On with Kara Swisher - Guns, Social Media & Loneliness with Surgeon General Vivek Murthy

Episode Date: July 18, 2024

Surgeon General Vivek Murthy isn’t afraid to go after powerful interests. In mid-June, he published an op-ed in The New York Times calling for a warning label on social media platforms that says they’re associated with mental health problems for teens. The following week, he declared that gun violence is a public health crisis. However, the surgeon general's powers are limited. It'll take an act of Congress to put a warning label on social media platforms, and thanks to the Roberts court, even legislators are limited in their ability to regulate firearms. Kara and Dr. Murthy discuss this country's seemingly intractable gun problem and the debate around the research into the harms caused by social media, along with his work on loneliness, and how Covid has eroded trust in the public health sector.  Questions? Comments? Email us at [e-mail] or find Kara on Instagram/Threads as @karaswisher  Learn more about your ad choices. Visit podcastchoices.com/adchoices

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all backed by their expert live customer support. It's time to get going and growing with Constant Contact today. Ready, set, grow. Go to ConstantContact.ca and start your free trial today. Go to ConstantContact.ca for your free trial. ConstantContact.ca. Hi, everyone. From New York Magazine and the Vox Media Podcast Network, this is On with Kara Swisher, and I'm Kara Swisher. My guest today is Surgeon General Vivek Murthy. This is Dr. Murthy's second go-round as Surgeon General. He first served under President Obama, and he's definitely not holding back this time.

In less than a month, he called for a Surgeon General's warning on social media platforms that would say social media is associated with significant mental health harms for adolescents, that would say social media is associated with significant mental health harms for adolescents, and then apparently not satisfied by kicking the tech hornet nest, he then decided to go after the gun lobby and declared firearm violence a public health crisis. And last year, he declared the country is suffering from an epidemic of loneliness and isolation, the culmination of years of research and discussion on loneliness. However, the Surgeon General's powers are limited, very limited. He'll need an act of Congress to actually put warning label on social media platforms, and the Supreme Court has severely limited Congress's ability to pass gun control laws.

I've said his call for a warning label on social media is a stunt, and it is. I'm not sure how effective it will be, but it's still a really good stunt, and it's forcing an important conversation, one that I'm excited to continue today. Our question for this episode comes from Evan Spiegel, the co-founder and CEO of Snap. This is the first of two conversations that touch on how social media affects young people. Make sure to listen next Monday for an interview with parenting expert Dr. Becky. She's a clinical psychologist, author, podcaster, entrepreneur, and social media star herself who has been grappling seriously with

these issues for years. By the way, I have a lot of kids, so I have a lot of questions. It is on. Surgeon General Vivek Murthy, thanks for being on On. Of course. Thanks, Cara. It's good to see you virtually. We know each other a little bit. We've run into each other many times. I'm going to get into what you actually do, but let's get to the news. A gunman tried to assassinate former President Donald Trump this weekend. He ended up killing one person at the rally, leaving two others critically wounded.

He nicked former President Trump. You recently released a Surgeon General's advisory on firearm violence that declares firearm violence in America a public health crisis. Is there any connection between what happened at the rally in Pennsylvania and a broader problem of gun violence? Well, Cara, look, I was horrified when I heard about the incident, but what happened to former President Trump and to people who were there at the rally, you know, what that shows us is in part that at every level of society, people are being impacted by gun violence. One of the things I put out in my advisory, one of the stats that I found chilling

when I came across it was that 54% of Americans are saying that either they themselves directly or through a family member have experienced gun violence. That could be losing a loved one. That could be being shot yourself and surviving, being threatened with a firearm. And one thing I don't think we paid enough attention to in the incidents that happened at the rally over the weekend were the feelings of the people also in the audience. Think about like that fear and terror that people felt worrying about their well-being, about family members and friends they came with. And the tragedy is that that kind of fear is what millions of people experience around

the country every day in neighborhoods where gun violence has become commonplace. So I worry, not just as Surgeon General and as a doctor, but as a father of two kids myself, that I worry that our children are saying that they are worried about a school shooting taking place in their place of learning. So we do have a profound public health challenge, but I wanted people to also understand that the toll goes beyond the nearly 50,000 lives we lose a year and extends to the millions whose mental health and well-being are impacted by gun violence. So when you think about it, the shooter Thomas Matthew Crooks apparently used a semi-automatic rifle that his father purchased illegally. There are more guns than people in this country. How do you respond when people say when it comes to guns, it's not about the weapons, it's about mental illness or it's about political discord or whatever, but how do you respond to that? Well, I tend to go back to what science is actually teaching us about gun violence,

which is I wish there was one simple cause of gun violence, and there's not. There is a component of mental illness. We know that 56% of gun violence-related deaths are suicides, but we also know that the kind of weapon actually does matter. We see in mass shootings that when an assault weapon is involved, that the likelihood of injury and would put time and space between an individual who would seek to harm themselves and others and weapons, but it also includes things like a ban on assault weapons and large-capacity magazines. Because, again, these have been associated with increased injury and death in mass shootings. Sure. Let's talk about the Surgeon General's advisory and why you decided to make it. Again, as you said, there's many stats that will surprise people, including the one you just mentioned about suicide.

Well, you know, it's hard to escape the fact that this is a public health challenge when you do what I do, which is to travel around the country and talk to people and ask them, what's on your mind? What is contributing to your mental health concerns? And look, I began this broader journey to thinking about gun violence or address gun violence years ago as a doctor, long before I was in government. But I was fresh out of medical school and started seeing patients

who were the victims of gun violence. I remember one patient in particular, a middle-aged man, who came in to me because he had an infection. And it turned out he had chronic urinary tract infections because years ago he had just been doing his own thing, walking down the street, and he was injured by a stray bullet that ended up severing his spinal cord. by a stray bullet that ended up severing his spinal cord. He was paralyzed from the waist down and had to have an indwelling catheter in his bladder that from time to time would get infected and would land him up in the hospital. And I just, I kept thinking about how profoundly this man's life has been affected for years, about the mental and physical impact on him as well as around his family. And when I became Surgeon General the second time around and began focusing on mental health, as I traveled the country asking people what was contributing to their mental health concerns, gun violence kept coming up. Young middle school students kept telling me that they were scared about going to school because they're worried about shootings. I had a mother who was

also a doctor who I encountered who had actually been in a mass shooting. She had had to flee and carry, you know, sweeping up her kids and trying to run away from the shooter. But she was in flip-flops that day, Kara, and it was hard to run. And now to this day, even though that was several years ago, whenever she leaves the home, she hesitates to wear flip-flops because she's worried that she might be in another situation where she has to run from a shooter. And just hearing again and again from people that this was a concern, it led me to dig more deeply into the data. And, you know, while gun violence

has been a public health problem for a long time, I think what we've seen more recently, which was profoundly concerning to me, was number one, this broader mental health toll, where again, 60% of people are worried about losing a loved one to gun violence. But we were also seeing that gun violence has become now the leading cause of death among children and adolescents age of 1 to 19. And look, as a father—

Over what would be number two? Motor vehicle accidents. Motor vehicle. Yeah. And so this is now exceeding motor vehicle accidents and drug overdoses, which we know are both major issues. Look, you're a parent. I'm a parent, right? which we know are both major issues.

Look, you're a parent, I'm a parent, right? And we know that if our children were in mortal danger, in profound danger, we would pull out the stops to be there and to help support them, right? As a country, shouldn't we do the same thing, right? The data is telling us, and kids are telling us themselves, that gun violence is having a profound toll on their lives. And I just, I worry that we have allowed ourselves to be lulled into a spate of complacency,

which will not get us to a safer place. You mentioned suicides. A lot of people would argue that reducing access to guns doesn't reduce the number of suicides because people, if they are in a profound state of despair, it wouldn't stop anything in terms of the number of suicides because that is an astonishing statistic, 56% are gone.

It is. And it actually turns out, interestingly, this may surprise some people, that the methods that people use to harm themselves and potentially take their life actually do matter in terms of whether or not they ultimately complete suicide. a firearm available, especially one that's unlocked and loaded, and you are suicidal, if you use that firearm to harm yourself, the likelihood that you will ultimately end your life is very high, like 90%. That is actually higher than other means that people use to take their own life. And so, yes, the means actually do matter. And it's one of the reasons why- Young people, it's probably a quick decision, right? It may be a quicker, like one of those things that could be stopped if it was harder, I guess. Well, so actually, I just want to go back to what you just said. It's a quick decision because you'll find, and this is so important for people to know, is that a lot of people who

take their own life don't have a preexisting mental health diagnosis. A lot of times it could be in the throes of a major breakup or a major disappointment. Someone makes this on-the-moment split decision in a moment of pain to end their life, right? And there may be nothing in their history that says that they wouldn't, you know, attempt something like that. Again, the means around them actually do matter as to whether or not they ultimately take, you know, complete suicide or not. This is one of the reasons why, you know,

what are called extreme risk protection orders, sometimes referred to as red flag laws, can actually be very helpful because they give, you know, law enforcement and the courts an opportunity to create time and space between an individual who is suicidal and a gun that they may use, you know, to actually take their own life, which would have a very high likelihood of succeeding. So homicides spiked during the pandemic, but then declined 13% in 2023, according to the FBI. What do you make of that spike and decline? What's the biggest takeaway from a public health perspective?

Because again, guns are the main weapon used in homicides. Well, I think the pandemic was an extremely stressful time for people. Our lives were upended. They were turned upside down. And we saw that stress manifest in different ways in people's lives. But one of the ways, I believe, was violence, right? And this is actually in keeping with what we've seen historically during times of stress. And we probably know in our own families, right, when things get really stressful, sometimes people lash out at each other. Sometimes it's verbally, emotionally, physically. But we saw that at scale. I'm very glad to see that since 2021, we've seen some declines in violence. But the level at which we're at right now is still

far too high. So you've been saying that gun violence ought to be treated as a public health crisis for years, and that's caused conservatives to come after you. Talk a little bit about the politics of this declaration. Why do it now? And what are the practical implications of making an official declaration about gun violence when legislators don't seem to do anything about it ever? In your voice, I hear what I hear echoed from a lot of people, which is a sense of concern, frustration, sometimes skepticism about whether things can really change, right, on this issue. And look, I get that, right, because we've been in what feels like an intractable place for years. There are a couple of things that give me hope. Like one is two years ago in 2022, for the first time in nearly 30 years, Congress actually did pass the first piece of actual legislation to address gun violence. Now, did it solve the whole problem? No. It's one step. There are more steps that are needed. But that was a point that made me hopeful. Five years ago, five to six years ago, Congress actually did something else that went under the radar,

which is they actually put some modest funding toward gun violence research, an area that had been starved for nearly three decades, but they put some money finally toward gun violence research, an area that had been starved for nearly three decades. But they put some money finally toward that. Now, do we need more? Absolutely. It's one of the things I call for in the advisory. But what that tells me is that it is possible for Congress in the right circumstances to step up, you know, and to consider actions they can take and then to move towards solutions.

actions they can take and then to move towards solutions. But this is something that, the reason I released this advisory is because I wanted people to understand that there's a great deal of urgency to this because it's having a much broader impact on us than I think many of us realize. But I also wanted to highlight that there is a lot we can do, not only lawmakers, but also healthcare systems, community organizations, individuals, and I wanted people to know what some of those steps were. What would you like to see them do, Congress, to pass? If you could go up there and get whatever you wanted. Well, I wish you could make me king for a day and I could go and create all these policies, Kara.

I'm making you king for a day. But look, here's what I'd like to see. And a number of this, if people are interested, is covered in our advisory. But number one, one of the strategies I lay out is to dramatically expand the research we invest in this area. Because we need to not only know with more clarity the fundamental drivers of gun violence, but we need to know if our interventions, well-intended as they are, are working. We need to know how to tweak them. The second thing that I've called for in terms of a strategy are community-based interventions. We know that there are community violence intervention programs, hospital violence intervention programs that can be remarkably effective at interrupting this cycle of violence. We need to invest more in those kind of programs.

And the third area that I called for is actually expansion of investment in mental health. We do need more access to care and investment in primary prevention programs. And the fourth and final bucket where I call for action is when it comes to firearm risk reduction strategies. And this is everything

from strengthening our background checks to ensuring that these extreme risk protection orders that we spoke of earlier that put time and distance between an individual who's at risk of harming themselves and others and a firearm are actually put in place. But they also include safe storage laws as well as restrictions on assault weapons and high-capacity magazines.

So speaking of community violence interventions, violence interrupters are notoriously difficult to study. Talk about why you want more funding for them then. Well, so here's an interesting thing that happens when you don't have funding in a space. It's not just that you can't do the studies, but you remove an incentive for people to be trained in doing that kind of research to begin with. The way you grow a field is you provide funding, then more people get trained in that, and then you actually do more studies, et cetera. What we actually need to do now is grow the field and fund the studies. And that's a place where

this kind of investment can help. But look, private foundations are trying to do some of this. They're trying to fill some of the gap. But the simple reality of the math here, Cara, is that the government is the biggest funder of research. And there is no single foundation or conglomeration of foundations that ultimately can take the place of government funding for research. It's been important for blood pressure, for diabetes, for a whole range of other illnesses. It's what we need for this public health concern, too. In terms of making it go away, it really does take getting guns off the streets, like beyond calling attention to it. And this is obviously it's your job is to call attention to it because you don't have any ability to make things happen, like to snap your fingers and say, now we're going to

have less guns or now we're going to restrict, you know, do background checks, et cetera. Correct. You don't have any actual power. So I can't make policy and I can't make regulations. Yes. So I can't do that. But to your point, yeah, one of the things we do need to do is ensure But to your point, yeah, one of the things we do need to do is ensure that you don't have dangerous weapons in the hands of people who would seek to harm themselves and others. That's why many of these measures, that by the way, have broad agreement in the public, including measures like strong background checks or like extreme risk protection orders. It's why in safe storage laws, there's a lot of support for these because they make sense. And this is why what also gives me hope, Cara, is I do think that the majority of the public wants to do something here.

I actually think despite what we read about- The vast majority of the public wants to do a lot of things that legislators don't do. Well, yes, that is right here. And I think we've been led to believe that this issue is far more polarized

in the public than it actually is. I think this is politically polarized. Oh, I don't think it's polarized in the public than it actually is. I think this is politically polarized. I don't think it's polarized in the public. I think it's polarized in Congress. I think the gun lobby is very powerful. I think the numbers always consistently show people want legislation. And then there's a very loud, noisy group of people. Speaking of which, recently, let's change tack.

You've spoken out on guns, obviously. You recently also called for a Surgeon General's warning on social media, warning labels, calling out its negative effects on youth mental health. I have called it a stunt, but a good stunt. I like the stunt. I like it a lot. And it's important to get people talking. And obviously, everyone is now finally aware of the dangers and the deleterious effects of these things. So I appreciate it.

But tell us why you did it. I'm really curious about the thinking behind it, because again, you have no force of law and there's been no laws passed. There's no privacy bills. There's no protection bills. There's no on and on and on. Speaking of no gun legislation, there's been no social media tech legislation. Yeah, it's a good question. And the call for a warning label that I issued last month was actually on the heels of an advisory I had issued a year ago, calling for a series of measures to ultimately make social media safer. Look, I fundamentally believe that a warning is one part of a much larger set of solutions, right? What we really need to do is make social media safer, right? We need to make it such that people can get whatever benefits they're getting from social media without being

harassed and bullied, particularly by strangers, without being extorted and blackmailed, as too many people are, without being exposed to sexual and violent content that's inappropriate for their age, and frankly also without being exposed to features, which often end up manipulating, you know, adolescent developing brains into excessive use, right? Those are the changes I called for in 2023. And I reiterated that call when I issued my op-ed a month ago, calling for a warning label. But here's what a warning label does also.

A warning label helps to inform people about risks that we see. And we have good data from warning labels now from tobacco and alcohol, right, where we have seen that warning labels, while they don't solve a problem entirely, they do make a difference in increasing awareness. Now, I've laid out the fact that there are a number of open research questions that we still have to answer about the impact of social media. Yeah, look, I wish we had answers to a lot more questions than we have right now. But we do have an answer to one, the most common question that parents ask me

around the country, which is, is social media proven to be safe for my kid? And the reason they ask is a lot of parents say, well, isn't it proven to be safe? Otherwise, why would it be free and open and available for my child to use? And there has not been data that has been published by independent scientists

that has demonstrated social media is safe for adolescents. That is not the case. Many parents don't know that. They think there is data around safety. They've led to believe that. That's one of the things a warning label can do is help people know that there is not safety data behind this product.

The second thing a warning label can do is inform people about what we do see, which is that there is an association in multiple studies between social media use and mental health harms among adolescents. Now, there's debate in the research community about how big is that association? Is it bigger for some groups than others? And those are important questions for us to answer. But we know enough now to know that there is significant evidence of harms here, and people should be warned about what we know. Well, except let me just say, I'm going to push back, even though I've been a critic of social

media, as you know, it's a very important conversation to me. On one hand, Facebook's own internal research, for example, and using the biggest one, found that, quote, we make body image issues worse for one in three teen girls. That obviously sounds pretty damning. On the other hand, the peer-reviewed research is mixed and inconclusive, as it was, as you recall, with video games, wherever it was thought, because we use video games, you're going to go out and shoot everybody. in your New York Times op-ed, which you just mentioned, where you call for the warning. You write, quote, one of the most important lessons I learned in medical school is that in an emergency, you don't have the luxury to wait for perfect information. You assess the available facts, you use your best judgment, you act quickly. It makes sense to act quickly when you're a doctor in an emergency room, but doesn't the federal government have a responsibility to get the facts right before it puts up official warning labels? Yeah, no, it's a good question. And that's exactly the kind of rigorous question

we should be asking ourselves. Are we at the right point to do this? Are we at the right point? And in coming up with this recommendation, that was a big debate we had internally in our office is we always kick the tires on our ideas to say, is this, are we too early? Are we too late?

Is this the right time to make this recommendation? And I'll tell you that looking at the data that I was looking at, I felt that there was enough data right now to make this recommendation for a warning label. Again, it doesn't, because we've talked about some of these broader population studies, some of these association studies.

What we have not talked about are the studies actually where young people themselves are telling us about the harms that they are experiencing, right? Nearly half of adolescents are saying that social media use makes them feel worse about their body image. Yes, my son is off social media because of that. He told me that. But that's anecdotal. That's my son, right?

Like he said I got off of it because I, yes, one of my sons, one of my sons. Fair enough. And I've actually encountered a lot of that anecdotal evidence too. But I'm not talking about anecdotes now. Here I'm talking about studies. A third of adolescent girls say they feel addicted to social media. A third of adolescents are saying that they are staying up to midnight or later, right, using their devices. Much of that they say is social media use. And we know when that fractures your sleep in terms of quality or quantity impacts

mental health, right? And here's, I think, the bigger picture thing we have to keep in mind, Cara. We have had now reports of parents who have said that they have lost a child to suicide after their child was mercilessly bullied or harassed or extorted or blackmailed on social media, right? If I told you that there was a medication that we just approved on the market, and it seems like five children lost their life after they started taking that medication, that would cause all kinds of concern rightfully so. We would pause.

We would do studies. We would investigate what's wrong. We would tell people, there's a reason to be concerned here. We're going to investigate further, but people should know that we're concerned about something here. And we do this all the time with drugs, right? Yet what I find very puzzling is even though we do that with drugs, even though we take safety incidents and reported safety incidents

seriously with car seats, with cars, with airplanes, with food, yet despite hundreds of cases like this, we have done next to nothing when it comes to social media. Oh, I'm aware. And I find that to be a profoundly disturbing exception that we've made for this platform. Why do you think that is? I think you have a far better sense of that than I do. Because they lobby our spineless legislators into inaction,

and they drive right through the middle of the dysfunction that exists in our legislative bodies at the right time. No one else gets off. As I always say, when a plane loses one door, there's 90 studies, there's lawsuits, there's so many manner of things happening. The CEO got fired. Things happen. That's right.

That's one door. And planes fly every day and doors don't come off, right? That's right. I didn't like the door coming off, but still. They're paying the price of that accident. Right. And, look, Kara, you've spent a lot of time in your career talking about accountability in technology.

I find myself asking, where is the accountability here? No. Why is it that, I mean, just give me one example. I had a parent who came to me who said that her child was really struggling with his mental health. He went on social media looking for some support. The algorithm kept suggesting videos to him that suggested that he hang himself and then walked him through step by step how he would do that. after her son tragically took his own life by hanging himself, and said, can you at least prevent other children from being exposed to these kind of videos

so they don't harm them like they harm my son? And yet she was finding out from friends and others that these videos were still popping up. Look, I don't doubt that these platforms are large, expansive, they're complicated, they're hard to navigate, manage, et cetera. But call me old-fashioned care, but I believe if you build something, you should take some responsibility for the effects

it has, intended or unintended. If I built a hospital that was doing a great job treating people with pneumonia and heart attacks, but was also causing plenty of, you know, line-associated infections, and people were slipping on floors because I had water everywhere, and they're breaking their hips, I would get shut down, even despite the fact that I was doing some good. So it just worries me that at a time where kids are struggling with their mental health and parents too, that there's no accountability here. I think one of the things that's difficult is that it's some of it's good and you even acknowledge that. Some of it is good. Let me say, you were using the Surgeon General's warning on cigarettes as analog. There were all kinds of strict bans imposed on smoking, taxes to make them more expensive.

Of course, there was the warnings. Were the warnings actually helpful in reducing smoking? Or is the cost and the lawsuits and the bans that helped people stop smoking? Well, this is exactly why we do studies of these things, right? Because sometimes our intuition takes us on the right path, but sometimes the truth can be hidden. And here what we found actually is in studies of tobacco labels, the studies actually have shown again and again

that the labels are effective in increasing awareness. With that said, I still believe what I said last year in my advisory and what I said this year in the op-ed, which is that the warning label is one part of a broader set of solutions. And the most important solutions are around making social media itself safer, which takes Congress to act. The thing that just really bothers me as a parent also is that, and as somebody who's spent a lot of time with thousands of parents

over the last three, four years, is that parents have had to have the entire burden of managing all of this placed on their shoulders. That's correct, yeah. And they feel guilty. They feel ashamed when they can't get it right. They're addicted themselves. Parents are struggling themselves, right.

I mean, like I've been talking about social media and youth mental health. At some point, we need to talk about social media and adult mental health, right? Because many adults will say to me, hey, I'm having a hard time too. You know the craziest people, just FYI, 30 to 55, but go ahead.

That would describe me actually as well. There you go. I'm in that age demographic. But I actually know firsthand because I have in the past struggled with my own use of social media and had to realize that, hey, this is not healthy. I need to fundamentally change

how I'm operating with these platforms. But with all that said, the guilt and shame that parents are carrying, realize that, hey, this is not healthy. I need to fundamentally change how I'm operating with these platforms. But with all that said, the guilt and shame that parents are carrying, feeling like, hey, I should be able to figure this all out by myself, even though I didn't grow up with these platforms, I didn't grow up using them as kids. And even though you've got some of the best resource companies with some of the best product designers, essentially using cutting-edge brain science to figure out how to keep people on, like that is just not a fair fight. And I just think that we have underestimated the toll, not just on kids, but really on parents as well. We'll be back in a minute. Fox Creative.

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anthropic.com slash Claude. So how do you get tech creation actually passed? I think one of the reasons cigarettes usage is cancer. You know, everyone was like, ah, cancer. Yes. In this case, it's mixed. The possibilities are positive and negative. That makes it harder for people to get off of it. It's necessary for your job. It's addictive. And it's entertaining, right? There's good and bad things about it, which makes it difficult to do it. But to go with a warning, what would be to you the most important piece of tech regulation to pass?

Well, so I think I want to make a distinction between, again, between kids and between adults, right? With adults, you're right. Like when you've got a job and you need to use it for your job, I think by journalists in particular, right, many of whom I've had private conversations with journalists who like lament the fact that they have to be on social media all the time, takes a toll on their health. This is complicated. But for kids, my hope is that we can agree that children should have some basic protections on social media. And yes, there are some benefits of social media, but if we can make it safer, then we can allow them to get some of the benefits without the harms. What about age-gating? So, yeah, and I've, look, I... My solution is to age-gate social media and to age-gate politicians past 75, but go ahead. You don't have to comment.

I'm curious, do you have... That would cover both of them, just so you know. Do you have a particular age in mind, Kara, when you think about social media? 13. Yeah. So, look, I think one thing that is clear is that there's no effective age gating right now, right? 40% of kids 8 through 12 are on social media, even though the platforms say 13, right? So that's not happening. 14, maybe.

Yeah. Look, I think that my belief is that even though I know every kid is different, you know, and every child is mature at a different rate, some may be ready to use it earlier than others. I think that middle school, if you're just making a broad generalization, middle school is a time when kids are at a very sensitive, vulnerable time of brain development. It's when we know scientifically they're more prone to social suggestion, social comparison, and where they haven't developed impulse control nearly as much as adults. And I do think that there are large vulnerabilities there. So for my own children,

for example, my wife and I have talked about this, and I'll tell you what I recommend to others as well, is that you wait until after middle school to start your kids on social media. Now look, this is easier said than done, right? It's one thing for me to say that. So now what if you're the parent whose child is coming up to them and saying, everybody else in my class is on social media and you want me to be left out and lonely. And this is one of the reasons why I also increasingly recommend that parents actually start talking about this openly with each other and partnering with each other to have common rules that they're putting in place for their kids so that their kids aren't the only one who are experiencing these limits.

Sure. But it's very difficult for them to do that given they're putting in place for their kids so that their kids aren't the only one who are experiencing these limits? Sure. But it's very difficult for them to do that, given they're addicted themselves. Every episode, we have an expert send us a question, and this one is no different. So let's hear the question. Hi, Dr. Murthy. I'm Evan Spiegel, the co-founder of Snapchat. I share many of your concerns about the health and happiness of young people in America, and also your belief in the critical role of social connection in combating loneliness.

The decline in mental health among U.S. teens since the 1950s is well-documented, and the causes are still being investigated. You've said that social media and loneliness are contributors to this decline in well-being. Can you share more about what parts of technology you believe are harmful and also how you believe technology

can help bring people together in positive ways? All right, why don't you answer what the most harmful thing is and then maybe something that you think is good about it. So look, we don't have enough data to tell us what specifically is the most harmful feature, but there are a set of features which come up again and again and again, especially in surveys that are done of youth, right? So number one, again and again, especially in surveys that are done of youth, right? So number one, the dramatic acceleration in culture of comparison that happens online, where young people can be comparing themselves

to thousands of images a day, young people consistently say that that often makes them feel worse about themselves. The second thing is features that keep kids on for longer and longer, especially at night, whether it's infinite scroll, autoplay on videos. These are features which we know kids are telling us they're having a hard time getting off the platforms. Sure are. They're meant to do that. It's a casino. Right. And they're meant to do that,

so this is not a bug. It's a feature, and it's a feature that's problematic. So these are at least two that I would offer. But the last one I would just say is, one thing that was different is when you and I were growing up, Kara, when others perhaps our age were coming of age, there were new technologies, right? There was television, you know, there was cable, there was all kinds of things. Television was the boob tube. Yeah, exactly. But, you know, what was different fundamentally about those is they didn't pervade our lives in the way that social media does. Right.

I couldn't bring my television into my pocket. I couldn't be watching it at night. I couldn't be contacted by strangers who were interacting with me and had data about me through the TV in very personalized ways. That contact also from strangers that would seek to cultivate a relationship and then later exploit and blackmail kids, that has been devastating to the mental health of many children. later exploit and blackmail kids. That has been devastating to the mental health of many children. And again, I think we have to go beyond the simplicity that says, well, if there are some benefits, then we should ignore the harms. Or if half of kids are doing okay, let's not worry about the other half.

I'm going to press you to name one benefit. Name one very brief benefit. Yeah. And so there are a number of benefits here. And I characterized some of these in last year's report. But one of them is finding a community that, you know, of shared experience, shares belief that you may not have in person. As long as they're not neo-Nazis, but go ahead. Fair enough. We can talk about what kind of communities people find. Yeah. Yeah. But that is a benefit, you know, that some people find

online. And look, I think the greatest promise of social media ultimately is to, would be to enable the kind of in-person connections that all of us need in our lives to address loneliness. If it can be a bridge, a way station to in-person connection, it can be incredibly powerful. If it takes people away from in-person connection to the point where not only do they have little of it, but they're not comfortable and haven't built up the social skills they need for in-person interaction, then we start to see what we're seeing on college campuses today, which is more loneliness and less interaction and more mental health challenges. One more question in this area.

China has very strict restrictions on social media for kids. Obviously, all of us are authoritarian-style laws, and children do have First Amendment rights, all kinds of rights, not as many as they wish they had. But one of the pushes is for school. I don't see us doing like you can't be on the Internet from 6 to 6 or whatever, that kind of thing. What about schools? People banning phones in schools is a very good idea for anyone who has children. And what role should the federal government play when it comes to phones in schools?

Because it's being done school by school at this point and seems to be rather effective. Yeah, so look, I've been a proponent of getting phones out of our learning spaces in schools. I think they're a distraction not only from learning, but I actually think they impact social interaction as well. Kara, I was in Lincoln, Nebraska recently at a high school that had just put in, that had somewhere recently put in place a phone-free, you know, sort of rule during classroom time. And I asked the students when, without any teachers present, how did you feel about that? And what they said is, you know, in the beginning we weren't sure, but then after a while we realized we were getting to know each other.

And that was kind of cool. We liked it. These were kids who had actually been in school together in some cases for a couple of years, but because they weren't, you know, actually talking to each other, they didn't know one another. And so I think that this can be beneficial. Look, we're in a situation where our country's setups such as school decisions are made locally, right? And we can argue whether that's good or bad and whether it's efficient or not. But I do think that we are seeing a growing movement to move toward more phone-free policies in schools. And I think that that is a good thing. I growing movement to move toward more phone-free policies in schools.

And I think that that is a good thing. I would like to see even more parents getting together to advocate for these measures. I've pushed them very hard at my kids' schools. But one of the things, it was interesting, but there was a party my son had, and they were all on phones talking to each other on the phones at the party. And so I walked through, I grabbed every phone, put in a bucket, and they're like, you're a dictator. I go, yes, I am. I just said, you're not getting these phones back until the end of the party. Sorry, it's my house, it's my rules.

But is there anything the federal government can do to incentivize schools to do this and then study its effects so you have some material to push out? Well, I suppose it is, I mean, certainly the federal government could make funds available to study these kind of interventions. They may be able to make funds available to support schools that want to explore such policies as well and implement them. And, you know, on those matters, I would certainly, you know, defer to, you know, to the Department of Education and the Congress in terms of putting that kind of funding in place. But I do think that this is a place where I think we have really dropped the ball when it comes to our kids' learning and social interaction.

I think that we just underestimate, especially those of us who are not digital natives, the toll on kids' social skills and comfort. Like when I did a tour recently, a college campus tour on loneliness and isolation, you know, the question that I got that was most chilling to me was the following. A student came up to me at a large university in the Pacific Northwest and said, how are we supposed to build connection with one another when the culture isn't for people to talk to each other anymore? And I thought I misheard him. So I said, can you repeat the question? He said the same thing. And I started hearing that again and again and again. Students kept telling

me, look, I just don't feel comfortable going up to somebody I don't know and who's in my college and having a conversation or sitting down next to somebody in the cafeteria who I don't know and just introducing myself. That's just not normal. People don't do that anymore. And I don't think it's a surprise that in a world where we're constantly on our devices, that those skills have weakened and atrophied. So let's talk about that. You've been researching and talking about it for years. You wrote a book about it last year. You said loneliness is an epidemic. I think loneliness is part of social media and mental health. Scott talks about this a lot, that loneliness is at the top of all these different things, whether it's COVID, gun deaths, mental health, social media. Talk a little bit

about this idea of loneliness being at the peak of it. Yeah, Kara, this is something that if you told me that we'd be talking about this 10 years ago, I would have been skeptical. It's not on my radar. I never learned about this in med school. But what I came to learn, just frankly, through conversations with people around the country, was that a lot of people were struggling with loneliness. And as I dug into it, to the research around it, I came to see that actually, not only is it a profound consequence of physical and mental health, where it affects not only our risk from depression, anxiety, but also for heart disease, for dementia, for premature death.

But I also started to see that it impacts economic productivity in the workplace, how our kids learn, and our proclivity or our tendency toward polarization and division. And so loneliness truly is a deeper root cause. It's one that I think, because it's such a fundamental human need to be connected to one another, when we don't have that in our lives, when we're feeling lonely and isolated and we feel the pain of that, it affects how we show up in every dimension of our life. And that's why I see it as a deep root cause issue. Yeah. Yeah. So I want to end talking about politics because we started talking about politics, but is the job of Surgeon General inherently political?

It's a politically appointed role. Is that harder for a doctor to be in? I know, you know, historically Jocelyn Elder, for example, during Bill Clinton's first term was fired after an offhand comment at a UNAid conference where she said maybe kids should be taught how to masturbate in school. Of course, 20 years later, it seems ridiculous that it got so much attention. But how difficult is now? Because it's more political than ever. And this was just about masturbation, right? I mean, you're talking about guns, you're going up against tech industry, it's very powerful. Politics has gotten so ugly. How do you bridge that gap as a doctor too? It's a good question, Cara. I mean, I tried to stay anchored to why I said yes to this job in the beginning. You know, I was never somebody who actually

thought I would work in government. I wasn't really interested in politics or policy. I was building, I was seeing patients, I was teaching students, and I was building my tech company, you know, that was my life, you know, before coming into government. It's one of the reasons why I'm a believer in tech and good tech. But the reason I actually came into government in the end when I was asked to serve in this role was not because of party or affiliation or anything of that sort. It was politics. It was because I fundamentally believed that there were public health needs that I wanted to be a part of helping address. that there were public health needs that I wanted to be a part of helping address, right? And I was seeing all these needs crop up in my patient population,

whether it was mental health or a chronic illness like diabetes and high blood pressure or obesity. And so one of the things I've told my team and I remind myself of is that whenever we feel we're getting pulled away from our North Star, which is being driven and guided by the needs of the public, of patients across America, that's when we need to get out and go spend time in communities. But we need to actually go visit people, talk to them, be reminded of why we do this work. And so it's not easy. You're right. These are a lot of political headwinds. Some people love the work we do. Some people hate the work that I do. Some people think it's all politically motivated. Some people love the work we do. Some people hate the work that I do. Some people think it's all politically motivated. Some people see the science behind it.

But as long as that is our North Star science and the public interest, then I can sleep at night knowing that we're doing what we're here to do. We'll be back in a minute. Do you feel like your leads never lead anywhere? And you're making content that no one sees, and it takes forever to build a campaign? Well, that's why we built HubSpot. It's an AI-powered customer platform that builds campaigns for you, tells you which leads are worth knowing, and makes writing blogs, creating videos, and posting on social a breeze.

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Support for this podcast comes from Stripe. Payment management software isn't something your customers think about that often. They see your product, they want to buy it, and then they buy it. That's about as complex as it gets. But under the hood of that process, there are a lot of really complicated things happening that have to go right in order for that sale to go through. Stripe handles the complexity of financial infrastructure, offering a seamless experience for business owners and their customers. For example, Stripe can make sure that your customers see their currency and preferred payment method when they shop. So checking out never feels like

a chore. Stripe is a payment and billing platform supporting millions of businesses around the world, including companies like Uber, BMW, and DoorDash. Stripe has helped countless startups and established companies alike reach their growth targets, make progress on their missions, and reach more customers globally. The platform offers a suite of specialized features and tools to power businesses of all sizes,

like Stripe Billing, which makes it easy to handle subscription-based charges, invoicing, and all recurring revenue management needs. Learn how Stripe helps companies of all sizes make progress at Stripe.com. That's Stripe.com to learn more. Stripe. Make progress. You started this sector in the middle of the pandemic. The polarization around COVID and the government's response to it has eroded America's trust in public health. I think that's pretty easy to see that. There's a larger erosion of trust, huge amounts of cynicism towards institutions.

Some of it is by design with people trying to pull it down. Others is because of stupid mistakes and miscalculations, etc. Ashish Jha, the former White House COVID coordinator, recently said that COVID vaccine mandates saved a lot of lives. It also bred distrust and were harmful as well. How do government officials fix that? Because mistakes were made, most certainly, at the same time, distrusting these institutions and then the advantage malcontents get when they can point to the government like this is a real problem. It is. Mistrust is a profound challenge and it has major public health implications. There's no two ways about that. And, you know, I think often about how I

used to handle things, you know, with patients, individual patients when I was practicing medicine, you know, up in Boston. And my approach was always, you're open with what you know, you're open with patients about what you don't know. You try to make a shared decision about why you're recommending what you are. And then you always tell them if the outcomes change or the circumstances change, we'll revisit. We may have to change course. But you try to let people know what you know and what you don't know.

I think that feels harder to do sometimes when you're speaking, you know, to don't know i think that feels harder to do sometimes when you're speaking you know to you know a broad audience things get cut down to a single sound sound bite sometimes you don't explain yourself or you assume you got to make things more simplistic and assume people don't have the ability to understand things are more complex and i think when we make those assumptions we do a disservice uh to people i think we actually do better when we're open again about what we know and what we don't know. So there is a lot of work that public health has to do to rebuild trust in the years ahead. But some of that, I think, is going to have to start at a very local level. It's interesting, trust hasn't vanished. As you know, Cara, it's actually kind of gone more local, right? So people

often still trust their doctor. We've seen that in stats. They trust a nurse who took care of them in the hospital. They may trust their local department of health, possibly. They'll trust the teachers in their kids' schools, right? The people they know and see, which is why like what clinicians and public health folks have to do now is increasingly get out of the clinics and departments of health and go into communities where people are so they can meet them, see them, get to know them, and rebuild trust. Because the best time to build trust is not in the middle of a crisis. You know, it's before the next crisis arises.

Sure, but in retrospect, thinking about growing distrust, do you wish the administration handled the vaccine mandates differently? It certainly created many more problems than it needed to. Well, certainly, yeah, they were controversial and challenging. And yeah, I think it's simple to say, well, some people liked them, some people were very much opposed to them, right? And those are the kind of things where I think in retrospect, having more engagement and conversations with the public about the pros and cons of these, about why they were being implemented, having more community organizations come together and say, hey, I'm actually in favor of this.

Here's why, let me tell you. Those kinds of processes I think would be helpful. I think the challenge whenever you're in the middle of a crisis is you're balancing speed with running through the full list of tactics. You don't know. And sometimes you gotta make calls and sometimes you're right, sometimes you're wrong,

like in those calls. And I think that there's a better way we need to find to bring people along with us on that journey of trying to figure it out, but recognizing that we're going to get some things right here, and we're going to make some mistakes that we'd want to do over. Okay, so my last question, I know you and I have talked about this. The Supreme Court recently sided with the Biden administration and found the federal government didn't overstep its bounds when it communicated with social media companies to take down posts that considered to be

COVID disinformation. I know you were involved in this. Obviously, it's important for the federal government to be able to communicate with major communications platforms in the middle of a deadly pandemic that killed over a million Americans

and in general over cybersecurity, attacks from other things, things, et cetera, et cetera. At the same time, Americans don't like being told what to think and there's a backlash. They're feeling they're

controlled in any way. I'd love you to comment on this decision because I know you have been in discussions with tech companies specifically about this topic. Thoughts after the Supreme Court decision, which was a victory, and how should future administrations decide how to interact with social media platforms during health emergencies? Because the principal way people communicate, right, is getting tweets or Instagram posts taken down or labeled as misinformation worth the backlash? Yeah, well, look, what I said to tech companies, and I've actually had limited interactions with them, you know, during the course of COVID and since then, but what I've said to them in those few interactions is what I've said publicly about health misinformation, which is that, you know, I think platforms, and I actually put out a whole advisory on this in July of 2021 about health misinformation, but I've said that I believe platforms have know how to manage misinformation on a social media platform because

I don't run a social media platform. I don't understand the fine details of how to tweak the algorithm here and there. That's the responsibility of a company to do that knows its technology. But ultimately, I do think we should all take a little bit more responsibility, frankly, for what our products do and the impact that they have and we have to do that though knowing that information shifts and changes over time right there look there's no greater example of this than nutrition right where we all know that what's healthy to eat has been the advice on that has changed and changed and changed over years in ways that have led people utterly confused and led some people to wonder is there really science behind this why are these recommendations

coming so we've got to be able to to recognize that and perhaps caveat the recommendations or flags that we put on things that are considered misinformation. But it's also clear that there are certain things that we know based on multiple studies are not true. One of those examples is the misconception or myth that vaccines cause autism, right? That the measles vaccine causes autism. That has been disproven so many times through multiple studies, right? So I think it's important for a platform to- It persists. It persists, right. And it's important for a platform to ask, okay, what role can we play in not contributing to this spread of something that has repeatedly

over many years proven to be false? Because the cost of not doing so can be somebody does not vaccinate their child, their child gets sick, and they lose their child. That's a pretty high price to pay. So I'm not under the illusion that this is an easy problem to solve, but it's why I think ideally there are partnerships between technology, government, private citizens, and community organizations that can help navigate this better. Because the notion that everything should just, you know, sort of be out there and that people, you know, can potentially be the victims of life, you know, costing or harming misinformation, that seems like a problem. We should be able to do better than that.

So how do you mitigate that backlash when people get upset when they see their views labeled as misinformation, even if it is? It's like, it reminds me, someone was doing that around exactly what you were talking about. And I said, you know, we don't use leeches anymore. And if you believe that, you're just an idiot. You're just, at this point, we don't need to cater to idiocy, essentially. I'm not going to be Surgeon General, obviously, because I would say you're an idiot. By the way, we do have a pandemic of idiocy, but go ahead.

Well, one day when you're a Surgeon General, that could be one of your first advisories. They think Jocelyn Elder was crazy. I'm going to go right to the edge with that one. Yeah. No, no, look, I think that this is not easy. And I actually am worried about it, particularly with the growth of artificial intelligence. One of the things we saw, I think there are going to be a lot of potential benefits of AI,

particularly in the healthcare space. Absolutely. But I also think that we have to ideally learn from our experience with social media and ask, can we understand, recognize, and manage a downside earlier than we did with social media? And frankly, we're still trying to do that with social media. One of the things I worry about is we started to see that even doctors and researchers at times were being misled by data that was being posted that looked like peer-reviewed published papers. Yeah.

But they weren't. They were actually false. They weren't papers at all, but they were concocted and designed to look like they were, and to have results that were completely false. But many experts were misled by that, right? And that was a couple of years ago. So the notion that the greater sophistication of AI could lead, I think, to even more danger in the spread of misinformation, I think, is real present. It's happening already.

And that's where I think, look, this is not an easy problem to solve. But I don't think it gets solved if there's a war between government and technology. I think it gets solved most readily if there's a partnership that also involves users, people in communities, clinicians themselves, and if you're talking about healthcare information and public health. And that's what we urgently, the kind of partnership we've got to build now. Well, it depends on which tech person you're talking to, though. That's the problem, unfortunately, because I feel like some of this extreme wealth and stupidity is a public health emergency as far as I'm concerned. But in any case, you don't have to comment on that at all. But I agree with you.

I think it's really, as we move into the age of AI, it's really important to understand it will not get better if we don't have some mitigation and guardrails in place, which is important to do. Anyway, I really appreciate it. I know you've got to go. I really appreciate talking. What a thoughtful, got to go. I really appreciate talking. What a thoughtful, interesting conversation. I really appreciated this too, Cara.

Thanks so much. And thanks for the thoughtful questions. And frankly, just for all the thoughtful interviewing you've done over the years. I'm a listener of your podcast. Thank you so much. I've enjoyed your interviews. On with Cara Swisher is produced by Christian Castro-Russell, Kateri Yochum, Jolie Myers, and Megan Burney. Special thanks to Kate Gallagher, Kate Verby, and Kaylin Lynch.

Our engineers are Rick Kwan and Fernando Arruda, and our theme music is by Trackademics. If you're already following the show, I will put out an official advisory on the epidemic of idiocy. If not, misinformation is sadly here to stay. It's like an STD, except there's no medicines for it. Go wherever you listen to podcasts, search for On With Kara Swisher and hit follow. Thanks for listening to On With Kara Swisher from New York Magazine, the Vox Media Podcast Network, and us. We'll be back on Monday with more. Support for this show is brought to you by Nissan Kicks. It's never too late to try new things. And it's never too late to reinvent yourself.

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