Huberman Lab - Efforts & Challenges in Promoting Public Health | U.S. Surgeon General Dr. Vivek Murthy

Episode Date: September 25, 2023

In this episode, my guest is Dr. Vivek Murthy, M.D., the acting U.S. Surgeon General who earned his undergraduate degree from Harvard and his M.D. from Yale School of Medicine. We discuss nutrition, food additives, social media and mental health, public health initiatives to combat the crisis of social isolation, the obesity crisis, addiction and other pressing issues in public health. Dr. Murthy explains the role of the U.S. government in promoting specific public health issues and the steps needed to rebuild public trust in scientific and medical information. We also discuss health care accessibility, insurance barriers and individual versus team-based medical care. We also discuss topics gleaned from listener questions, such as the facts and myths about “Big Pharma” and “Big Food” industries, scientific research and public health policies. For show notes, including referenced articles and additional resources, please visit hubermanlab.com. Use Ask Huberman Lab, our new AI-powered platform, for a summary, clips, and insights from this episode. Thank you to our sponsors AG1: https://drinkag1.com/huberman LMNT: https://drinklmnt.com/hubermanlab Waking Up: https://wakingup.com/huberman Momentous: https://livemomentous.com/huberman Timestamps (00:00:00) Dr. Vivek Murthy (00:02:10) Sponsors: LMNT & Waking Up (00:04:35) Surgeon General Roles (00:07:44) Illness Framework, Enhancing Wellbeing (00:12:42) Priorities as Surgeon General (00:19:50) Public Health Message Distribution (00:28:24) Diagnosis vs. Optimizing Health (00:33:24) Sponsor: AG1 (00:34:01) Food Additives, Highly Processed Foods, Food Availability (00:39:11) Difficulties Addressing Health Issues & Highly Processed Foods (00:49:53) Retribution, Integrity & Public Trust (00:54:41) Company Opposition (00:59:50) Public Health Communication, Masks & COVID-19, Public Trust (01:07:01) Masks, Humility; Building Public Trust (01:10:45) Rebuilding Relationship to Public, Vaccines (01:17:41) Community Core & Diversity; Federal Funding (01:24:55) Big Pharma, “Pill for Every Problem” Society  (01:31:48) Interdisciplinary Medical Teams, Individualized & Value-Based Medical Models (01:38:44) Insurance Barriers, Mental Health Care, Drug Prices (01:44:40) Isolation Crisis, Social Disconnection, Health Risks  (01:49:15) Community Organizations & Modern Life, Social Media (01:56:36) Youth & Social Media, Parents, Policy Change (02:06:45) Real Life vs. Social Media, Kids & Playtime (02:11:56) Social Media Advice for Parents (02:20:43) Society & Disconnection, Human Connection & Service (02:31:20) Zero-Cost Support, Spotify & Apple Reviews, Sponsors, YouTube Feedback, Momentous, Social Media, Neural Network Newsletter Disclaimer Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome to the Huberman Lab podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today, my guest is Dr. Vivek Murthy. Dr. Vivek Murthy is a medical doctor, an acting Surgeon General of the United States. As Surgeon General of the United States, Dr. Murthy oversees more than 6,000 dedicated public health officers, whose job is to protect, promote, and advance our nation's public health. Dr. Murthy received his bachelor's degree from Harvard University and his medical degree from the Yale University School of Medicine.

Today's discussion covers some of the most important issues in public health, not just within the United States, but worldwide, including nutrition and the obesity crisis, as well as food additives and why certain food chemicals and additives are allowed in the United States versus in other countries. we also discuss mental health, the youth mental health crisis, the adult mental health crisis, and the global crisis of loneliness and isolation. We also talk about corporate interests, that is, whether or not big food and big pharma industries actually impact the research

and or decisions that the U.S. Surgeon General takes in his directives toward public health. And of course, we discussed some of the major public health events that occurred over the last five years, and the current and future landscape of how to restore faith both in public health officials, in public health policy, and science more generally. By the end of today's episode, you not only will have learned

a tremendous amount about public health and why you hear the particular public health directives that you do, but also how to better interpret future public health directives. You will also come to learn that as surgeon general, Dr. Murthy has both an extremely challenging job, but one that he meets with a tremendous amount

of both rigor and compassion. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero cost to consumer information about science and science-related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast. And now for my discussion with Dr. Vivek Murthy. Dr. Vivek, Murthy. Welcome. Thanks so much, Andrew. And please call me Vivek. I'm informal. Vivek. Okay. Vivek.

my understanding based on my internet search is that the role of the U.S. Surgeon General is to provide scientific information on how to improve health and reduce risk of illness and injury. Do I have that correct? That is correct. What are some other roles that you play that perhaps would not come up in a top-hit Google search that I ought to be aware of and that our audience ought to be aware of? Well, here's how I generally explain to people. There are two primary roles the Surgeon General has. One is to engage with the public and make sure that people know about critical public health issues so they know what they are, how to protect themselves and their families. The second role of the Surgeon General is lesser known, but it's equally as important,

which is to oversee one of the eight uniformed services in the U.S. government, and that is the United States Public Health Service. Many people are familiar with the Army, the Navy, the Air Force. We also have the U.S. Public Health Service, which is 6,000 officers. They include doctors, nurses, physical therapists, pharmacists, public health engineers, a whole range of health care folks. And their job is to protect our nation from public health threats. So when Ebola came on the scene in 2014 in a major way in West Africa,

we sent hundreds of officers to West Africa to say, set up the Monrovia Medical Unit in Liberia to treat people with Ebola. Domestically, when there are hurricanes or tornadoes, we dispatch officers and deploy them to go help strengthen the public health infrastructure, but also to provide direct care. We deployed thousands of officers during COVID. So these officers, I'm incredibly proud of them. They could be doing lots of stuff outside government in the private sector, probably making a whole lot more money and working a lot less hard, but they're really committed to protecting

the public health of the nation. So I have the privilege of overseeing that services surgeon general, and those are the jobs that I've signed up for in this role. Got it. I was not aware of that role. And if I understood correctly, these people, these public health officers that presumably are made up of physicians and licensed psychologists and nurses and so forth, you said they could be making substantially higher incomes in the private sector, but the work that they're doing with you is their sole career at this point. They're completely devoted to that, or they're doing this as a side hustle? They are full-time government employees and members of the Public Health Service.

Their day job is often in public health agencies where they're embedded in communities helping day-to-day to advance public health, and during times of emergency, we deploy them. And they're extraordinarily well-trained. They're experienced dealing with adversity. but they bring a combination of skill and heart to their work. And you really need both to be effective at public health. I'm glad that you mentioned the word emergency because in preparing for our discussion today,

it occurred to me that in this list of roles that your title assumes, that scientific information on how to improve health comes first. Then you mentioned emergency. So what I'd like to talk about first is health, Not lack of health, but health. So often we hear about the mental health crisis, but what we're really talking about is the lack of mental health crisis,

aka mental illness. And rarely do we hear, for instance, what constitutes mental health. We hear what constitutes mental illness. Whereas in the domain of physical health, there's a lot of information out there about how to be more physically healthy, cardiovascular exercise, resistance exercise,

yoga type exercise, mobility, etc. And of course, some people have physical health ailments and there's a lot of information in terms of how to deal with that as well. But what I would like to know before we get into the long list of issues that our nation confronts, everything from obesity to food additives to mental health issues, what is going well? In other words, in the last, let's say, five to ten years, have there been any areas of physical health and mental health improvement in the U.S.? at large that we can attribute to some of the public health initiatives directly.

So that's a really good question. And let me just also say about the very first point you raised that you're absolutely right that we have operated primarily through an illness frame when we look at health. And in my mind, that's only one half of the equation. So when we are talking about physical illness, for example, you know, as a doctor, I learned how to diagnose and treat some with diabetes or with high blood pressure or with coronary heart disease. But we also know that even if I don't have diabetes or coronary heart disease or high blood

pressure, even if I don't have any diagnosable medical condition, I may not be at an optimal level of physical health, right? I may not be able to, for example, walk around the block without getting short of breath. I may not be able to play with my kids because my physical fitness and stamina is insufficient. I may not be able to lift my luggage when I go to the airport. because I don't have enough strength in my body, yet I wouldn't have a diagnosable mental illness. So I think it's easier to understand there with physical health

that we're not just aiming for lack of illness. We're aiming to optimize our physical health. The same is true with mental health. And I think when we talk about mental health, people think the sole goal here is to prevent diagnosable mental illness. That is one goal to both prevent and to manage mental illness when it arises.

But we also need to recognize there's a whole other half of the spectrum where there are people who may not have diagnosable mental illness but are not operating optimally in their lives. And that's detracting from their fulfillment, from their functionality, like in not just at work, but also in their communities and in their families. And so I think part of the conversation that I want us to have as a country is about how to optimize mental health and well-being. And that includes preventing mental illness, but it is much broader and bigger than that alone. Great. Yeah, I think it's so important that we recognize that treating disease is critical, obviously,

but that there's a lot that can be done to improve one's health, even in the absence of any known disease. And you've got all these officers, these incredible physicians and nurses and people at your disposal, my hope is that they would also be accessible for and currently carrying out efforts to transmit information to people about, hey, here are the things that you can do every day, every week, every month in order to make your life as healthy as possible, as well as, you know, rushing in under conditions of, you know,

public health crisis. Yeah, it's a good, good point. And it's certainly, you know, many of our officers do focus on this broader rubric around well-being. But it's part of how we need, I think, the broader health system and public health system to operate even outside of government. And And this, I think, will require significant change and shift in how we think about our jobs. Like when I went to medical school, the vast majority of the focus was on diagnosing and treating illness. It was much, much less focused on thinking about how to enhance well-being. And when you ask and talk to people in their lives, it becomes clear that they want to do

more than just prevent diagnosable illness. They want to be able to walk their child down the aisle. They want to have the endurance to do that. They want to be able to be independent often and carry their groceries or carry their luggage. This is why I think we've got to broaden our focus in public health. And look, when I came into this role, by the way, I was not expecting to serve in government. This is not part of some 5, 10, 30 year plan. When I was a kid, I was interested in medicine, but I always thought I was going to practice medicine,

like my dad did, and like the clinic my mom ran, you know, set up, put up a shing. see patients and be a primary care doctor and feel good about the work I was doing. But what happened to me along the way is, you know, I trained in medicine, I got interested in technology, spent seven years building a technology company that was focused on health. I became increasingly worried about the way we were delivering health care. It felt like our health care system was broken. People who needed care couldn't get it. It was often too expensive to get care.

We were focusing on treatment solely and not enough on prevention. So I started getting involved in advocating for a better health care system with doctors around the country. When despite all that, I still never thought I would work in government. But in 2013 is when President Obama's team had reached out to me and asked if I'd be interested in considering the position of Surgeon General. And what was interesting to me about this position is it's actually very different from most positions that are appointed by president in government in that it's supposed to be an independent position. So my agenda, the issues I choose to take on are not determined by a president or a party. They're determined by science and the public interest. And that's what guides me.

And that's what guided me in that first term when I served. And when President Biden asked me to come back and serve as Surgeon General, the second time, that's what's guided me here too. So Biden is not sending you notes saying, hey, could you put some effort into, you know, getting messages out about, you know, COVID or could you put more effort into getting your team over to Maui to deal with the, you know, the tragedy there, which is a long arc tragedy, right? We get the news in a blast of this happened and then the next blast comes in about something else and we forget that there are physical and mental health crises that are ongoing.

and then I have to imagine then start to overlap with one another. So is it your decision where and how to deploy the financial and human resources? Like, okay, we're going to put 10 people on Maui. We're going to put five people in the central states going around talking to major organizations about what they need to do to prepare for this winter.

Is that how it works? Or are you getting memos? In other words, who's your boss? Everyone has a boss at some level. Mine are the listeners of this podcast at some level. I work for them. It used to also be my bulldog Costello. My boss, my wife and my two kids, we were five and seven.

I do what they tell me too. Got it. Got it. But how we make our decisions in the office, actually, it's a bit different with those two roles. So with the second one, with overseeing the Commission Corps, our 6,000 officers, there the decisions about how and when we deploy officers are collaborative. So, you know, we work with other colleagues throughout the Department of Health and Human Services. We work with people in FEMA across the administration.

But we also work with states. So sometimes states, often, often states will put in a request and say, hey, we need support here. Can you help? So we'll work with colleagues across our department to say, okay, well, we can mobilize our commission corps officers. What asks us can you mobilize? And then collectively, we will send a team out there. So, for example, we have officers helping in Maui right now, particularly with. with mental health needs, which are, I worry,

only going to continue to grow over the weeks and months ahead. On the other side of the House, when it comes to deciding which issues we engage with the public on, like in this case, mental health has been a big focus area for me. On that front, well, we certainly, you know, are open to suggestions from the public, members of Congress sometimes say,

hey, can you help the public understand about this issue? You know, a lot of people have ideas and opinions, but the decision about which issues to focus on, those are our offices. And to me, that's important because part of the reason over time, I believe the public came to have some degree of faith and trust in the office is because they hope that the office was functioning the way you hope your doctor is functioning, which is being an independent source of information for you and a source that has your best interest at heart that's not being pulled aside by political interests or by other agendas. But the primary agenda is how can I help your help? And so for me, like we have to make an independent assessment there and say, okay, where is the need the greatest here? Where can we make the biggest difference?

Sometimes we may not build an initiative on an issue, and that doesn't mean that that issue is not important or that it's not affecting a lot of people. But we have to make hard decisions about where to pull limited resources. And so when I was a surgeon general, the first time, one of the big areas I focused on was the opioid crisis that we're dealing with, as well as the e-cigarette use among youth, because we were seeing a dramatic impact. increase among kids in e-cigarette use. Can I just ask you, sorry to interrupt, but I think it's relevant here. Has that increase continued or e-cigarette use, aka vaping? Yeah.

So we still see, unfortunately, there's been some improvements, but we still see way too many kids who are using vaping devices early on. And part of what we did from our office is recognizing that. We actually issued the first federal report on e-cigarettes and youth. We call the country's attention to the fact that this is a crisis. We worked with members of Congress to talk about the kind of action we needed from a legislative and regulatory perspective and worked with colleagues at the FTA and in government as well. But there are two things that are really most important in guiding our choice about priorities.

One is data. We look at what the numbers actually tell us about the impact these issues are having on the population, as well as the trajectory of rise if something is getting dramatically worse and people don't realize that might be an area for us to focus. but the other critical factor is what I hear from people on the road. So I try to spend as much time as I can visiting communities across the country, doing town halls, meeting with community members, and just trying to, frankly, just listen to what's on their mind.

And that's where I actually get a lot of information as well. That's actually how I came to focus on the issue of loneliness and isolation. It wasn't because it popped up in a report as being the leading public health issue in the country. was because everywhere I was going in 2014, 2015, when I was talking to college students, talking to retired Americans, talking to parents in rural areas and urban areas, I kept hearing these stories about people who felt like

they were all on their own, or they felt invisible, or they felt if they disappeared tomorrow, no one would even care, or they felt like they just didn't belong. And it's heartbreaking to hear that from anyone. It's particularly heartbreaking to hear it from kids, who you hope are entering life and looking forward to what comes,

but many kids weren't feeling that way. That is very useful context, and we will get back to the isolation crisis, such an important initiative that I just will thank you now for having put out the message on social media and elsewhere about that, because I think one of the questions I have in light of what you just said is, It's clear that you've got your ear to the ground, you're talking to different people. It's also critically important that people hear from you and know not just what's happening, but that you perhaps want to know where the issues lie and what the actionable steps are that people can take.

And I think that we now live in a hyper-connected world. So, you know, in fact, I'll just say that one of the reasons I launched this, podcast is in 2020, I was going on podcast talking about things like maintaining sleep and circadian rhythm and stuff from my lab related to trying to adjust anxiety under conditions where I think everyone was anxious and sleep rhythms were disrupted, et cetera. And I was somewhat surprised that I didn't get a warning on my phone. Hey, make sure you're getting morning sunlight. You know, like I'll get a flood warning. You know, I'll get a warning that I might get a warning, but it's only a test warning. I'll get the three of those yesterday, living here near the coast.

But I don't think once during the pandemic did I get a email or a public service announcement saying, you know, if you are going to be indoors a lot, you're going to have to be mindful of maintaining your circadian rhythm. Because if you're not, I mean, we know based on hundreds of studies now that drifts in circadian rhythmicity are a precursor to mental health issues. I mean, in fact, there's a new idea that many, not all, suicides, are preceded by a period of disrupted sleep, which is, you know, kind of makes sense. And it's not causal, of course. But how come during the pandemic, we each and all, as U.S. citizens, did not get an email or a text message saying, hey, these are five things that you need to do every day to try and stay a stable.

as possible in this very uncertain landscape that we're in. Well, and it's a really good question. And I think it's a reasonable and a very good suggestion to say that, hey, look, there should be a clear and comprehensive way that we can get messages out to everyone. Like if we were working in a hospital system and there was a safety issue that came up, there would be an email sent to all the hospital staff members saying, hey, this is something you need to be aware of. So I think it's a reasonable expectation.

Practically, if you go back, though, over the last 20, 30 years, on health issues, there hasn't been sort of an agency or an entity that has sent emails out to everyone. First of all, how to send an email out to everyone in America is not a simple proposition either. Technically, it's challenging. There are some legal issues you'd have to deal with as well. But you could do a night where you go CNN, Fox, NBC, 8. ABC, New York Times, Wall Street. Like, you could hit the right, the right wing, the left wing and everything in between.

Yeah, that's really interesting. Like one, but one, one video, just where they all agree, like, hey, this is important information. Sure. So apolitical, like, no. Yeah. So I would say that that kind of messaging, I would say, through traditional media certainly has happened, you know, and it happened during COVID. It happened, for example, when, you know, in the first year of COVID, I was a private citizen,

you know, in the private administration. but I watched both then and at the beginning of the Biden administration, many officials would go out in front of cameras and say, here are three things you need to do to keep yourself safe, you know, from COVID. And that was a big question people had. How do I keep myself safe? Okay, here are three things you can do. A couple of challenges I would say here is that, number one,

even if you hit all the major network and cable news shows, you're still not reaching everyone, right? Because we're living in a society where increasingly people are not watching TV, right? They're getting their news from other sources. The other thing that's important to know is that attention shifts quickly, you know, in traditional media also from issue to issue. And so you might get a clip, you know, out at a certain day or you might get on all the Sunday shows, for example.

But the next day, you know, that message isn't necessarily there. You know, it's gone and people's attention has also switched off too. So they were, I mean, I can count, and you know, we've logged probably thousands of interviews at this point that we've done with mainstream media with sort of, you know, concise messages about three things you can do to protect yourself, et cetera. And, you know, I'm glad we did those. We got to do them. But I think one of the things we don't have right now in the country, and this is, I think, a bit of a health infrastructure challenge is we actually don't have a quick, efficient way to reach everyone in the country with a health message. just like what you said. You know, if you wanted to get that message about three things to protect yourself from, let's say, COVID,

or three things to do to support your health and well-being during a time of crisis. Or during a time of health. I mean, again, like not just the flood warning, but the daily, because I do think that most of mental and physical health is the result of daily practices that are, you know, the build on themselves, sort of like compounded investments.

And then, of course, there are acute challenges and chronic challenges that people face. but things of that sort too. I think those kind of messages in time of health are absolutely important as well. And I think in the sort of, I think fast-paced crisis-driven environment that we live in, unfortunately people are often paying less attention to those maintenance and improvement messages than they are to managing the crisis messages. But I think that they're equally as important.

But I do think that what you're pointing out is an infrastructure piece 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 C. Everett 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. Yeah. This thing you read about in the history books or something shows up in your mailbox and you open it and hopefully it's something you want to read. But in this case, he was worried about HIV, about the fact that people didn't know about it. So he worked through, and as I understand it, with a member of Congress, found 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 of 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. The 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 Paxovid, that we 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 had to, again, there too had to sort of creatively cobble together resources funding. This is all sort of, you know, sort of behind-the-scenes government stuff. But the bottom line is,

what you want in an 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 traditional media to cover the initiatives we put out, whether it's on social media in 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. And then together we try to get our messages. Our office does all three of these, but it's a patchwork. And it's not always ideal, but it's what we're. 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 just as 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, right? Right, because one problem feeds the other. Exactly. The kids that are state, listen, 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 to friends on the phone late at night, right? So it's not a criticism, 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 in this other side of what you do in terms of, and here I'm 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. I 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. 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. I pay federal and state taxes. Me too. 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, but 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 youths and mental health or whether it's around isolation or a 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 the core pillars of a healthy life, right, which are sleep, our nutrition, our physical activity, our social relationships. 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 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. I could not agree more. We have a series that's out now with a psychiatrist of Paul Conte 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, 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. I'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 a day 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 and nutritional needs are met. And it tastes great.

If you'd like to try Athletic Greens, you can go to athletic greens. You can go to athletic greens.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 in the car, on the plane, et cetera. and they'll give you a year supply of vitamin D3K2. Again, that's athletic greens.com slash Huberman to get the five free travel packs and the year's supply of vitamin D3K2.

There's lots 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 and that I got more than 10, 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, though, Andrew. One, I'm really glad that you asked folks to submit questions, and I 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 building a channel to the public to let people know about these topics that, you know, 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. And 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 Huberman 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 dies and things of that sort that are not allowed in Europe or allowed in U.S. food products? It's a really good question. And decisions around food and food safety in particular are made by the Food and Drug Administration. So that's the FTA. It's not, it's a separate independent agency. It's not one that our office is involved in 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, 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, et cetera. 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. When 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 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 other piece of this that worries me are just how much refined sugars are being added to so much of our foods. And most people think that sugars are only added to things like desserts, et cetera. But you look at spaghetti sauces. Salad dressing.

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 processed food composition in our diet. And I think part of the reason this is happening, and I want to 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. And the cheapest foods, unfortunately, are often the most unhealthy foods, the most highly processed foods. If you are somebody who lives in a low-income neighborhood, a number of these neighborhoods don't even have grocery stores in them, which is a tragedy because you can't get fresh produce, et cetera, a lot of times your shopping, your grocery shopping may be done at a local convenience store, at a 7-Eleven 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'll occasionally have some lemons or apples or oranges and bananas. But when I walk into a convenience store, what I see as 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, highly processed foods. And keep in mind, I was a teenager. I mean, I drank my slurpees. I had my butterfingers, you know. I wasn't, you know, Bart Simpson-like in my level of butter fingers, but I liked them. But it was a smaller fraction of what we ate.

And when we were at home, those foods were either not available or we certainly weren't allowed to eat them in ad libidum. You 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 foods. so that they don't taste 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. Okay, 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 taxpaying citizen, speaking on behalf of many other taxpaying citizens, I have to sort of take a step back and say, how long do we wait, right? Do we have to get a randomized clinical trial about the, you know, 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 unprocessed vegan or unprocessed meat and vegetable or unprocessed, you know,

know, starch and vegetable. I mean, I 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've 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 err 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% of these foods is potentially going to lead to serious issues down the road. And 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? So 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, 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 vexing, it's complicated. It's incredible.

confusing if 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 read 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? But 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 risks they want to take.

The other thing that concerns me here, Andrew, is I, look, I'll tell you, I have a bias here, and my bias is that I am worse. about the additives and other products we have in food that don't have long-term data that's clear in terms of health risk. And so because of that, like my bias is generally to think, how can we get people 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 make 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. But 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?

How 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 detracting from sleep, detracting from in-person interaction, detracting from anything else it'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?

How is that impacting our situation? 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, the 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 with a 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 was trying to see the scope of the problem and the mechanics involved in trying to alleviate these issues are complex.

I see that. They aren't also. One of the things is important to do that, though, is you need to have authorities that can speak to these issues that are insulated from political retribution, right? So, and explain this. Amen to that. Yeah. I mean, listen to somebody, forgive me for interrupting, but somebody who from time to time will make not recommendations,

but will offer information about potential actionable items, you know, things that people could do or not do according to a couple of studies that have come out. I mean, I've come under intense scrutiny from my colleagues who are like, wait, that's not a randomized controlled trial. How can you do that? And 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, but 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'd lose their job almost instantaneously because they're controlled substances. That'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. Right. If people understood, I think, that is sugar poison? Well, some of my audience will say sugars, 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 are, 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. And 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 treating 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, you know, autism or schizophrenia, but is going to be a major health challenge. And that is serious. And now's the time to intervene by avoiding certain things. And 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. Yeah. Because there's also, and we know this from my colleague Ali Crum'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 that 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, ghrelin secretion, et cetera, that change. So people can feel better on a healthier, slightly lower calorie nutrient-enrich diet of healthy proteins and fruits and vegetables. And it's not a mind trick. It's physiology. Anyway, I think I feel your pain, frankly.

And I'll tell you, look, sometimes people ask, hey, why don't you just go out and say a couple of statements that you just said? Would that be fine? Like, why is time needed to prep something like that? Why are a resource needed, etc.? Here's actually why. Like, I know in today's day and age it's easy to just go and like rattle off, off the cuff statements or shoot from the head, etc.

My social media channels any time. Really, to get their word out to millions of people. No, 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, 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, the behind-the-scenes work. that we do before we put out sort of reports and initiatives. Because we want people to have confidence in what they're hearing. We also know that when we put out initiatives that other people build on them.

Philanthropists and foundations will then think about should I fund work in this area. Schools and workplaces will think about shifting some of their practice. Policymakers 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 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 taxes.

This is what I meant, which is that saying things about diet, saying things about tobacco, these can be challenging for some folks because their industries built around these, 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, and 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. Folks 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? once you take alcohol out of the title, you know, all of these sort of, you know, concerns were raising. So these are people who get paid by the alcohol industry? No, these are people in government who are reading the tea leaves

and who are supportive of the work we're doing but are saying, hey, like, you're going to really upset a lot of people in industry. You're also going to help a lot of people. Yeah, well, this is what it comes down to. 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 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. I'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 want to be able to go to sleep at night, look myself in the mirror and know I did so with integrity. So that was an easy decision for me. But my point is that like we have to. to be thoughtful in these issues that they're going to be headwinds, right? I'm sure in your case, for example, you've probably gotten pushback from folks about talking about certain things that may have rankled folks who may have had an interest in those issues, and that's okay. You keep talking about them as you should, and I'm grateful for that. But this is 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. So 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 U.S. that are not allowed in Europe that may be of risk. We don't have enough data at present to say to avoid these things. but here's a kind of a yellow zone.

You know, green, known to be safe, red, clearly known to be unsafe. Yellow, we just don't know yet, not enough data. So here's what my recommendation would be for my children. Yeah. It's free country, you know. There are 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 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.

I mean, certainly the government has not had problems saying to do things or to not do things that upset companies or shut down companies or elevated companies and their success. So I'm confused. 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, whether it's in the private sector and government, people weigh with, 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 pushback from the public, people say, hey, that doesn't make sense, something, et cetera. You should listen to that and 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 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 hear from anyone in terms of their concerns or pushback. But the end of the day, what's going to guide my decisions about what issues we take on, what decisions we make,

and what we say to the public is going to be what isn't driven by science and the public interest. And if that means it's politically inconvenient, that's okay. If that means that something happens, you know, it's 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 may as to 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. So 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 by not giving them the information that they need to make decisions.

So even if you have resources, I guarantee there are people listening to this podcast and many more people out there who go to the grocery store and just feel confused. Like 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, you know, that it 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.

The 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 landed like a parent telling their teenage kid to always wear a seatbelt,

but then you look into the front seat and Tom and dad aren't wearing seat belts. And as anyone who's been around teenagers or 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,

But what I don't recall happening was a, like a, 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 now may change again. We're navigating this in real time. It's dynamic. Please stay with us because, you know, goes without saying there's been a huge case. around this and related issues. Yeah, and look, it's an important question.

And look, 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 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? So 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 certainly try to follow, but one, 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 that 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? Because sometimes, as you know, 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? You evolve and update recommendations. We do that with lipids. Here, too, I think that has to be like a key part of the approach. 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 soundbite 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 being recommended. That's what's being required, et cetera. 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.

But I think that that's a challenge, right? It's like, 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. to be able to follow your guidance. And 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.

And 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 was often people who were upset about some of the requirements that were being put down from local departments of health. And you can understand that COVID was as stressful

a time, as we've seen recently. People lost their jobs. People were 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 to 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, I think what we also need to restore is an environment where we, of frankly, of humility and civility where we don't attack people, you know, who maybe have different views or are coming

out with recommendations that, you know, 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. And, you know, while that may have been at times done for political reasons here or there, the people who suffered were both the public health leaders who were trying to do the right thing for their communities and the public themselves who weren't able to have a clear direct channel 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 getting violent or harassing people with whom you disagree is totally inappropriate. Andrew, the one thing just to say about the humility piece, and I'll give you an example here of where I think this could have and should have been done better, is in 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 schools requiring masks, 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 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 social development. Some worried that it was adding stress to their kids.

People had met 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 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. It was incredibly hard for us. Even when they got back to school in 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 may have a different point of view or may make a different decision for their child. And I know that when localities made the decision in many cases to require schools and their, you know, kids in their district to wear a mask, that put some parents who didn't want that, they 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 it's us against them. And 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 sides. 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 we had one, it was one of the, I think, most historic and effective vaccine distribution efforts in this country, even though it certainly could have been better, but it was historic by all measures. We've learned a lot about how to do vaccines, therapeutics, a lot of the nuts and bolts of a pandemic response well. But 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 divided the way we were during COVID during the next pandemic or the next, you know, a threat 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? to 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 it 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, and 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 if 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, which is if there is a medicine, you give a patient. And even if it helps 99.99% 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've, together, trot out a 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. Here are 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. I think here to similarly, 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 were they correlated or where there's actual causation there, right? Because, you know, if today, for example, I felt unwell and I trace 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, you know, something that happened? that it's independent of how I'm feeling. Maybe 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, like when I got vaccinated for COVID, for example, I felt like I had mild flu-like symptoms for a couple of days, you know. It wasn't great. I would have preferred I didn't, you know, have those feelings. Like, you know, and then I felt better a couple of days later and then I moved on.

But, you know, I acknowledged it didn't feel good, you know, to feel that way. There are other people who may have had experiences where they felt that they had more serious, you know, side effects. And there may be a question, 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. If 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. So 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, et cetera. But people who track the data know that Tylenol by and large is generally speaking a 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 side effects common or rare, right? But 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 NyQuil. Like, no one would take any of the common medications that we pick up at the drugstore and that we commonly use. So that's how I think we have to approach this with a combination of clear communication, empathic listening, and data and context. Again, that doesn't fit neatly in a social media post per se. But I think part of 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. One 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 but one citizen, but I'm putting up both hands, both feet and all toes, and saying that 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.

Yeah, 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 helping to build. It was something called the Community Corps, right, where we actually, we recognize so very clearly, and this is something I, you know, I came to see as a doctor. Sometimes I was a right person, a message to a patient. Sometimes I wasn't, right? 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. So part of this work is knowing when to step up, when to step back, right? But the community core that we were building was a really diverse, you know, a group of people. And a lot of 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 their trusts 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 you. 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 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 taken 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. Now, you know, I'll tell you 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? Because it's important that many of them were showing up in their communities.

We're knocking on doors. We're doing local, you know, podcasts, et cetera. And that was great. But I would have liked more of their faces like carried on TV, right? So that's a place where 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 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. This is like the public health community is big. It's broad. It's diverse. It has a lot of voices. And the more voices we can hear from is public, the better off we are.

Yeah, here, here. 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.

But 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, we're not talking about groups of hundreds of people, but small groups. Yeah. So I think we're aligned in that way. Yeah. And look, there's, I think, a notion that, um, 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, if something doesn't quite work out if 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? 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 note if you turn on the TV because you were seeing the same couple of faces. So I think we have to certainly diversify that. One other thing I think I'll 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're like, oh, yeah, that's the person from organization X. They understand us. They get us. They're looking out for us. A 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.

So 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. So 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 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 community, what happens is a federal government often will give it to states.

States will then give it to local communities, to like the local department of public health potentially, and then they will look to distribute it to others. That 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 their relationships. Because at the end of the day, it's those relationships that create their trust. It's a trust that allows life-saving information to get to people, and that's the link that's missing. Very interesting.

Pharma. 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. We 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. Yeah. Okay. 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. So that's one question. And then I want to dovetail into that question.

What are your thoughts on the fact that, you know, there's a history of, say, the tobacco industry being, you know, very interdigitated, shall we say, with government policies in ways that had us basically injure, if not kill millions of Americans? and then eventually say, you can't smoke near a hospital. You can't smoke anywhere. There's very few places where you can consume tobacco products. You know, that kind of relationship and financial incentives and then a lot of backpedaling later, I think war on people's trust. So how should we frame the relationship between the pharmaceutical industry, government, and public health initiatives in a way that is, you know,

at least halfway functional. Look, I understand where the concern and the suspicion comes from, right? And look, 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. And we have a history in medicine, right, of doctors who were, you know, 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. And now we're seeing a lot less of that, which is good.

A lot of rules that are being put in place by medical societies and professional societies and by academic institutions to say this is an unacceptable way to practice. And 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, 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. Or 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 I want to separate one thing, though, like taking money from a 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's 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. And I would prescribe those again. I am glad that those exist. In many cases, they've saved the lives, you know, 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, right? 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 know this is obvious to you, but I'll say just to be clear for everyone who's listening. Like our office doesn't take any money from industry, not just farm industry, from any industry. Like the money that we get is allocated by Congress at the end of the day. It's taxpayer money. And that's all we get. And that's important.

We don't want money 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. where we look for a quick fix of a medicine for every challenge that we may incur. And 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 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 when I think about that bias, that to me is not always, you know, stemming from money that came from a pharmaceutical company,

although I think 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. But I think it's more complex than that. And I think that even for, you know, in the health care setting, like 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 deal with non-medication 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're living. we increasingly reach for something that we see as a quick, immediate fix. And 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. And 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, you know, and in addition to that, I think the person should have on hand, you know, a five-millimeter dosage of a prescription drug that if they need it, they could take. And I think it would provide a lot of protections against, you know, potential adverse effects of any one of those things in isolation. There's 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, for lack of a better word, a more holistic perspective. Why not?

I mean, you're just driving the dream. I 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 the sort of virtual room, if you will. The second is how do we create a structure, a healthcare system

where that can actually happen with efficiency, where it can be reimbursed appropriately. But that's what we should be doing. And then the third leg of that is the group experience for patients, right? And there's increasingly more clinics and health care systems around the country that are working on creating group experiences where patients who all, let's say, are working on their diabetes, come together, let's say, once a week and they meet with the health care practitioner. That might be in 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.

But 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 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, and 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. And then you as a patient are stuck trying to piece all this together. While often in pain. Well, yeah. In physical and emotional anguish. I'm not referring to my own experience, although I've had mild examples compared to what other people have dealt with. But people with chronic pain are irritable for understandable reasons.

I mean, it's or 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 to 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. It really is cumbersome. And like you, look, having worked with many medical professions over the years, like, 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 I'll tell 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 and 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 right this happens to pediatricians and primary care doctors more broadly all the time with mental health right

most of the mental health care that's delivered in this country is delivered in primary care offices right 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. And 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, then you're stuck on your own figuring that out. And so I think the pain is being experienced mostly by patients, but also very much so by clinicians. And that's why that overhaul is needed. And I think, look, 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, what 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 I'm getting reimbursed for every procedure, we're going to take more of a value-based approach here where we say, okay, we've got a certain 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. We're getting reimbursed for the care, overall care that we're taking for a patient. 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. Tough 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 one second, Andrew, before we go there, one thing I'm about the tough problems, right? You're exactly right, and the problem is the longer we take to acknowledge and address these tough problems, the more entrenched the interests become that profit from the status

quo, right? 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. They know what care is needed, but prior authorizations, you know, get thrown up there and required. Even for a medicine that clearly your patient needs urgently, you know, 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 to yourself, does this make any sense? Like this is an urgent situation? My family member needs his medication. I'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't go home. I know they need to be in rehab. There's nobody literally to help them at home, but then not having 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, how are you going to keep fighting all of this and sending more and more paperwork? Eventually you'll just give up. We have a lot of problems right there in an industry that should be delivering care. Often is doing good things, but too often I think is allowed. 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. but how 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 right 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 skirting it, right? So one, the law wasn't even being adequately reinforced for many years.

But two, insurance companies sometimes would say, okay, you know, we're reimbursing adequately, but when you look in the network, they had very few providers. So you really couldn't access somebody, right? So 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, et cetera, again, throwing up more and more barrier So very recently, in fact, just a few weeks ago, President Biden just announced that we are from as an administration putting out a proposed rule to actually strengthen the mental health parity law to prevent some of these what I think of as abusive practices because they're preventing people who need care from getting it. 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 a mental health concern,

what you need in that circumstance is help. You 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 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 board. 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, anyway, 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 the barriers are being thrown up by industry. But I say all of 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 a 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 is 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. And we got to get, Look, if you're collecting taxes as government, you should be doing your best to 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 to 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. So 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. And the truth is, it was familiar to me because of my own personal experiences.

You know, 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. You know, there were times when I, I would like, in elementary schools and there were days where I pretended I had a stomachache and so that 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 like walk into the cafeteria one more time and be scared that there was nobody to sit next to or that no one would want me to be at their bench. 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 that something's wrong with me. I'm not likable. 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. And I never took a on loneliness in medical school, who wasn't part of our residency curriculum. Yet when I showed up in the hospital, I found that the patient who had come in with a diabetic wound infection

or who had come in, you know, 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, you know, we need to have a difficult conversation about your diagnosis.

Is there somebody you'd want me to call to be with you during this time? too often the answer was, you know, I wish there was, but there's nobody. I'll just have the conversation by myself. But it was when I was Surgeon General that I realized that those experiences weren't limited to me and my patients, that 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 percent who say that they are struggling with loneliness. So 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, you know,

to the mortality impact of many other illnesses. In 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. You mentioned community organizations. Could you elaborate on those? You know, growing up in the 70s and 80s, I was exposed to like community soccer. 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, you know, 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 a decline in participation and community organizations. This isn't a recent phenomenon. This has been happening over the last half century in America. We've seen lower participation in faith organizations, in recreational leagues,

in service organizations, and other community groups that used to bring us together. And I think, you know, 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. So 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. One is that just from a cultural perspective, as modernity has arrived, not just in the U.S., but in other countries, we've seen that people are more mobile, right? 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 a 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're having 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? If we know what the costs are of certain actions, we may still take those actions, but we may find ways to mitigate the cost. We may, in this case, invest more in our relationship, be more conscious about reaching out to other people going to visit them.

But that has been a quiet but devastating consequence. The other pieces 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. Now, 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 costs. And one of interesting thing about COVID, as many people in the first year of COVID, when we were all separated from one another, you know, when we finally came back together again, 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 I ran into at the grocery store or seeing neighbors as I walked down the street. Like, I 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. I 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 like 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. Like you and I are sitting across and we're both processing like our body language, right? And I'm seeing you nod your head and I'm seeing your eyes focused. 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 with 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, one that can be quite hurtful at times.

And I also think that 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's 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, for many older people, too, is their experience on social media has shredded their self-esteem, as they're constantly comparing themselves to other people. Like when you and I were growing up, you know, in the 80s, we compared ourselves other people too, right? 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 roundtables 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 of 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. So 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. You know, 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. Like 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. And these are people on the outside look perfectly fine, right? They're posting happy things online to the folks at work. They're seeming like everything's 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.

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, that we realize that, wow, the majority of people in our country are actually struggling with loneliness. Yeah, I'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 is it's clearly going to lead bad places it's also clear to me as based on what you just described that you know when we go on social media we see something but they don't really see us you know hence perhaps why people get aggressive in the comment section you know they

want to be heard yeah we want to be seen I think all of us want to be seen and see other people yeah and social media doesn't allow for it so easily I also know that a lot of young people will congregate with their friends to play video games online. But that's different. You're essentially showing up as an avatar. And when we were kids, we also played different characters in our games. But oh, so 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, nope, no more. We're going to rebel. 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 chairs in rooms, counting their money. That was what actually was successful in getting kids to not smoke because kids have a rebellious streak, as opposed to when they were told, hey, smoking's terrible for you. Your lungs are going to fill with cancer. Kids didn't stop smoking.

teens didn't stop smoking. It was, you know, rebellion has been baked into our nervous system in the adolescent and teen years. So do you see a rebellion against this social isolation? Our kids are 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. 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 that kids together have decided that they're going to delay using social media and, you know, to pass middle school or in some cases even later, or were they're deciding that they're going to draw boundaries around social media use or 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 but doesn't necessarily have social media apps on it that this is still a small

minority and and we're 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 then you might feel left out which is why it's so important for parents and kids actually do this together but I do think that to use your with smoking, that one thing that I think many young people bristle against is this notion of being manipulated and used for the profit of a social media platform. And the reality is that the, again, we've talked about how the fundamental business model is where most social media platforms is built on how much time you spend on those platforms, that translates to add revenue and that translates to the bottom line.

Whereas what I care about as a parent, as a surgeon 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.

But 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 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. And 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

I think 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. Just 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.

And if the average use is 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. But 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? Like, kids are experiencing exposure to harmful content to harassment and bullying online. Six out of ten adolescent girls are saying they've been approached by strangers on social media in ways that made them feel very uncomfortable. Our kids are also finding that health promoting activities in their lives 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 know, you need that not just for social interaction, but like, look, as 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. I 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, my big concern with parents is, look, we've taken this technology, which is rapidly evolving, which we didn't grow up with as kids. And we've told parents, you manage it all on 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 the price of modern life. We just have to accept it 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 death. We need to make this experience safer. And so we put in place with the advocacy and support of incredible groups like Matt and others across the country, that would mean mothers against drunk 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. We also need a policy that requires data transparency from the companies. You know, researchers tell us all the time that these 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 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. We 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. You 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 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. But 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.

This 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, a 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 got to leave the house. You've got to go down the street and play. 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. 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. If you think about, that's kind of crazy. But I guess they want to capture that unique experience. 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. Yeah. 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. Learn on, my stance is glean and learn information online, then 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? Because 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, right? It's giving us like even just take, you know, just take the images that we see of people. They're, you know, their summer beach images. They're 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 in their life. And we've just got to get, you know, your mom, I love what your mom did of getting you guys outside. My parents did the same thing too. Like I was very blessed to have two parents who didn't, you know,

they didn't have a lot of resources growing up. They didn't come to this country with a lot of resources. But one of the greatest gifts they 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, riding our bike around the neighborhood.

And that's what we did. But right now, two critical things that kids need for their mental health and development, or 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 playtime that kids have.

Like unstructured playtime is time when we as kids learn how negotiate situations with other kids, how to resolve conflict, how to recognize what's going on in someone else's eyes before they say something. We learn how to collaborate and play with other kids. There's a lot you learn on the playground, as it turns out. But 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 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. I love the idea 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. 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. I'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, 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. Well, not maybe.

Limits their screen time. Force them outside in the safe weather and safe conditions, of course. But what about adults as well? I mean, 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.

Let me actually go through some of these things that parents 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. 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 where all kids are on social media and you don't want your child to be the only one left out and to be. 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 there are other kids who are also delaying use. That means your child is not alone. And I think if you start the conversation with other parents, who'll 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 to be. 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 because 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 the bathroom, maybe to get some water, and then they get back on their devices again.

So 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 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 at a birthday party, et cetera, make that 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 then the last thing I'd recommend here, the many things I think parents could do, is to start a dialogue with your child about their use of social media. We don't always know how social media is making our kids feel. 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 hard not to be on it. Everyone's like texting on this, or 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 little 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 that'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 flag and to get help, you know,

that they shouldn't just scroll past that. So that conversation is really important. And finally, as 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 Surgeon General's advisory was on. But I have concerns about adults too. I said it's somebody who's had challenged,

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 I'm going to check something for five minutes, an hour later, I'm still there, you know, scrolling through something. And sometimes, you know, like, 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 as 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 son was born, my older child, I was actually, I was searching general at that time.

You know, I had, you know, it was a lot going on. It was a busy job, et cetera. but I wanted to make sure that I protected bedtimes 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 bedtime and bedtime routine and getting my son ready for the night, my wife was 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 it just very quietly, but I felt such a sense of shame when she did that because I 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 and my phone, like, this is terrible. And look, I know that all of us do this, and maybe 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 and 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 a

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 with patients over the years around physical activity and diet, all of this is harder to do when we're doing it by ourselves. It's a lot easier to do when 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 Sonny, who are 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 sound 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, a lot of us are 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 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 the example you gave, it becomes reflection. We're just, you know, we're not necessarily seeking pleasure or looking to engage in online battles. It's just, it's become reflexive. Sort of like finding yourself with your hand in the refrigerator, just even think about it. Yeah. You're 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 I can this when you mentioned kids awake in the middle of the night looking at their phone I just I saw you flinch oh my goodness it just it pains me and like I've looked at my phone in the middle 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 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 really want to thank you.

First of all, for the conversation today, you're incredibly busy, you're responsible for an entire country's worth of people. So to take time to sit down with me and to discuss these topics for our audiences, 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, as well as the huge array of issues that you confront.

And it's clear that it's a challenge that you've embraced for many years now under difficult conditions and that you're clearly willing to get out and talk to people and hear their criticism, hear their concerns. hear and learn from them. And so it's been of great benefit to us to hear and learn from you. And I hope this won't be 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 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 thing. It's just incredible kind of you. 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 the surface issues 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 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. and 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 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 just pause for a moment, and if you just think for a moment in your own life, about 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. When 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 think we need to ask ourselves, who are we? Like what defines who we are? What are 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, people who are mean, who only care about ourselves, who are 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're interdependent creatures who recognize that if someone else is suffering, we want to be out there 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 make a clear choice here about our identity, you know, as individuals and as a country, and recognize that that choice has real implications for everything else that we're talking about here. That's the foundation. And when I think about my own kids growing up, 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. I worry that they're going to stumble and fall down and people are just going to keep 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.

What 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 problem 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 to 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 at a 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 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. who are seeing anger and resentment and vitriol bubble up at extraordinary levels, who are seeing mistrust in institutions soar. Many countries are experiencing this. I would love America to lead the way in some ways

in showing what it's like to embrace a more human identity that's centered around kindness and service and friendship and generosity. To me, all of these values ultimately, Andrews stem from love. right love is our greatest source of power it's our greatest source of healing i say that as a doctor who's prescribed many medicines over the years but there are few things more powerful than 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 to have an md after our name uh or have gone to nursing school to be healers we all

have the power to help each other heal. Like, Andrew, we are not fundamentally a nation of bystanders who just stand by while other people suffer. Like, we're a nation of healers and hopemakers 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. That's the identity that I think we now more than ever need to improve. Christ. 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've all benefited in. And thanks for your open-mindedness. especially around some of the questions that invoke 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.

I look forward to the next time to staying 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 importantly, thank you for who you are, you know, like who you are, Andrew, like, comes across very clearly. 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.

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