be committees rather than individuals. I know we, you know, this is a thing in this country. We like the idea that one person's going to save the climate, one person's going to save transportation, one person, you know, the covers, the person of the year type approach. I know.

1:20:48But we, but then we get frustrated when that person does things or makes decisions that we don't like in their public or personal life, and then it all seems to fall into division. And I just feel like I'm not talking about groups of hundreds of people with small groups. Yeah. So I think we're aligned in that way. Yeah. And look, there's that thing in a notion that I think sometimes we do want like the one person who can not only necessarily have all our trust and we can look to, but also who we can hold accountable, you know, something doesn't quite work out. We don't like something. And while I get that sort of mentality, I think that in this moment, especially when we're trying to rebuild trust, I think it's important for people to know that what they may be hearing in terms of medical or public health recommendations, it's important for them to know how broad an audience that's coming from or brought a group of experts, right?

1:21:36And we, there was a lot more broad agreement, for example, during COVID and during Ebola, during Zika on public health recommendations, but you wouldn't always know it if you turn on the TV because you were seeing the same couple of faces. So I think we have to just certainly diversify that. One other thing I need to tell you that's important here is, I think we have to also think about how we fund groups on the ground that are doing the hard work of getting public health messages out because one of the things that those groups often would tell me, and these are, I might say, the groups I'm talking about, the community organization that spent years in a neighborhood getting to know families, where folks who recognize them when they're walking down the street, they'll go, yeah, that's a person in an organization X, they understand as they get us, they're looking out for us.

1:22:22A lot of those organizations had spent their resources helping the community getting to know the community, but they didn't have sophisticated mechanisms to apply for grants, for example, they didn't have grant writers who had done this a thousand times. Historically, those groups have a hard time getting support and funding. So I'll tell you one interesting thing my wife did, which I certainly was very proud of, is she was helping to build an effort and to build a nonprofit organization with a couple of colleagues that, a big organization of people who knew how to get money, how to apply for grants, how to get foundation support, but who also had the wisdom to know that the most important they could do was to give portions of that money to groups on the ground.

1:23:06So they saw themselves as an organization that channeled money to groups that had trust and they executed their mission that way, and that was very effective. And I think we need more of that when it comes to disseminating funding. One thing I think many people may not, may or may not appreciate is that when you, it's actually hard from government to put out a lot of money at once and to do so quickly, right? Like when you've got a lot of funds that you need to get into communities, what happens is a federal government author will give it to states. States will then give it to local communities, to like the local department of public health, part potentially, and then they will look to distribute it to others.

1:23:42That takes time, but it also means if you're not connected to that network, if you don't know your local department of health or you're not connected to the state department of health, sometimes it can be challenging to figure out how to get the money. And so I think we need more operations like, you know, like what my wife and others have been building to try to get those funds directly to the folks who not, you don't necessarily have the most fancy, you know, grant writing operation, but they have the relationships. Because at the end of the day, it's those relationships that create the trust.

1:24:11It's a trust that allows in for life saving information to get to people, and that's the link that's missing. Very interesting. Farma, big pharma. I got a lot of questions about whether or not big pharma is on the take for every public health initiative. Now as somebody who understands a bit about and certainly believes in the use of certain prescription medications, I find most questions about, quote, unquote, big pharma to overlook the fact that there are thousands, if not hundreds of thousands of medications that save lives and enrich people's lives, that are prescription drugs. I also believe, my audience knows, I say it over and over again, that better living through chemistry still requires better living.

1:24:58We still have to get our sunlight, get our sleep, social connection, good nutrition, exercise and all those things. There's just no pill that's going to replace those. But I think it's a valid question that people are asking. Is there a direct relationship between big pharma and public health initiatives in a way that should have us concerned about the messaging that we're getting at times and the fact that the United States consumes the vast majority of drugs for mental health, for instance, as compared to other countries? That's one question. Then I want to dovetail into that question. What are your thoughts on the fact that there's a history of the tobacco industry being very interdigitated, shall we say, with government policies in ways that had us basically injure, if not kill, millions of Americans?

1:25:52Then eventually say, you can't smoke on near a hospital. You can't smoke anywhere. There's very few places where you can consume tobacco products. That kind of relationship and financial incentives and then a lot of backpedaling later. I think war on people's trust. How should we frame the relationship between the pharmaceutical industry, government and public health initiatives in a way that is at least halfway functional? Hey, look, I understand where the concern and suspicion comes from. I think it's important that public health initiatives and medical advice is independent of the influence of industries that may seek to profit from what's being recommended or from medications that are being prescribed.

1:26:44We have a history in medicine of doctors who were given gifts and vacations and all kinds of fancy things by pharma companies in an effort to influence what they prescribed. That was really problematic. Now we're seeing a lot less of that, which is good. A lot of rules are being put in place by medical societies and professional societies and by academic institutions to say this is an unacceptable way to practice. That's really important because I do think that human psychology is that sometimes we underestimate how much we're influenced by incentives. We think, yeah, I'm getting that, but I know how to make independent decisions, but at the end of day we're human and we're influenced.

1:27:23Or it's a great drug. It could be, wow, this is a drug that's really helping my patients. I'm happy to recommend it to them. Yeah, so this, so one is separate one thing, though, like taking money from pharma companies as a physician, I think is highly problematic, right? I think it's hard to say that it doesn't influence practice, maybe it doesn't for some people, but it's just it's really hard to know who those people are. I do think that separate from that, you can be a physician who prescribes medications because you believe they work. Look, as a doctor, I have prescribed many antibiotics during cases of infection that have helped my patients.

1:28:00And I would prescribe those again. I'm glad that those exist. In many cases, they've saved the lives of patients I was caring for in the hospital. So that's what, what should drive us? Is does the data show that they work and does our patient need them? That's what should drive our decisions. When it comes to public health recommendations, here too, I think a similar principle holds, which is that I don't think that pharma money should be influencing our public health decisions, which means that it shouldn't be funding our public health organizations that are making recommendations. Certainly, I'll, you know, this is obvious to you, but I'll say just to be clear for everyone who's listening.

1:28:38Like our office doesn't take any money from industry, not just farm industry, from any industry. Like our, the money that we get is allocated by Congress at the end of day, it's tax payer money. And that's all we get. And that's important. We don't want money from the, you know, from pharmaceutical companies. But that's important because people need to know that these decisions are not being made for financial gain. That's being said, there's a broader concern I have, Andrew, which is I think that we have become a pill for every problem society, where we look for a quick fix of a medicine for every challenge that we may incur.

1:29:20And sometimes, yes, I'm a believer that if science, you know, helps us create medications that can help solve disease, we should use them appropriately. But I think we discount heavily the behavioral changes that we need to make, the more broader societal and environmental changes that we need to make that influence our health. Like our food environment matters for our health, our decisions about how physically active we are matter for our health, whether or not we sleep matters for our health. And all of these impact our mental health and well being as well. And so I, when I think about that bias, that, that to me is not always, you know, stemming from money that came from a pharmaceutical company, although I think it, the ads that we see all the time from pharma companies, I think try to convince us that, hey, just take this pill once a day and all your problems will go away.

1:30:10But I think it's more complex than that. And, and I think that even for, you know, in the healthcare setting, like if you're, if you're seeing a patient who has pain, who's having intense pain, it feels easier sometimes to prescribe a medication for that pain, rather than trying to to deal with non -medicative and based, you know, approaches or try to get the deeper origins of the pain. I'm not saying that's what doctors do all the time, but I'm saying that we're living in an environment and a broader culture, where we, I think, increasingly reach for something that we see as a quick immediate fix.

1:30:48And again, don't blame people for that. We'd rather take a quick fix over something that's going to take a long time. But I think it is selling us, I think, sometimes a false hope, which is that that's all we need to solve our problems. And I think a lot of times you need more, you need the behavioral changes, you need the environmental changes. That's one of my big concerns in terms of how we communicate about health. Would a potential solution be this idea of small committees? So let's say somebody is experiencing chronic pain, localized or general, that they would go to their general practitioner, but in the room would also be somebody who understands somatic medicine, a trained clinical psychologist who understands somatics that the body and the brain are linked through the nervous system and could also assess possible psychological roots of the issue.

1:31:40And then somebody in the room who can make behavioral, nutritional, maybe even supplementation -based, safe supplementation -based recommendations, and then the physician who can say, in an addition to that, I think the person should have on hand a 5 milligram dosage of a prescription drug that if they need it, they could take. And I think it would provide a lot of protections against potential adverse effects of any one of those things in isolation. There are great protections in having people meet in groups for lots of reasons. And the person would feel very well cared for. So again, small committees of people with diverse expertise pooling together to treat people from a lack of a better word, a more disarmament of the dream.

1:32:30I think that's exactly what we need. Interdisciplinary teams that can provide integrative care, recognizing that in this day and age, there's not one person who has all the expertise to help us figure out how to best manage our health challenges. I think what we have not figured out are a couple of things. Number one, who are all the right people who need to be in the room or in the sort of virtual room, if you will. The second is how do we create a structure, a health care system where that can actually happen with efficiency, where it can be reimbursed appropriately. But that's what we should be doing.

1:33:04And then the third leg of that is the group experience for patients. And there's increasingly and more clinics and health care systems are on the country that are working on creating group experiences where patients who all, let's say, are working on diabetes, come together, let's say once a week and they meet with the health care practitioner, that might be an addition to their individual appointments. But there is so much power in groups coming together, groups of patients who can find community who can help each other learn from each other's experiences. That's highly underutilized right now in medicine.

1:33:38But to really do this well, Andrew, I think means that we have to pull back from the model we have had for years in medicine, which has been a very highly individual type model, which says, okay, you go to your doctor, you see your doctor one on one, you get everything you need. Maybe you need to go see a specialist, okay, then you wait a few weeks, get another appointment, drive 30 miles, go see somebody else, maybe they're connected to the electronic health system, maybe they're not, maybe they know what was discussed, maybe they don't, maybe they'll call and talk to their primary care doctor, but maybe they won't because they're too busy.

1:34:11And then you as a patient are stuck trying to piece all this together. What while often in pain? Well, yeah. In physical and emotional anguish. Not referring to my own experience, although I've had mild examples compared to what other people dealt with, but people with chronic pain are irritable for understandable reasons. I mean, maybe somebody is close to veering towards suicidal depression, then there's the interpersonal effects. I mean, I feel like the crisis is one of a lack of efficiency and thoroughness. And again, I'm not throwing stones at the medical profession. I like you believe that it's a collection of mostly well -meaning people trying to do their best, but the specialist model and the referral model is incredibly cumbersome.

1:34:57It really is cumbersome. And like you look, having worked with many medical professions over the years, these are colleagues who I deeply admire. I mean, they're there for the right reasons. They want to help people alleviate suffering. But they too are feeling burned out and frustrated by the inefficiencies of the system. Because that's how you, one of the greatest contributors to burnout for doctors and nurses is a lack of self -efficacy. It's seeing a patient who has a problem in front of you and feeling like you can't get them the help that they need. That is the greatest paper cut, if you will, to the sort of spirit of clinicians.

1:35:33And many find themselves in that circumstance where they either find that they know what's needed, but the system is throwing up prior authorizations or other insurance hurdles and preventing their patient from getting that care. Or they are kind of at the edge of their expertise. This happens at pediatricians and primary care doctors more broadly all the time with mental health. Most of the mental health care that's delivered in this country is delivered in primary care offices. Now primary care doctors didn't necessarily train specifically and only in mental health. Yet they find themselves having to manage a lot of that, including increasingly complex substance use disorders and treatment resistant depression.

1:36:11And they need help figuring that out. But if you don't have a lot of resources to get that referral to collaborate with mental health professionals and you're stuck on your own figuring that out. And so I think the pain is being experienced mostly by patients and but also very much so by clinicians. And that's why that overhaul is needed. And I think a lot of this is, you know, I'm not a health care economist per se, but I will say that a lot of this I think is tied into the business model that we built around medicine. The notion that, you know, we're paying individual people for individual services and individual procedures that are done while that has some merit in some cases.

1:36:48What we really care about is that the person is getting efficient, integrated, multidisciplinary care overall. And so when health systems, for example, come together and say, okay, rather than sort of focusing on the amount of getting reimbursed for every procedure, we're going to take more of a value -based approach here where we say, okay, we've got to run amount of money to care for certain people. What's the most efficient way for us to provide them care? Recognizing if we don't do that, it's not only bad for them, but our costs in the long term will go up because we're not getting reimbursed for every procedure.

1:37:21We're getting reimbursed for the care overall care that we're taking for patients. So there are more of these value -based models that are being adopted, certainly in 2010 when the Affordable Care Act was passed and when other measures were taken in the Obama administration in Medicare, like that really pushed value -based payment models forward. And again, they're not perfect. They need their own tweaks. But I don't think that the existing financial structure that we had in medicine was serving us in terms of delivering the kind of multidisciplinary, integrated, efficient care that we increasingly need.

1:37:57Tough problem, but through recognition of tough problems comes good solutions. That's my belief. I'm an optimist at the end of the day. You mentioned mental health lately. You've been increasingly vocal about the crisis of isolation. Just once again, but before we go there, there's one thing I thought the tough problems were. You're exactly right. And the problem is a longer we take to acknowledge and address these tough problems. The more entrenched the interests become, that profit from the status quo. So if you look at the private insurance industry right now, there are so many challenges we have right now with patients and clinicians saying that they know what care is needed, but it gets denied.

1:38:38They know what care is needed, but prior authorizations get thrown up there and required. Even for a medicine that clearly your patient needs urgently, I've had the experience myself of having a family member who is needed a medication for an urgent situation and then being told that the pharmacy will not fill it because it requires a prior authorization, but that can't be processed until the weekend is over because no one's in the office to approve the prior authorization. And you're thinking yourself, this is make any sense. Like this is an urgent situation. My family member needs this medication.

1:39:13I've also had the experience as a doctor of fighting for my patients who have been denied care by an insurance company. Being on the phone saying, I'm sitting here in front of my patient. I know that they are sick. I know they can go home. I know they need to be in rehab. There's nobody literally to help them at home, but then not having like the rehab bed approved by somebody who's not even there, right? And there's also just a practice that we've seen time and time again where insurance companies will also just burden clinicians with more and more requests for information before they will agree to reimburse for services that have already been delivered for a patient who needs them, which is just creating more and more barriers, hoping that if you're a small time doc out there who's got a shingle that you put up, you don't have a lot of resources.

1:40:03How are you going to keep fighting all of this and sending more and more paperwork? And eventually you'll just give up. We have a lot of problems right there and industry that should be delivering care. Often is doing good things, but too often I think is allowing barriers to be put up to the care that's needed. And this is particularly true with mental health. I know we're going to talk about that, but mental health care has just been such a difficult thing for people to get in our country. And part of the reason, there are many reasons, but one of them is that insurance companies historically did not reimburse adequately or in the same level for mental health care as they did for physical health care, or if they did they would only reimburse for a limited number of sessions that you could have.

1:40:46But if you're a mom out there who sees her child struggling with depression, you're really worried. You don't want to be told, you know what? You can only get three sessions. That's it. What are you supposed to do after three sessions? And so what has happened is that even though in 2008, there was a law passed called the addiction equity and mental health parity law, even though that was passed to try to close that gap, there were many ways that insurance companies were scurrying it. So one of the law wasn't even being adequately reinforced for many years. But two, insurance companies sometimes would say, okay, we're reimbursing adequately, but when you look in the network, they had very few providers, so you really couldn't access somebody.

1:41:31So that was a problem for patients. And then the other challenge is that they would say, okay, you can see somebody, but you've got to complete this prior authorization, have that completed by your primary care doctor, etc. Again, throwing up more and more barriers. So very recently, in fact, just a few weeks ago, President Biden just announced that we are from as administration putting out a proposed rule to actually strengthen the mental parity law to prevent some of these, what I think of as abusive practices, because they're preventing people who need care from getting in. And if you've ever been, as I know, many people have been who are listening to this, if you've ever been in a situation where you or somebody you love has struggled with the mental health concern, what you need in that circumstance is help.

1:42:13You don't need to be filling out paperwork. You don't need to be waiting three months to actually get care. You don't need to show up and be told only you only have two more appointments. You need to know that help is there when you need it. And a lot of these denials are being issued to people who have done their part of the bargain. They've paid their premiums. They've held up their end of the bargain and care should be there for them when they need it. So, this is something that upsets me a lot because I just, I have seen too many patients over the years struggle without the care that they deserve and should get because of barriers that are being thrown up by industry.

1:42:49But I say all that just to say that when you take on big problems, you will run up against entrenched interests. And that's a fight we have to take on. We can't shy away from it. We can't say, you know, this is politically too difficult. Like one of the things I'm very proud of is that we're finally negotiating on drug prices through the Medicare program. Something that should have been done decades ago. But it's finally happening now. You know, the administration just decided this has got to happen. It was passed by Congress. This was good. And it just, it makes no sense that we would pay more than we need to and pass the cost on to taxpayers when we can negotiate.

1:43:28And we've got to get, look, you got to, if you're collecting taxes as government, you should be doing your best and make sure every one of those dollars is being spent well, right? Because somebody took money out of their paycheck. Didn't use it for their family. Didn't use it for their kids. And they gave it to the government for good reason, because that supports first responders, police officers, a whole bunch of services that we need. But the response being in government is to make sure that money is being used well. And to pay more for medications than we should makes no sense at all, especially for our patients and taxpayers.

1:43:58So clearly some steps in the right direction are occurring while on the topic of mental health. Let's talk about the isolation crisis. What is the isolation crisis? What aspects of mental and physical health is it impacting? And then perhaps most importantly, what can we each and all do about it? Well, this is one of those issues that I, if you had told me, Andrew, 10 years ago, hey, you and I are going to be sitting here talking about loneliness and isolation. I would have said, I don't think so. But I was really educated by people I met across the country about the fact that this is a real problem.

1:44:36And the truth is, it was familiar to me because of my own personal experiences. As a child, I struggled a lot with a sense of loneliness and isolation. I was really shy as a kid. I was pretty introverted. And I wanted to make friends and hang out with other kids. But it took me a while to actually build those relationships. So I spent a lot of time feeling left out. There were times when I, I would like my elementary schools. And there were days where I pretended I had a stomach ache. So my mom wouldn't make me go to school. And it wasn't because I was scared of a test or a teacher. Because I didn't want to walk into the cafeteria one more time and be scared that there was nobody to sit next to, where they know and want me to be at their bench.

1:45:19As I know what it feels like, and I also know what the shame is like, because I never told my parents about this. I never told anyone about that. Because even though I knew my parents loved me, I just felt like, hey, if I'm feeling this lonely, it means it's something's wrong with me. I'm not likeable. I'm not lovable. I'm something's got to be, it's got to be my fault in some way. There's only years later, Andrew, when I talked to friends from grade school, that I realized that a lot of them were feeling the same thing. We were all struggling by ourselves. No one really knew it. And I came to see a lot of this as a doctor when I was taking care of patients.

1:45:52And I never took a class on loneliness in medical school, who was in part of our residency curriculum. Yet when I showed up in the hospital, I found that the patient who would come in with a diabetic wound infection or who would come in, because they had had a heart attack, when I sat down and talked to them, often in the background, they would talk about how lonely they were. Sometimes I would ask them, hey, I need to have a difficult conversation about your diagnosis. There's somebody who'd want me to call to be with you during this time. And too often the answer was, you know, I wish there was, but there's nobody.

1:46:27I'll just have the conversation by myself. But it was when I was surgeon general, I realized that those experiences weren't limited to me and my patients. But they were incredibly common. And two things I learned when I dug into the data, Andrew, was number one that loneliness is exceedingly common, with one in two adults in America reporting measurable levels of loneliness. But the numbers are actually even higher among young adults and adolescents. The numbers and among youth actually, depending on the surveys you look at are between 70 to 80 % who say that they're struggling with loneliness.

1:47:02So that's the first thing that I learned. But the second thing was how consequential loneliness was. I used to think loneliness was just a bad feeling. What I came to see in digging into the scientific literature was that feeling socially disconnected, being lonely and isolated, was actually associated with increased risk of depression, anxiety, suicide, but also an increased risk of cardiovascular disease of dementia. And these are not small risks. We're talking about 29 % increase in the risk of coronary heart disease, 31 % risk and the increased risk of stroke, 50 % increased risk of dementia among older people, increased risk of premature death and the mortality impact of loneliness, by the way, and loneliness and isolation is comparable to the mortality impact of many other illnesses.

1:47:51In fact, it's even greater than the mortality impact we see associated with obesity, which is something we clearly recognize as a public health issue. So you put all this together. And for me, one of the key takeaways is that loneliness and isolation are critical public health challenges that are hiding behind the curtain, behind this wall of stigma and shame. And unless we talk about it and address it, unless we reconcile what's been happening to us over the last 50 years, where fewer and fewer people are participating in community organizations, where more and more people are feeling isolated, then we're not going to be able to repair the fraying foundations of society, which are grounded fundamentally in our connection to one another.

1:48:36You mentioned community organizations. Could you elaborate on those growing up in the 70s and 80s? I was exposed to community soccer teams, swim team, there was a community pool, these were all public things. There were churches, synagogues and mosques. Are we not seeing as much participation in those types of organizations anymore? And what other types of organizations are out there that come to mind when you think about the isolation crisis? Yeah, so there are several factors that have led to us being as isolated as we are. One of them, as you mentioned, is the decline in participation in community organizations.

1:49:20This isn't a recent phenomenon. This has been happening over the last half century in America. We've seen lower participation in faith organizations, and recreational leagues, and service organizations, and other community groups that used to bring us together. We can talk about the reasons why that has been the case. But one of the key consequences of that is that people don't have places where they can come together and get to know one another, especially across differences. We actually associate more and more with people who are like us. But this has also been fueled by a few other factors that are going on at the same time.

1:49:57One is that just from a cultural perspective, as modernity has arrived, not just in the US, but in other countries, we've seen that people are more mobile. They move around more. We don't always stay in the community that we grew up in. We tend to, even if we move somewhere else for school, we may go somewhere else for a job. We may change jobs and move somewhere else. We are leaving behind communities that we grew up with, that we went to school with, that we worked with. And I'm not saying that's all a bad thing, right? We have more opportunities, and that's a really good thing. But I think one thing that we have not accounted for is the cost of these changes, right?

1:50:29If we know what the costs are of certain actions, we may still take those actions, but we may find ways to mitigate the costs. We may, in this case, invest more in our relationships. We more conscious about reaching out to other people going to visit them. But that has been a quiet but devastating consequence. The other piece is with modernity is that we have more convenience in our life, which means that we also don't need to see other people to get certain things done, like buying groceries or mailing an item out or getting something from the store. I can sit in the comfort of my home and have everything just come to me.

1:51:03Now, on the one hand, that's incredibly efficient, right? But I think efficiency is an interesting thing because it's only one factor we should be considering in our lives. There too, we have to ask the cost. And one of the interesting things about COVID, as many people in the first year of COVID when we were all separated from one another, when we finally came back together and I had so many people who said to me, you know what? I expected to miss my parents and my siblings and my friends not being able to see them. But I didn't expect. Was missing the strangers that I saw at the coffee shop or the folks who are ran into the grocery store or seeing neighbors as I walked down the street.

1:51:39I actually missed that more than I thought I would. So we have lost out on some of those interactions and those loose ties. But the final thing to keep in mind also is about what is happening with how we are using social media technology, which I think is fundamentally transformed how we interact with one another and how we see ourselves and each other. And this is particularly true for young people who are growing up as digital natives. But what has happened there, I worry, is that, and it's not that social media is all bad just to be clear, you know, technology. Look, I'm a believer that in technology broadly speaking, you know, I'm a user of technology.

1:52:18I spent seven years building a tech company. I'm a believer in tech. But I think whether technology helps or hurts us is about how it's designed and ultimately about how it ends up being used. And what we've seen with social media as well is that for many people, it ended up leading to in -person connections being replaced with online connections. We came to somehow value and almost seek out more and more followers and friends on social media feeling somehow that made us more connected. But the nature of dialogue also changed. Like as human beings, we evolved over thousands of years to not just understand the word someone is saying, but to hear the tone of their voice, to see their facial expression.

1:53:00Like you and I are sitting across and and we're both processing our body language, right? And I'm seeing you nod your head and I'm seeing your eyes focus. Like all of that matters to how we communicate. But also like you and I are less likely to say something hurtful right now to one another because we can see each other. If I said something or hurtful to you, like I probably see the pain or consternation on your face and that might give me pause, right? When you're communicating online with other people without any of that information or without any of the sort of barriers, if you will, that make you pause before you hurt someone, it leads to a very different kind of communication.

1:53:37One that can be quite hurtful at times. And I also think that one thing many people don't recognize is that to communicate with somebody else and reach out and build a relationship with someone, it actually takes a certain amount of self -esteem to do that. You have to believe the other person is going to want to hang out with you. They're going to see something valuable in you. And for many young people, what has happened, and I think, frankly, from many older people too, is your experience on social media has shredded their self -esteem as they're constantly comparing themselves to other people.

1:54:08Like when you and I were growing up, in the 80s, we compared ourselves to other people too. People have for millennia. But what's fundamentally different now is that in a given day, you can compare yourself to thousands of images that you see online. That's actually literally what young people tell me. I do round tables with college students and high school students all the time around the country. And the three things they tell me most consistently about their experience as social media is it makes them feel worse about themselves, worse about their friendships, but they can't get off it because the platforms are designed to maximize the amount of time they spend on them.

1:54:41So you put all of this together, and I think what has happened is that we're talking more, but we understand each other less. We have a lot of information, but we're lacking in the wisdom that comes from human relationships. And I think that that's really hurt us. We see it certainly in the data that tells us about mental and physical health outcomes, but there's also the human suffering component, Andrew. It's really heartbreaking for me to travel around the country and to hear from people of all ages, often in quiet whispers about their struggles with isolation about how they feel like they just don't matter at all, about how they feel like they just don't have a place where they belong.

1:55:23And these are people on the outside look perfectly fine. They're posting happy things online to the folks at work. They're seeming like everything is going great. This is why I always tell people like loneliness is a great masquerader. It can look like withdrawal and sadness. They can look like anger and irritability. It can look like aloofness as well. And so it's only when we stop to ask someone how they're doing when we take pause for a moment to maybe reflect on what's happening in their life. But we realize it, wow, the majority of people in our country are actually struggling with loneliness.

1:55:58I'm a firm believer that our nervous system evolved under conditions of close interpersonal and direct connection and to suddenly throw a technology in front of ourselves that deprives our nervous system of its normal development. It's clearly going to lead bad places. It's also clear to me as based on what you just described that when we go on social media, we see something but they don't really see us. Hence perhaps why people get aggressive in the comment section, they want to be heard. We want to be seen. I think all of us want to be seen and see other people. Social media doesn't allow for it so easily.

1:56:40I also know that a lot of young people will congregate with their friends to play video games online.

1:56:49But when we were kids, we also played different characters in our games. But also different now. Do you think that there will be a youth rebellion movement against these kinds of technologies? I mean, there's a long history of young people rebelling against the stuff that's been put in front of them. And they're like, no, no more. We're going to rebelle. In fact, that was the way that youth overcame the nicotine epidemic, if you recall, it was the advertising pitching them against, or pitting them, excuse me, against wealthy, cackling older men in rooms counting their money. That was what actually was successful in getting kids to not smoke because kids have a rebellious streak.

1:57:34As opposed to when they were told, hey, smoking is terrible for you. Your lungs are going to fill with cancer. Kids didn't stop smoking. Teen's didn't stop smoking. Rebellion has been baked into our nervous system at a lesson in teen years. Do you see a rebellion against this social isolation? Are kids going to start putting away their phones and hanging out together again? And that's going to rescue us. And that's a way of saying, what can we do for them? What can they do for themselves? And what can we do as adults? Because there are a lot of the silent suffering is the thing I also really worry about.

1:58:06Yeah. So it's a good question. And I think there is already a movement that's building among young people to create distance between them, themselves, and their devices, and particularly social media. And it's cropping up in different ways. I'm meeting more and more. Some of these are organized efforts, but I'm also meeting more families where the parents and kids together have decided that they're going to delay using social media and, you know, past middle school or in some cases even later, or where they're deciding that they're going to drop boundaries around social media use, where they're going to replace their smartphone with a dumb phone that allows them to do things like text and make phone calls and use maps and all that stuff.

1:58:50It doesn't necessarily have social media apps on it. That this is still a small minority. And where's you dealing with a bit of a network effect here, right? Because if you're the only one who's not on social media in your middle school class and you might feel left out, which is why it's so important for parents and kids to actually do this together. But I do think that to use your analogy with smoking, that one thing that I think many young people bristle against is this notion of being manipulated and used for the profit, you know, of a social media platform. And the reality is that the, again, we've talked about how the fundamental business model is, or most social media platforms is built on how much time you spend on those platforms that translates to ad revenue and that translates to the bottom line.

1:59:39Whereas what I care about as a parent as search in general is about how well that time is being spent, is it actually contributing to the health and well -being of a young person or is it not? Is it actually harming them? And this is where I think when I go out and talk to young people about this. Number one, I'm so impressed by a lot of young people because they already have a lot of these insights. They're the ones living it, right? They're not thinking that this is all, you know, perfect and it's all a pure benefit here. They're the ones telling me that it makes them feel worse about themselves and their friendships.

2:00:09But they are also having a hard time getting off of it because, again, of how these platforms are designed. So about a third of adolescents are saying that they're staying up till midnight or later on weeknights using their devices and a lot of that is social media use. And this takes away from sleep, which we know and you know better than anyone is so critical to the mental health and well -being of all of us, but of young people in particular who are at a critical phase, you know, of development. The other thing that is very concerning to me is nearly half of adolescents say that using social media has made them feel worse about their body image as they're constantly comparing themselves to others online.

2:00:43And we used to think that this is just girls who are experiencing this. And yes, it is a lot of young girls who are experiencing these body image issues, but now it's increasingly boys as well. So this is happening across the board. But the other piece that concerns me thinking about mental health symptoms is that we look at how much time kids are using social media on average adolescents are using it for three and a half hours a day on average. So many social media. Just social media. And that means many are using it for far more than that. And what you're finding though is that for adolescents who use it three hours or more in a given day, their risk of anxiety or depression symptoms double.

2:01:23Right. So and if the average uses three and a half days, that means that millions of kids all across our country, the majority of our kids are at risk here. And so, you know, you put all this together and it paints a very concerning picture, whatever benefits there may be for some kids of using social media. And there's some and we lay out some of this in our advisory on social media. Some kids find social media is a great way to express themselves to reach other people to find support, especially if they're from a community that doesn't have a lot of folks who are like them around. It can be really reassuring to connect with others.

2:01:55But we can't say that just, you know, that to get those benefits, we have to subject our children to all of these other harms. Right. Kids are experiencing exposure to harmful content, to harassment and bullying online six out of 10 adolescent girls are seeing they've been approached by strangers on social media and ways it made them feel very uncomfortable. Our kids are also finding that health promoting activities in their life are being cannibalized by their use of social media that it's detracting from time for sleep in person interaction, physical activity. And the erosion of self -esteem really concerns me as well because you need that not just for social interaction, but like look as a is a father I want my children to grow up being confident about who they are being confident enough to be authentic as they show up in the world to not feel like they need to create some brand that's different from who they fundamentally are just to sell that to the world.

2:02:46I want them to know who they are and to be comfortable being who they are and to encourage other people to do the same to support them in their efforts to be authentic. That's what I want my kids to do. That's not what's happening to a lot of kids on social media. So I think we not only need more kids to understand this and just support them in their efforts to create space and sacred spaces away from social media, but we need to support parents here too because Andrew might be concerned with parents is look we've taken this technology which is rapidly evolving which we didn't grow up with as kids.

2:03:21And we've still parents you manage it all in your own. We put the entire burden on parents and kids to manage this. You know when we were growing up you remember the motor vehicle fatalities were really high in America. And we didn't say okay you know what that's just a price of modern life which is that we accepted and keep moving on with our lives. We said hold on we don't have to go back to horses and buggies but we also don't need to accept this. We need to make this experience safer. And so we put in place with the advocacy and support of incredible groups like Mad and others across the country.

2:03:56Add me mothers against strong driving. Ultimately the government put in place safety standards that got us seat belts airbags crash testing to make sure the frame of cars were robust in the setting of an accident and that helped us reduce motor vehicle accidents and deaths. And that's what we need here too like we need to have the backs of parents and kids and that means from a policy perspective putting in place safety standards to protect kids from exposure to harmful content from the experience of bullying and harassment and that also protect them from features that would seek to manipulate them into excessive use which is happening far too often right now.

2:04:36We also need the policy that requires data transparency from the companies. You know researchers tell us all the time that they are independent researchers. They tell us they are having a hard time getting full access to the data from the social media platforms about the full impact of the platforms on the mental health of the kids. As a parent look I don't when we bought car seats for my children when they were born we looked up the safety data like many parents wanted to make sure the car seats were safe but if you had told me that hey you know the manufacturers of these car seats are actually not disclosing some of the data on the impact on children but go ahead and buy it anyway.

2:05:13You know I'm sure other people are buying these car seats you should be fine. I would have been very disturbed by that right no parent wants to feel that information is being hidden from them about the health impact of products on their kids. That's what we have right now. So this is a place where I think while yes and we'll we should we'll talk about some steps parents can take because I want to get to practical steps that people who are here as parents or people of kids in their lives can take. We need policymakers to step up and step into the void here and to fill the gap because this is too much again to just ask parents to manage entirely on their own and this isn't again about telling parents what to do and restricting them.

2:05:51This is about giving them the support they need so they have confidence when they see you know a technology out there a device out there product out there for kids that they know it's been tested that it's been studied and that it's actually safe for their children. My understanding is that in countries like China there are limits as to how many hours kids can be on screens period and when I was a kid we were allowed to watch TV for a certain number of I think it was a half an hour or an hour. My mom was constantly kicking us out of the house. Like literally you gotta leave the house you gotta go down the street and play.

2:06:25Yeah. Unfortunately I liked outdoor activities. Nowadays we also have the issue that a lot of parents are on their phones at soccer games and at kids events and so the kids are modeling their parents. Yeah. Parents are distracted as well so there's a lack of social connection. People even in immediate family. People are screened in you know the TV there's laptops there's multiple phones, iPads. People are more engaged in the screen portals than often than their own portals. You go to a concert and people are watching the concert through their screen so that they can send the same image that everyone around them is sending out to the world.

2:07:02If you think that's kind of crazy but I guess they want to capture that unique experience. Yeah. But it's not unique at all. That's the myth that's the illusion. There's nothing unique about your post of something that you went to go see. What would be truly unique is to just experience that in real time. It's so wild to think about like what we think of as our unique portal is actually not unique at all. It's what we do with it. My stance is glean and learn information online and go use it in real life. Come back from time to time. You know maybe an hour a day maximum or so. Can I just underscore the two words you said real life?

2:07:40Because that I think is a really important key here which is that all of real life isn't happening on social media. There's a whole world out there which I think is real life which is happening offline and what's happening online too often is distorted. It's giving us like even just take the images that we see of people there. There are some or beach images there like great vacation images. That's not representative of their entire life of how they're living their life. But we see that. We see people's anger and their vitriol and we come to believe over time that that's how people feel. That's what people are dealing with and experiencing their life.

2:08:19And we've just got to get you know your mom. I love what your mom did. I'm getting you guys outside. My parents did the same thing too. Like we I was very blessed to have two parents who didn't come you know they didn't have a lot of resources worrying up. They didn't come to this country with a lot of resources. But one of the greatest gifts they gave that gave us is that they loved us unconditionally. The other great gift that they gave us is they pushed us to just explore to meet people to learn about the world. They wanted us outside playing you know experimenting just discovering the world you know writing our biker on the neighborhood.

2:08:56And that's what we did. But right now two critical things that kids need for their mental health and development are two important forces I should say that are impacting their mental health and development. One is social media but the second also is the lack of unstructured play time that kids have. Like unstructured play time is time when we as kids learn how to negotiate situations with other kids. How to resolve conflict. How to recognize what's going on and someone else's you know eyes before they say something we learn how to collaborate and play with other kids. It's a lot you learn on the playground as it turns out.

2:09:29But I worry that right now that we've almost somehow made that kind of unstructured time seem inefficient. You know we've set these standards for our kids that they need to be you know getting fancy jobs and into fancy colleges and making an X amount of money and the path to doing that is you know to be enrolled in X number of activities after school and to do all this stuff in school and their lives are so hyper structured that I worry that the time to just play to be creative to reflect and think to just have unstructured time with other kids has evaporated and I think that that also is hurting the mental health and well being of our children.

2:10:06I love the idea that that unstructured play time could be framed in the accurate context of the nervous system developing the way it was supposed to develop. I mean I would argue that success is going to be easiest for children that engage in the real world more. In fact there's great risk to posting everything that you do online. We've seen some examples of that preventing people from getting into or staying in college based on things they said or did previously that they shouldn't have said or done. That's what those are kind of you know negative highlighted cases. But in general we know that the nervous system thrives on diversity of types of interactions and social interactions in particular.

2:10:45I'm just restating what you just said. So if ever there was a call for kids to get out into non -screen life let's call it and engage their nervous system that way it without question is going to benefit them in terms of their ability to learn and retain information, perform well in school which is not everything life's about. But let's face it we still live in a society where hitting those milestones on a consistent basis is the best predictor of people being able to live self -sustained lives, build families and that sort of thing. So you mentioned a few actionable items for parents as it relates to kids and maybe well not maybe limits their screen time.

2:11:26Force them outside in the safe weather and safe conditions of course. But what about adults as well? What can we all do? Should we be restricting our screen time to X number of hours per day? I mean you're the surgeon general. If you had a magic wand which I realize you don't and you could make a highly informed recommendation about what the thresholds for too much time on social media are. What would it be? Two hours three hours? Yeah so it's a good question and let me actually go through some of these things that parents can can do for kids and that we can all do for ourselves with kids in particular what I would do specifically with social media is and this is frankly what I'm planning to do with my wife for our kids as they grow up.

2:12:17And number one I would seek to delay the use of social media past middle school at minimum and I know that that is hard to do at a time when all kids are on social media and you don't want your child to be thrown them and left out and to be lonely as a result. So that means no account of their own. It means no account of their own. Okay. And I would make see to the best of your ability see if there are other parents that you can partner with to do this because it's hard to do alone as a parent but it's also if there are other parents you're partnering with that means your other kids who are also delaying use that means your child is not alone.

2:12:54And I think if you start the conversation with other parents who will realize a lot of them are worried about the same things you are they may have thought about delaying use but they also don't want their kid to be the only one so this becomes a numbers challenge but partnership can help us if your child's already on social media. What I'd recommend is to create sacred spaces in their lives that are technology free and specifically I would think about the hour before bedtime and throughout the night as time that you want to protect this kids are losing not just sleep because they're going to sleep later because they're on their devices but they're also waking up in the middle of the night maybe to use a bathroom maybe to get some water and then they get back on their devices again.

2:13:33So the quality of their sleep is being significantly impacted by access to those devices during the night. So I would protect that time hour before bed throughout the night. I would also create make sure meal times were tech free zones so that people actually that you talk to one another you see one another and time with friends and family members when you're out you know at a birthday party etc. make their tech free time let them focus on their time with other people. Those three tech free zones can do a world of good to help your child and the last thing I'd recommend here are the many things I think parents could do is to start a dialogue with your child about their use of social media.

2:14:14We don't always know how social media is making our kids feel. From the item and we may realize when we talk to them that they actually have their own concerns they might say yeah it's not making me feel really good but it's just like card not to be on it everyone's like texting on this everyone is you know everyone's you know sharing information and posting pictures on it I feel like I need to be on it. You can only help them start to manage that if you know that that's a challenge that they're having so opening a conversation so your child knows that you're not judging them but you're trying to understand their experience is important also so that you can help them understand what is not acceptable for them to experience on social media if they're being harassed or bullied by strangers that is a problem you want your child to tell you about that to report that if they see something posted online it's really concerning to them let's say they see a friend post that they're thinking of taking their own life or harming themselves in another way you want them to know that that's important to flying and to get help you know that they shouldn't just you know scroll past that so that conversation is really important and finally his parents we can lead by example right and this is hard because the truth is we've been talking about social media and youth and that's what the subject of my search and journals advisory was on but I have concerns about adults too I said as somebody who's had challenges in my own use you know of social media finding sometimes it bleeds you know past my bedtime and I'm realized you know I think M &H checks something for five minutes an hour later I'm still there you know scrolling through something and sometimes I you know I find myself over the years I find myself comparing myself also to posts I see online in unhealthy ways sometimes I find myself sort of pulled into content that you know ends up being angry and vitriolic and leaves me feeling worse you know at the end so I've experienced this as well and I think his parents one of the hardest things to do is to follow this advice we're giving our kids to draw those boundaries as well and to put our devices away when we're around our kids one experience I had which sort of I still feel bad about but which really helped kind of knock some sense into me was after my my son was born my older child I was actually I was searchin general at that time you know I had you know the local non was busy job etc but I wanted to make sure that I protected bed times and meal times for us to be together as a family yet one day when I came home you know after dinner when we were doing the bath time and bedtime routine get him my son ready for the night my wife is changing his diaper and instead of helping I was just standing at the side scrolling through my inbox and my wife who has infinite patience and is like one of the most well -adjusted people that I know just paused and she turned to me and Alice said do you really need to be doing that right now and she said just very quietly but I felt this like such a sense of shame when she did it because it was like what am I doing like this is my infant child you know and the rare few hours I have with him during the day and I'm just scrolling through my inbox my phone like like this is terrible and look I know that all of us do this and it may be in different contexts but it was a wake up moment for me because I realized like one like as you know well as a neuroscientist we can't really multitask right we're rapidly task switching right and that was time in my when I head was in my inbox and my head wasn't with him you know my heart wasn't with him right I was just distracted and so as parents if we can honor those sacred times you know when we're with our children to keep our devices away meal times sleep time as well it's not easy to do but it really sets a good example for our kids all behavior change that we're talking about here the kind of behavior change I've worked with the patients over the years around physical activity and diet all of this is harder to do when we're doing it by yourself it's a lot easier to do when we're we have a couple of friends or family members who we agree to do this with we hold each other accountable we encourage and support each other it's how I've been able to make the most successful behavior changes I've made in my life have come about because I have two good buddies Dave and Sunny who are my my part of my brotherhood and the three of us as brothers talk about health we talk about our finances we talk about our family and our friendships and our failings and we help keep each other accountable and so I would just encourage parents like is this sounds daunting or overwhelming you don't have to do this alone think about one or two people other parents who you might want to do this with and I guarantee you there are a lot of us struggling with the same stuff and they would probably welcome an opportunity to do this in collaboration with another parent such spectacular advice that I hope everyone will follow not just for their kids but for themselves I think that whether or not social media is addictive in the in the true sense of the word is kind of a meaningless debate at this point it's at the very least a compulsive behavior for many of us and as you described it in example you gave it becomes reflexive yes we're just you know we're not necessarily seeking pleasure or looking to to engage in online battles it's just it's become reflexive so like finding yourself with your hand in the refrigerator just you can't even think about it yeah just doing it so becoming more conscious of the use and thereby more conscious of the value of putting away the screens and social media for extended periods of time each day and certainly in the middle of the night folks neuroplasticity brain rewiring happens in the middle of the night while you're asleep and like this when you mentioned kids awake in the middle of the night looking at their phone I just I saw you find oh my goodness it just it pains me and I've looked at my phone in the middle of the night I try not to but but I'm certainly not in the window of maximum plasticity either it's terrible for everybody but especially terrible for kids um what you just provided it is an incredible let's just call it a I'll call it a mandate you didn't say it but a suggestion of of teaming up with people to become more like minded around these issues and to really promote health along those lines I I really want to thank you first of all for the conversation today you're incredibly busy you're responsible for an entire country is worth of people so to take time to sit down with me and to discuss these topics for our audiences it incredibly appreciated by me and by them I feel comfortable extending their gratitude here and it's also clear based on today's conversation that you face an enormous number of challenges at the level of budgetary challenges by the way I'm going to work on that it's hard to shut me up um as well as that the huge array of of issues that you confront and and it's clear that it's a challenge that you've embraced for many years now 100 difficult conditions and that you're clearly willing to get out and talk to people and hear their criticism hear their concerns hear um and learn from them and so it's been a great benefit to us to hear and learn from you and I hope this won't be the the last of our conversations there's many more topics to cover but I just really want to thank you thanks ever so much for the the the intellectual power and the emotional power that you put into what you do because that is very clear you're a physician first and you care about your patients and your patients are all of us so thank you so much Andrew that's first when you just incredible kind of you I thank you I appreciate that and I've loved our conversation and you know for me what what I hope most of all for my kids for our country more broadly is that is that we can go deeper like beneath this these surface issues I've I worry that we find ourselves disagreeing about and fighting about online and recognize that there is a deeper challenge that we are facing that I think underlies a lot of these the anger and the vitriol and this issue around how disconnected we've become from one another I think is at the heart of that I don't think that there's any policy or program we can implement that's going to ultimately fix what ails society without fundamentally realizing that a lot of this is a manifestation of a society that has become more disconnected and more disinvested in one another like over time and that's just not who we are it's not how we evolved over thousands of years it's not how we're going to thrive in the future so I know that sometimes when you look at these big intractable problems like widespread loneliness in the United States that it can seem like hard to address these but I do want to encourage everyone to to recognize that when it comes to human connection that it is small steps that can make a big difference because we are hardwired to connect as human beings and if you if you just pause for a moment and if you just think for a moment in your own life about is someone who has been there for you during a time of great need somebody who has stood up for you and you couldn't stand up for yourself someone who's helped to remind you of why you're still a good person why you still have worth and value to add to the world even when you had lost faith in yourself and you think about their faith in you about their support for you about their love for you think about how healing that was that's the power that we have to help each other heal we are going through an identity crisis in many ways as a country where I wonder the set of values that we want to guide us in our life and to guide our country and I know that it feels like we're a nation of people who are mean who only care about ourselves we're throwing blame and anger at each other all the time who are pessimistic about the future but I actually don't think that's really who we are I think at our heart we are hopeful and optimistic people I think in our true nature we are kind and generous to one another in our hearts we we're interdependent creatures who recognize that if someone else is suffering we want to be out there to support them and who want people to be there to support us as well that's who we really are but we have to to make a clear choice here about our identity you know as as individuals and as a country and recognize that that choice is real implications for everything also we're talking about here that's the foundation and when I think about my own kids growing up like like many parents I worry about the world that they're coming into I worry that they're going to use the wrong word even though their intentions are right and people are going to blame them or cast them out no I worry that they're going to stumble and fall down and people just think you're walking by not caring you know because everyone's living their own life I worried that they might become someone who does the same thing to other people right none of which I want but I want for all of our kids is for them to grow up in a society where we care about one another we have each other's backs we recognize as that old African proverb goes that we can go fast if we go alone but if we really want to go far we go together and that's what I want for my kids in our country but that's what we each have the power to create in our own lives it starts with the decisions we make but how we treat one another do we for example reach out for five minutes a day just someone that we care about do we pick up the phone and call them to say hey I'm thinking about you we can all do that today do we give people the benefit of our full attention recognizing that while time is scarce our attention has the ability to stretch time it can make five minutes feel like half an hour but it's a hard thing for people to get because they're distracted by their devices but do we give people the benefit of our full attention and do we look for ways to serve one another recognizing that it's through our acts of service that we actually forge powerful connections but we also remind ourselves how much value we have to bring to the world and this is important in the time when the self -esteem of so many of us and our young people in particular is being eroded particularly by their use of social media so these are the steps that we can take to build connection in our life but the core values I believe that have to be at the heart of our identity these values around kindness and generosity around courage and service these also have to animate the decisions that we make in our life about programs we advocate for the policies we support the leaders we choose these should all be reflections of the values that we want to see in our children and in society more broadly because I'll tell you that 90 % of the plus of the decisions leaders make they make behind closed doors and what's guiding them in those moments are their values that's true whether you're the leader of a company or a nonprofit organization or a leader in government so those values matter and I want us as a country to speak more about the values that we choose about the identity that we want to anchor ourselves to that's the way in which I feel like America can be an even greater beacon of hope for the world because the world is struggling with this too we're not the only ones who are dealing with loneliness and isolation we're seeing anger and resentment and vitriol bubble up at extraordinary levels who are seeing mistrust and institutions soar many countries are experiencing this I would love America to lead the way in some ways and showing what it's like to embrace some more human identity that centered around kindness and service and friendship and generosity like to me all of these values ultimately Andrew stem from love right love is our greatest source of power it's our greatest source of healing I say that as a doctor is prescribed many medicines over the years but if you think it's more powerful then love and its ability to help us through difficult times and help mend the wounds seen and unseen that we all carry with us and I think if we recognize that we recognize that you know we don't have an MD after our name or have gone to nursing school to be healers we all have that power to help each other heal like Andrew we are not fundamentally a nation of bystanders we just stand by while other people suffer like we're a nation of of healers and hope makers who can restore hope that the future can be better who can create a better life for ourselves and the people around us right now it's what we're capable of it's what we're built for and that's the identity that I think we now more than ever need to embrace amen thank you for that I agree love is definitely the verb that can get us where we need to go thank you so much for your words for your incredible efforts to support public health and hopefully to continue to support public health I know you've been at this a long time and we have all benefited and and thanks for your open mind in this especially around some of the questions that invokes some challenge and again for your taking the time to come talk with us today and I really also enjoyed it it's been a real pleasure and there was a lot of learning for me and like I said before I hope it won't be the last time I hope not either now I look forward to the next time to stay in touch and just love this conversation thank you for what you've done for being this beautiful channel of information for the public but it's most more than thank you for who you are you know like who you're Andrew like comes across very clearly with you know when I meet you you just you have a good heart and you have good intentions you're good man and we need more people like you in the world thank you right back at you thank you for joining me for today's discussion with Dr.

2:30:44Vivek Murthy the surgeon general of the United States I hope you found it to be as informative as I did if you're learning from end or enjoying this podcast please subscribe to our YouTube channel that's a terrific zero cost way to support us in addition please subscribe to the podcast on both Spotify and Apple and on both Spotify and Apple you can leave us up to a five star review if you have questions for me or comments about the podcast or topics or guests that you'd like me to cover on the Hubertman Lab podcast please put those in the comment section on YouTube I do read all the comments in addition please check out the sponsors mentioned at the beginning and throughout today's episode that's the best way to support this podcast not on today's episode but on many previous episodes of the Hubertman Lab podcast we discuss supplements while supplements aren't necessary for everybody many people derive tremendous benefit from them for things like improving sleep for hormone support and for focus the Hubertman Lab podcast has partnered with momentous supplements and we did that for several reasons first of all their ingredients are of the very highest quality second of all they tend to focus on single ingredient formulations which make it easy to develop the most cost effective and biologically effective supplement regimen for you and third momentous supplements ship internationally which we realize is important because many of you reside outside of the United States to see the supplements discussed on the Hubertman Lab podcast go to live momentous spelled OUS so it's live momentous .com slash Hubertman if you're not already following me on social media you can do so by going to Hubertman Lab on all social media platforms so that's Instagram Twitter now called x LinkedIn Facebook and threads on all of those platforms I cover science and science related tools some of which overlaps with the content of the Hubertman Lab podcast but much of which is distinct from the content covered on the Hubertman Lab podcast again that's Hubertman Lab on all social media platforms if you haven't already subscribed to our neural network newsletter the neural network newsletter is a zero -cost monthly newsletter that includes podcast summaries as well as toolkits so toolkits for sleep toolkits for learning and plasticity toolkits related to dopamine regulation and much more again it's all zero cost you simply go to Hubertman Lab .com go to the menu tabs scroll down to newsletter and simply enter your email and we do not share your email with anybody thank you once again for joining me for today's discussion with the usurgeon general dr.

2:33:00vivic murthy and last but certainly not least thank you for your interest in science