A Conversation With Surgeon General Vivek Murthy

Dr. Vivek Murthy, the 19th and 21st U.S. Surgeon General, discusses his role as the nation's doctor, including addressing the loneliness epidemic, the importance of social connection, and combatting the youth mental health crisis.

BOLLYKY: Good evening. I’m Tom Bollyky, the director of the Global Health Program here at the Council on Foreign Relations. And I’m so pleased to welcome you to this event, tonight’s conversation with Dr. Vivek Murthy.

The surgeon general needs no introduction but let me attempt to provide one anyways. Vivek is both the nineteenth and twenty-first U.S. surgeon general. That makes him effectively the Grover Cleveland of U.S. surgeon generals, the only person to serve in the role twice in nonconsecutive terms.

Before and after his first government service Dr. Murthy founded successful organizations dedicated to extending access to affordable care both in the U.S. and abroad. He is a well-regarded physician, a research scientist, an entrepreneur, and a bestselling author.

In his latest tenure as surgeon general he has focused on drawing attention to and working across the U.S. government to address public health issues such as social isolation, loneliness, social media and the youth mental crisis, and parental stress and it is those topics that will be the subject of our discussion tonight.

Now, for you in the audience it may seem surprising that loneliness, parental, stress, or social media might be the focus of the U.S. surgeon general’s activity, known more informally as the nation’s physician. You may think of the history of the surgeon general’s role in controlling outbreaks of yellow fever and cholera and U.S. port cities, in facing down the tobacco industry in the 1960s, in educating the public about AIDS in the 1980s, and it may also be surprising to you that these topics like loneliness, social media, and parental stress might be the subject of a Council on Foreign Relations event which might be expected more to focus on U.S. foreign policy or transnational health threats like pandemics or climate change.

So it’s early but I feel like both Vivek and I have a lot of explaining to do at this event and that’s what we will actually spend our first thirty minutes doing, having a conversation about why these issues matter and why they have global implications.

After that we will turn to you to give you an opportunity to ask questions. As a reminder, tonight’s event is on the record.

So, Vivek, let’s start with that question, which is why as the surgeon general have you decided to highlight loneliness, social media, and the youth mental health crisis, parental stress issues like this as pressing U.S. public health issues and why is it important that we focus on them now in the aftermath of the COVID-19 crisis?

MURTHY: Well, thanks so much, Tom, and wonderful to be here back at CFR again with all of you.

You know, when I came into office the second time around, and I wasn’t planning, by the way, to come back to government. Just the pandemic turned everyone’s lives upside down and changed how our—what our futures looked like and that was true for me, too.

But when I came we were in the throes of COVID-19 and that was my first focus was to figuring out how to work together with partners across government and people in communities to help make sure people knew, you know, how to protect themselves, they knew how to get treatment, and to make sure that we were moving the government response forward with other partners.

So that was, you know, first and foremost where I was focused. But it was very clear to me even from before I started when just as a private citizen I was watching the first nine to ten months of the pandemic that the mental health impact of this pandemic was going to be extraordinary and there was going to be a long tail to that effect, and that’s not surprising, I think, to anyone who’s in public health who’s looked at natural disasters, for example, and has seen that long after the last house is rebuilt and the last, you know, piece of debris is cleared out there are the mental health challenges that people struggle with. In fact, they often tend to peak later. So that was on my mind.

The other thing, though, that was on my mind, Tom, was what I had seen during my first tenure, which is when I served as surgeon general from 2014 to ’17 I was traveling around the country and talking to people about what was on their minds, trying to get a sense of what their agenda was and what they wanted my agenda to be, and in those conversations mental health came up all the time.

It came up from young people who were talking about their struggles. It came from parents who were worried about their kids. It came from members of Congress who were concerned about their own mental health, from CEOs who talked about struggling with a sense of profound isolation.

Like, the issue of mental health and well-being broadly was coming up everywhere and so I was seeing this trend of growing concerns around mental health and I worry that the pandemic was just going to pour fuel on that fire, and that is why, you know, especially after we got through the emergency phase of the pandemic I started to shift my attention more and more to the topic of mental health and well-being beginning with the youth mental health initiative that we launched in 2021 and then working through other topics as well.

We, for example, issued a framework on workplace mental health and well-being to call attention to the fact that, you know, around 60 percent of people say that their workplaces are having negative effects on their mental health whereas there are things that we can do in a workplace to help alleviate that, recognizing it’s not just good for individuals but it actually positively impacts the productivity and output and retention within an organization.

So we moved to that and started also working on issues related to health worker well-being and burnout. You know, burnout was already high in the health worker profession but in the midst of COVID what we were seeing is that more than 50 percent of nurses were saying that they were seriously considering leaving clinical practice. A quarter of physicians were saying the same thing.

And can you imagine the impact to the American health-care system, not just for emergency care but routine primary care, if those people left, right? It would be catastrophic. We were already facing a shortage.

And then finally, you know, in ’23 and this year we started focusing on issues related to social media’s impact on youth mental health, the impact on parents as well, and a lot of this is organic. I didn’t start in 2021 with a list of all of these topics and we’ve just been checking the boxes on that list.

Learning from my first, you know, tour of duty, one of the big learnings from that was you can come in with your sense of what’s important but if you actually stop, pause, and listen to people they’ll usually tell you what they need and that was something that was really impressed upon me in medical school by my mentor my first year who said, you’re going to read a patient’s chart and you’re going to think, based on their lab values and their imaging studies, that these are the top one, two, three things you need to do.

But then you’re going to walk into the exam room and you’re going to sit and listen to their story and if you’re smart, if you’re thoughtful, if you’re a good doctor, then you’ll let that story guide you because the patient’s trying to tell you what their priorities are and those might be different from yours.

And I’ve—you know, I haven’t always lived up to that lesson but I’ve tried in this role in particular to really consider that lesson and to let what people were sharing on the road and guide us, you know, into where we started putting our focus, our research, our energy, and ultimately our reports and initiatives.

BOLLYKY: Great. You know, as you said, there’s—I think most people can appreciate the social strife and the isolation that came with the pandemic and how that manifested in their own lives. But it has been brave to take on this agenda. There has been pushback.

I saw recently the critique in the Atlantic that argue that these types of issues—these social, emotional drivers of public health—are wellness, not public health. Hard to measure the problem. Hard to measure progress in addressing it.

How do you think about these issues that can have these challenges of measurement and, you know, what do you—how do you weigh the tradeoffs of elevating issues on the surgeon general’s agenda so that they can resonate more with the U.S. public?

MURTHY: Yeah, it’s interesting because this is a place where I actually think the medical and public health establishment tend to be behind the U.S. public. The general public knows that how they feel matters, right? There are millions of parents around the country who are seeing their kids going through a mental health crisis and are worried about that, right, and they don’t know what to do.

Yet, we are still dealing with the vestiges, I think, of a way of thinking that tells us that physical health is the most important dimension of our health and everything else is quite literally and figuratively in your head.

But I think as we—if we even pay attention to the literature around this what you see going back, you know, more than two decades you see growing evidence that tells us that our mental health impacts our physical health, right, and you see now growing evidence that tells us, as we shared in our report last year, that issues like loneliness, which I didn’t even think of as a public health issue when I began my tenure as surgeon general, that these issues have a profound impact on public health and I say profound, you know, just not in terms of how it feels but in terms of numbers.

If you look at people who struggle with social disconnection, for example, 29 percent increase in the risk of heart disease, 31 percent increase in the risk of stroke, 50 percent increase in the risk of dementia among older adults, increase in premature death. Overall mortality impact of social disconnection comparable to smoking and obesity, right.

These are—I mention smoking and obesity in particular because we think of these as bread and butter issues, right? Although even obesity, you go back a few decades and people would say, well, that’s not really a health issue, right, which seems preposterous to say today. But this is how our thinking has had to evolve, right.

I think that the data and the stories from individuals are telling us very clearly that when it comes to your health and well-being your mental health is health, that it’s just as important as your physical health and, again, this is a place where I think the public—a lot of—the majority of the public, I think, understands that.

But in medicine and public health we have to do some catch up here and start to shift and expand our way of thinking about health because the consequences of not doing so are quite profound.

It means that we are missing profound drivers of pathology and dysfunction that we’re not going to be able to address if we can’t see it.

Finally, just on the issue of measurement it’s absolutely the case that when we think something’s not important we don’t focus as much on not just measuring it but investing in research in that space, right?

So you look at, for example, how much research we dedicate to cancer, hypertension, and diabetes versus to depression, anxiety, and loneliness, right? There’s a wide gulf, right? But that reflects, again, part of this evolution in our thinking and understanding about what’s important and, hopefully, we can close that gap.

But to not look at something, an issue, because we don’t have great ways of measuring it yet to me that’s letting the cart lead the horse, right? It reminds me of that old story about the man who loses his keys and says—you know, and he loses keys in his house but it’s dark in his house—it’s at night—and he says—he looks outside and he sees that there’s a lamppost out and it’s lit the street. And he says, you know, why am I wasting my time looking in the dark here? I’m going to go out there in the light and look there.

And a neighbor passes by and says, oh, what’s wrong? He said, I lost my keys. Let me help you. I’ll look for it. They start looking. Finally, he says, are you sure you lost your keys around here? He’s, like, no, I lost my keys in my house but I’m not going to look around in the dark. I’m going to look here. It’s easier, right?

It seems silly, right? But in some ways we have to avoid the temptation to do that like in health care of studying things that are easy to understand, that are well established, that have concrete measures that have been in place for decades and decades.

Sometimes our job in public health in particular is to be on the frontier, is to look at something that’s important and to find the language and the mechanisms to describe it, the ways to measure it, the funding to do the studies on it. Like, sometimes that’s what our job is in public health and if we don’t do that then I worry that we will miss really important factors that are driving the health and well-being of the country.

And, finally, I’ll just say this. Look, I think in public health we have to—and medicine we have to do what that mentor of mine for medical school—first year of medical school—was reminding me to do back in the day, which is really listen to people and allow that to guide our work.

You know, I always tell our team in the office that there’s only so much we can learn from reading reports in Washington, D.C., in our office, right? To some extent, you need to get out there and go into the community and start talking to people and have them challenge your sense of what’s important or what the drivers are behind a certain problem.

Sometimes we think we know but sometimes we don’t know and when we listen to people who may not have degrees or may not have medical public health backgrounds we get tremendous insights.

Some of the greatest insights I’ve gotten into public health have been from college students, high school students, from parents who may not have a lot of money or education but they’re rich in life wisdom and they can tell you what they and their neighbors and their family members are going through and that kind of data, you know, it may not be the kind of data that we publish, you know, in the—you know, as we would in RCT but it ends up being really valuable data to add to the broader mix to help us understand the fundamental issues facing Americans.

BOLLYKY: Yeah. And I think on this issue of listening to people it’s also important to acknowledge that you’ve heard them and I think one of the issues that, perhaps, people don’t associate with the surgeon general role is, again, the importance of that the nation’s doctor witnessing, seeing the challenges people are having.

So I think of C. Everett Koop during the AIDS crisis in the 1980s when, perhaps, there wasn’t as much recognition from the White House going on in the problem, using that position to give voice to what was a(n) emerging and fast-growing health crisis in the U.S.

Talk about your sense of bearing witness through this role and what that might mean for either parents or struggling with social media or stress or this isolation function of giving witness to a problem that’s emerging in U.S. society.

MURTHY: I love the term that you use for that, bearing witness, and I think that’s actually the right term.

If you look at religious scripture or if you look at William Osler’s writings, one of the sort of fathers of modern medicine, you find a similar description about the power of bearing witness because there’s something really powerful about witnessing someone else’s journey, right.

If you’ve ever, like, gone through a very hard time in your life—just think about some time you went through a crisis, and when you reached out to a friend who came and sat with you. Didn’t fix your crisis. Maybe they couldn’t. But they sat with you through that. They listened to your story. They reminded you that you aren’t alone.

You know the power of bearing witness to someone’s journey, and it took me a long time to sort of fully appreciate the value of that when I was going through medical training because we were so trained to think that the greatest power we wield is to prescribe medicines and to perform procedures, right, and sometimes we don’t fully appreciate the power of bearing witness.

But, you know, I think that—you know, I was with Abraham Verghese the other day, a physician at Stanford who wrote a book that profoundly influenced me when I was in medical school in my own country about his journey caring for people with HIV in rural Tennessee in the early days of the epidemic in America.

And what Abraham would often tell me is in those days—this was even pre-AZT. There weren’t medications to give. There weren’t any heroic measures to take. But there was still healing that you could provide by bearing witness, by reminding people that you were still a partner in managing their symptoms and caring for them, that you would be there when their family ostracized them because they had a disease they didn’t understand.

So and what—as I’ve thought about this work as well what I’ve been really struck by is that even though, Tom, in our reports I always tell our team we never put forward a problem without offering solutions, right? We always lay out in our reports what not just government can do but what private sector can do, what the health-care system can do, what individuals and families can do, we lay this out because we want people to feel empowered by this.

Yet, I’m constantly surprised that the most common feedback that we get about these topics is, I feel so seen. That’s what people say.

I was just coming here from New York. You know, I was there for an event earlier today and at the airport multiple people stopped me about the parents advisory that we just issued. They were all parents who had been struggling on their own and they all said the same thing, I felt so seen when this report came out, right.

You’ve talked to them long enough they’ll say, oh yeah, and that—I think that would be a great idea about what I can do from this report here and—but the first reaction is, I felt so seen. Thank you for recognizing what I’m going through.

I just think that that’s a fundamental human need that we have to acknowledge and I think when my predecessor C. Everett Koop acknowledged HIV as an important health issue, not just some throwaway concern, not something that should be a source of shame or judgment in our lives but as an important health issue just as important as heart disease or cancer, that meant a lot to people who were struggling with HIV, who felt cast aside by society, ignored like their lives didn’t matter, and finally felt like, ahh, I do matter.

It’s hard to underscore the profound consequences not just to health but to productivity, to education, to society, when people feel they don’t matter, and I want to underscore that. Like, there’s no amount of policy that you can put into place that will fix the effects of people fundamentally feeling like they do not matter, that people don’t care about them, right, and that’s one of our jobs, I believe, in public health and in medicine.

It’s not only to have the right policies and invest in the right programs and do the right research but it’s to build a human connection with the people we are trying to serve so they feel seen, they feel valued, they feel understood.

And you and I, Tom, were talking about trust, you know, just a little before this. That’s actually how you build trust is you help the people recognize that you see them, you value them, you respect them, you understand them.

Yes, you want to deliver, you know, on the promises you make. Yes, you want to offer real solutions to their problems. But I can tell you this. If you offer real solutions and actually bring them to people but you haven’t helped them feel like you understand them, you see them, and they matter in your eyes then even doing all the right things from a policy perspective will not build trust and I think we’ve seen a lot of examples of that in recent years.

BOLLYKY: Yeah. I do think that part of listening and feeling—making people feel like they’re being understood is a fundamental component of being trustworthy, which is, ultimately I think what that trust agenda is about. And as a parent of three kids during the pandemic, when I saw the statistic that you all just put out, that two out of five U.S. parents feel extreme stress in their life I did feel seen. I also felt that three out of five U.S. parents are liars. (Laughter.)

MURTHY: That’s—(inaudible).

BOLLYKY: But leave that aside. I want to shift gears a bit to the international side.

MURTHY: Can I say one quick thing on that topic?

BOLLYKY: Yeah.

MURTHY: To this point, just to underscore the numbers, like, the numbers Tom’s putting out I’ll just give you two more as well. In our parents advisory we noted that 48 percent of parents say that on most days their stress is completely overwhelming in their life—48 percent. That is not normal, right, for half of parents in a nation to feel completely overwhelmed by stress most days but that’s a reality we’re living in.

The second thing we noted is that when it comes to loneliness parents actually struggle with loneliness at a higher degree than the average population. In the study that we looked at it was 10 percentage points higher. Sixty-five percent of parents overall struggle with feeling lonely and if you look at single parents that number goes up to 77 percent.

Now, people—a lot of people on the outside don’t realize this, one, because parents don’t talk about this that openly with one another because we’ve sort of created a society—a perfection oriented society where it seems like there’s a formula for success for you, for your kid, for how to parent, such that if parents are struggling they feel like they’re failing.

They feel like they’re, you know, not doing right by their children and who wants to really admit that, especially when you look on social media, you look at the world around you, and it seems like everyone else is leading a perfect life.

So there’s this real sense of shame that has set in in parenting and led to this kind of loneliness and surprises a lot of people who aren’t parents because they figure, hey, you’re a parent. You have a family. You’re not going to be lonely or you’re going to be at least less lonely than somebody who doesn’t.

But it turns out to be one of those many examples of—humbling examples of how sometimes the data and the stories can be counterintuitive and that’s why it’s important to do that research and to ask those questions.

But to me it points, again, to why, as we work on these broader issues related to mental health, we have to try to understand which groups are being particularly affected, you know, at a higher rate by things like stress and anxiety and depression because sometimes it’s not intuitive .

Even with loneliness, you know, most people think kids are probably the least lonely because they’re connected by their devices. But it turns out rates of loneliness are highest among young people—not lowest, highest—despite, and in some cases because of, the way that they’re using technology.

BOLLYKY: Great. No, that was a good intervention.

Let me shift a little bit to the international piece. You referenced before this metaphor of shining the light in other places. Fortunately, the U.S. is not the first country onto this problem. The United Kingdom established a minister of loneliness in 2018. Japan has adopted this issue in 2021.

You recently visited both of these countries. What have you learned from their early experience on trying to tackle this agenda?

MURTHY: So this has been really interesting. Yeah, I just came back from Japan and U.K. just a few months ago and, you know, more broadly, as I was sharing with Tom, I co-chair a WHO commission on social connection that brings a number of countries together—health ministers from Chile, from Japan, from Morocco, Sweden, and other countries to jointly help create an approach that we can take—really, a community of nations that can help to address social connection.

The reason doing this, to Tom’s point, is because this has become increasingly clear that this is a global issue. This is not just an American issue and, you know, the U.K. and Japan have moved early on establishing cabinet level leadership on this issue. Australia has also worked very hard to make this a national priority and other countries are starting to follow suit.

But what I learned when I visited there was that as these countries—as U.K. and Japan have talked about loneliness it has been incredibly resonant in their populations, and think about it—two very different cultures, right, the U.K. and Japan. Yet, people are responding because the visceral feeling of loneliness is both so deep and so widespread and people has had so little conversation about it—it’s been hidden in the shadows—that an opening like this, the government recognizing it’s a concern, people starting to talk about it, is like letting oxygen into the room.

The second thing that I’ve learned from these countries is that this isn’t—there’s no playbook for how to address this right now and nobody has quite figured it out. So Japan actually passed major legislation that is going into effect now to help address loneliness.

The U.K. their—the ministry there, the ministry that was in charge of loneliness spearheaded an effort to develop a national strategy for how to address this, and in our case in the United States, you know, last year our office issued a framework for a national strategy and a call to action for the country.

But the bottom line is it was sort of clear from my visit there that we actually really need each other. We need to learn from one another in how to study this issue more consistently, how to invest more in it, how to make the case that this is not just a health issue but it’s an economic, education, and national security issue as well.

And why do I say that? Because we know that when kids are experiencing disconnection it actually impacts not just their mental health and physical health but it also impacts their educational outcomes, how they perform in school. In the workplace when people struggle with loneliness we know that that impacts their productivity, their creativity, their engagement, and their retention.

But loneliness also has profound contributions to what we’re seeing in more and more countries, including our own, which is division and polarization, right. If you are a foreign adversary trying to think, how can I weaken the United States, right—how can I create and sow more division you would look for populations that are struggling with loneliness because in that—when people are dealing with chronic loneliness they enter into a state of hyper vigilance.

In a state of hyper vigilance you are more likely to be suspicious of people around you and in that heightened state of suspicion you’re more susceptible, as you can imagine, to conspiracy theories, to stories that might be told about your government may be doing nefarious things even if it’s not, right? Like, you’re more susceptible to being turned against people in your own country, right? Because, again, in a state of hyper vigilance you may not evaluate things the same way.

The reason—there are biological reasons why we operate that way in that state of hyper vigilance. It sounds counterintuitive. It seems like, hey, if you’re lonely wouldn’t you want to connect more with other people versus turn against them.

But if you imagine—go back in your head and imagine what it might have been like thousands of years ago when we were hunters and gatherers on the tundra and imagine that in those days that your survival depended on being part of a group, right?

The person who said, you know what? I’m going to just go it on my own. I’m going to do it and I’m going to be my own man. I’m going to be my own woman. Don’t need anyone else. That person died. They got eaten by a predator. They starved from an insufficient food supply.

It was the people who built trusted relationships, shared food, took watch, you know, at night to make sure predators weren’t approaching the group, helped with childcare—those are the people who survived such that when you—and this became baked into our nervous system over thousands of years such that when you were separated from your group you knew that your life was in greater risk.

And so in that moment of separation and risk if there was a twig that cracked behind you, even if there was a 1 percent chance that that was a predator stalking you, you wanted to interpret it that way because your life depended on it. Now, you try—fast forward to modern day America, even though, like, our circumstances are different our nervous systems are very much the same, and so if I’m feeling separated and little bit, you know, lonely and isolated hyper vigilance kicks in.

And if Tom comes up to me recognizing, hey, maybe I’m struggling with loneliness and says, hey, Vivek, you know, do you want to have lunch tomorrow? It seems like you could use a friend. Why don’t we hang out? The normal response of somebody you would think would be, oh, that’s so nice. Tom reached out. Yeah, I’d love to have lunch. Thank you. Thanks for thinking of me.

But a hyper vigilant response might be like, hmm, why is Tom asking me to have lunch? Is he taking pity on me? He’s trying to ridicule me? Does he just feel sorry for me? Does he think he’s better than me? Screw that. I’m not going to hang out with Tom. Nah, I’m good, right? And that seems like an irrational response but it actually biologically makes sense, right.

So, again, to come back to, like, why this matters to society and what more and more countries are starting to realize is that whether you care about, again, polarization, division and national security, whether you care about, you know, sort of your economy, educational outcomes, or health we have to repair the social fabric of our society.

We have to make sure that foundation is strong because it’s on that foundation of social connection and cohesion and trust that we build everything else including our institutions, and if we don’t invest in that social fabric then it’s like building a house, you know, on a foundation of sand. It’s shaky and too often it falls down.

BOLLYKY: Great. That makes me think two things. One, I’m going to pause before I ask you to lunch. (Laughter.)

Second is that, you know, we were talking about trust before and the, you know, work that we’ve done here with collaborators looking at trust in terms of mobilizing people to protect themselves and to seek to protect others in the pandemic.

But there have been many studies, really, frankly, on this issue looking at previous outbreaks, other health emergencies, that this ability to mobilize, for people to have a pro-social response really depends on how they trust one another, which depends on having a long-standing—not just in a crisis but a long-standing social connection with one another.

With that in mind, with these early experiments that we’re seeing in Japan and the U.K. on this agenda is there any emerging evidence around the success of any interventions in that context? Anything we might take from that that can help feed back into this broader public health relevance of trying to build the social connections so that we can better pull together at times of crisis?

MURTHY: Well, it’s a really important question, Tom, and I think especially as we think about the prospect of a future pandemic down the line or any other public health crisis, and I was sharing with Tom that this WHO commission that I co-chair is actually putting together a report and one of the things that report is doing is actually summarizing the evidence we have on interventions, and our hope is that that will come out in the early half of—in the first half of 2025.

But, look, a few things that we do know already is, one, we know that the most important time to build trust is not when you need it. It’s beforehand, right? It’s before the crisis, and that means, like, right now is when we need to be building trust.

The second thing we know is that trust is about building really fundamentally human relationships. We think about it often—too often, I think—transactionally, like, if I give somebody X and they want X then they will trust me, and that’s actually not always the case, right?

They may take it from you because they need it but that doesn’t mean that they trust you, right? People trust you when they think that you understand them, that you respect them, when they understand what your intentions are, and they feel like they have a sense of who you are as a human being.

It’s why when just if you have to spend any time in the world of community organizing, you know, one of the very first things that they teach you is if you’re trying to mobilize people to action you have to tell them the story of self, us, and now. But self is part of that. They need to know who you are. What are your values? What do you care about? Do you care about me?

So that piece is really important. During the pandemic one of the things that we found is that when we were trying to understand a little bit more about, you know, the uptake that we were seeing around COVID vaccinations, for example, and even the uptake of therapeutics like Paxlovid—one of the things that sort of became increasingly clear is that even though people may have had distrust about institutions a lot of times if their doctor told them to take something then they were much more likely to do it than if a large health institution told them.

And why was that? Because they had a personal relationship that generated trust, like, with that doctor. So, to me, one of the encouraging things about this is as despairing as it can sometimes feel when we look at the data that tells us that trust in institutions has declined, I don’t think trust has disappeared. I think it’s actually flowed more locally and, you know, into people’s—in people’s lives and so the people they tend to trust are maybe family members or friends or their doctor or—and even there, there are limitations, though. That doesn’t mean that because you trust your doctor that you’re going to take your doctor’s advice on what car to buy, right, just like you wouldn’t, you know, trust your car mechanic to tell you what medication you should take, although it’s interesting how often that actually does happen, sadly, as we find. (Laughter.)

But, to me, what that means in terms of our learning is that this difficult but essential work of building relationships and communities is at the heart of what we actually need to do to start rebuilding trust, and that can look like in a school thinking about how do we actually help kids in school build trusted relationships with each other, with teachers, and with a counselor?

How do we actually rethink the health-care system so that our outcomes that we’re actually measuring and look at—and looking at actually include satisfaction with the quality of relationship that you have with your health-care provider and the trust you have in that health-care provider, and the sort of drive toward efficiency and, quote/unquote, “hard outcomes” those things were getting shoved out, you know, or shoved aside as being less important than am I checking the boxes on asking these key questions, delivering these key preventive interventions.

But we think we’ve learned the hard way that actually measuring the quality of relationship actually matters a lot, right. That’s a key way that we can rebuild trust. So I think that these—and I would say, finally, even in workplaces, right, whether you’re doing—whether you’re building trust and social connection in the workplace because you’re interested in your own bottom line and outcomes or because you care about people or because you want to contribute to the long-term trust that we need as a country, whatever the motivations are we need to do this, right, and right now, like, people are—many people in workplaces don’t feel a sense of connection with other people even though we know there are all these benefits to that.

The move to hybrid work and remote work I think has made this more challenging. It’s not that there aren’t benefits to hybrid and remote work. There are, and this is partly what we have to try to balance here.

But when you’re in a situation where you’re completely remote, you know, a lot of the conversations that may happen spontaneously don’t happen, right? So if we were having a meeting in person there’s, like, the couple minutes before the meeting when everyone’s filling into the room and you see somebody, like, oh, hey, how was your weekend? How was your summer? And maybe you pick up on something. Maybe it was great and you share a moment of joy or maybe you pick up a hint of concern in their voice and you realize that maybe their mother or father was sick and that really was—is weighing on their mind.

You might pick up things that people are doing during the meeting also. Say, oh, so and so is quiet and so maybe a couple minutes after the meeting when people are filing out you pull the person aside, hey, just want to check on you—are you doing OK, right. These are the things that are harder to happen, right, when you’re not in person.

Now, what that means, in my mind, is not that we should ignore the benefits of hybrid work and flexible work structures but more so that we have to more proactively compensate for the lack of in-person opportunities by having moments where we gather and pull people together in person from time to time, where we actually focus on proactively helping people get to know one another.

I’ll give you one simple example of how we do that in our office. We have something we do once a week that we call our humans of OSG exercise. It’s office of the surgeon general’s OSG. It’s a very simple thing. It takes about ten minutes, right.

We’ll pick two people in the office and we’ll have one interview the other about their life. It can be anything about their life as long as it’s not about their current job in the office, and we learn all kinds of very interesting things about people, right.

We learn about what their childhood dreams were, what their favorite band was, what they do when they’re feeling sad, what’s their go-to. We learn about their relationships with their family. We learn all kinds of things.

The thing is we learn things that make them more human, right, and to build real relationships in a workplace you have to see people as more than skill sets, right. Like, people are more than, like, Lucy, who’s great at Excel, or Brian, who’s great at pricing strategy, right.

People are real human beings—parents and sons and daughters and brothers and sisters who are having real life joys but also real life hardships, and when people feel like they can’t bring some of that humanity to the workplace it actually impacts their ability to connect with one another and be real with one another.

So that’s a simple ten-minute example of something we do, recognizing that we’re in this hybrid world, that helps people actually find points of human connection and then build off of that, you know, during moments where we’re all together in person.

So these are all—this feels like a fundamental rewiring that we have to do of society because what has happened, even though we spend 99 percent of our life or as our sort of history as human beings living in a way where we were connected with one another, the last couple of decades have fundamentally transformed how we interact with each other, right?

With all the blessings and benefits of technology one of the things we haven’t done necessarily is to figure out how to mitigate some of the downsides and manage those, right. So the fact that we can get everything delivered to our home means we also see other people less often, right, in a grocery store or in a retail store.

The fact that I can stream everything I want at home might mean that I’m less likely to go to the movie theater or to have friends over and watch something on TV because it’s coming on at 7:00 p.m. on Wednesday, you know, or 9:00 p.m.

And with social media as well, while there’s some benefits there that some people may accrue—staying in touch with old friends, learning new information—one of the challenges is that shift from what used to be in-person relationships to online relationships has come with profound consequences because the quality is not the same.

We’ve replaced friends with followers, confidantes with contacts. We’ve replaced a focus on quality with a focus on quantity. I remember the early days of social media people saying, wow, I’ve got this many friends. How many do you have? Like, oh, I’m going to try to get this many, et cetera.

And it seems almost comical to say that now but we’re often driven by these kind of numbers and the gameification of relationships, which social media and technology have enabled, I think has in many ways been detrimental to the real human relationships that we need.

So this rewiring might feel profound but it can start really small with the actions that we take, like, in our days. Like, can we spend fifteen minutes a day, for example, connecting with someone we care about?

Can we make that time tech-free time or create tech-free zones in our life where we’re just going to be with another human being over a meal, when we’re taking a walk, and focus on deepening that relationship with them?

And, finally, can we find ways to build service more into our lives and into our culture? You know, service is a powerful antidote for loneliness. It’s a powerful way to build connection and build trust.

But service has actually been declining in the United States and if you talk to young people today, as I do all over the country, you don’t necessarily hear that they are getting the message from society that service is important.

The message they’re getting that they tell us is that they have to hustle. They’ve got to hustle after internships. They’ve got to hustle after other things that are going to pad their resume. They have to hustle to get good scores on standardized tests to get into a good school to get, you know, a high-paying job. They have to hustle to build their brand.

The number of times I’ve heard high school and college students tell me that their goal is to build their brand might shock you but there’s, like, a small part of me that dies every time I hear that because—not because there’s anything wrong with building your brand, not that there’s anything wrong with being famous or being rich or being powerful.

But what is problematic is when we think that those are the key to fulfillment, right, because they’re not, as it turns out. You can do all of those things, and I suspect all of us know people who are rich, powerful, and famous and profoundly unhappy, right?

But the people who are happy they have something else. They have relationships and this is something I think that—it’s not just the data that tells us this, but I just find in my own life that when I listen to the stories of patients over the years, especially patients who are at the end of their lives, when I listened closely to what they were saying as they reflected on that broad arc of their life what they talked about were not the size of their offices or their bank accounts or how many followers they had on Instagram.

What they talked about were their relationships. They talked about the people who loved them, the people who they loved. They talked about the people they wished they had spent more time with. You know, at the end of life when only the most meaningful strands of our existence remain it’s our relationships that come to the top that become clear.

And we don’t have to wait until the end of our life to realize that, to start living in that way, to start modeling that for our kids, to start helping our kids recognize that what’s valuable in life is not just what you learn and what you get but it’s the relationships you build and kids are hungry for this.

I will tell you this from direct experience. Young people are not sleepwalking through life thinking everything is peachy. They recognize that something is missing, right? They recognize that the path to fulfillment that they’re being prescribed is not necessarily cutting it.

So they want a different path. They want a better path, and I think it’s up to us to think about how we build that model for social connection for kids to see how we lift up those models of people who are living connected lives as examples of success because if we do that then we’re giving our kids the most powerful tool they need to lead a life that’s happy, healthy, and fulfilled.

BOLLYKY: As a parent I have a lot of questions about social media and the broader connectedness agenda that you just powerfully laid out but I’m also cognizant that we are running short on time. So I want to give the audience a chance to ask questions, and why don’t we start up here?

Q: Thank you very much for your very insightful comments. I’m Beverly Lindsay and I’ve been at several major research universities—California, Penn State, et cetera.

My question is perhaps more speculative in light of some of the issues in terms of diversity, equity, and inclusion and the Supreme Court’s decision of June of last year. There are programs at Harvard, MIT, UCLA, et cetera, that try to have diverse groups of medical students, of Ph.D. students, with whom I work all the time.

But how do you think some of these, on paper at least, restrictive measures that have been proven successful in the past may play out in terms of who’s going to these graduate schools, medical schools, et cetera, because there are diverse populations and, again, that’s interaction and human connection.

Could you offer a few comments on that, please?

MURTHY: Yeah. I think we underestimate how important it is to have diverse representation in the health-care workforce and if you need any reassurance about how important that is you just talk to the patients, right—the people who are being served—and they tell you that, I want somebody who understands my life experience and my background, and there’s nothing wrong with that. I don’t think we should shame people for a feeling that way in the same way that if you’re a woman you might want a physician who’s a woman. If you’re somebody who—you know, take my parents, you know, who come from a South Asian background and from an Indian background and you have a mental health need you might want a therapist who understands your cultural context, you know, and maybe has grown up with that, too.

That diversity in our workforce actually makes us stronger, not weaker. Like, I think we all know that there’s a standard you need to maintain, like, in medical training. But I think where I worry that there has become just a sort of a misunderstanding is around this idea that somehow in this search and then the quest to ensure we have a diverse workforce we’re going to compromise on quality or standard, like, of training and that’s not the case, you know.

But what it does mean is sometimes we have to make it a point to look harder for candidates and people we can bring into the workforce because, you know, as so many young people have told me over the years if you don’t see somebody who looks like you, like, in a field you think that that field is often not for you or that you can’t do it, right.

So if we want to change that and if we want to take a field—like, take medicine as a great example. It’s been a great concern to many of us that the number of Black men in medicine has been declining, right, at a time where—and we have a significant gap in representation in the workforce compared to the population, right?

But if more and more Black men don’t see themselves—they don’t see other Black physicians in medicine the message that sends to them is that this is not a place for you, right? If we want to change that then we’ve got to work hard to, one, change that understanding but to recruit people in, right, to make sure that they have the tools and support they need to see that, hey, this is a path that I can go down.

And I don’t think that there’s anything wrong with that. I think that, in fact, that’s something that is beneficial, you know, for the population at large.

So I know that this is an issue that can get politicized sometimes and has been especially recently, but I think as people in the world of public health and the healing professions more broadly I think we have to keep our eyes squarely on the fact that diversity is actually important for the care that we deliver and we have to make that case, you know, to the public as well so people don’t see this as something else like some political choice or something like that.

This is actually an outcomes driven choice. It’s a—we want to optimize health outcomes. We want to build trust, which is a key part of that, and we know that a diverse workforce is a key factor in doing that.

BOLLYKY: Great. Next question, please. Up here.

Q: Hello. Thank you very much for this important conversation. My name is Jinnyn Jacob and I’m—I work at Booz Allen Hamilton. I’m in our philanthropy team.

And, you know, Booz Allen, we’re the largest provider of AI services to the government. We’re a leading technology and management consulting company, and because we’re leading in technologies like artificial intelligence, you know, we understand that there is a national and economic security imperative for equitable access to responsible AI education.

So what does that mean? So we’re thinking a lot about AI literacy and a lot of that is the human part of AI. And, you know, we were just talking about social media and I think we’ve seen some of the mistakes that we may have made by not being a little bit more thoughtful in terms of social media use. So we’re trying to think about that from the perspective of artificial intelligence, right?

So what does things like chatbots or deepfakes—how does that change human connection especially as it relates to our future leaders? And so I would love your perspective on these, you know, new technologies and things that we may need to be aware of and how as citizens and, you know, folks in this room representing different parts of America how we can help your agenda in this as well.

MURTHY: So thank you for that thoughtful question and for being thoughtful about how to approach AI.

Look, at the end of the day, I think that technology is a tool. It’s, like, how we use it, how we design it, that ultimately shapes its impact on us. But that also includes how we establish guardrails around it, right, to ensure that it does what we intend for it to do.

I think social media is in many ways a cautionary tale. It was a series of platforms that began with an intent that I think was actually quite good in many cases, which is building community, connecting people with one another.

And then you saw sort of what happened as there sort of became an increasing focus on a business model that prioritized engagement and time spent that you started—if that’s your business model then the best way to engage people is outrage, right, and that helped birth, you know, or I should say fuel the outrage industrial complex which now we’re all caught up in, right?

But it fundamentally helped break the dialog and the conversation between people and I think has also contributed, as we laid out in our reports, to some of the major mental health struggles that kids in particular are facing today.

So how do we avoid doing that? Well, I think one thing that we can do which we didn’t do with social media is to have a conversation early on about what we want out of AI—for example, what are the goals that we’re seeking to achieve—and as part of that talk about what are we not willing to sacrifice in pursuit of that goal.

Are we not willing to sacrifice mental health, security, trust? Like, what are we not willing to sacrifice? And the second thing that we have to do then is we have to try to understand how can we then measure technologies that emerge against those goals and standards, right?

By the way, we didn’t do this with social media. We just sort of let this natural experiment happen over the last two decades and now we’re still trying to figure out the full impact of it. But if we learn from it these are some of the things we would do.

I think the third thing that has to happen—this is the part that is challenging—is, look, I recognize that the United States is one country. Many other countries are also developing AI. China is, certainly, you know, in this whole race around AI and building all kinds of applications, you know, around AI as well but many other countries are as well.

And so one of the challenges we have as a global community is how do we establish a set of guardrails and standards that we can all abide by, recognizing that if a few of us who don’t that can unleash technology that can have massive negative effects across the world, right?

And so, I mean, the same way that we think about epidemics and increasingly pandemics now as ones where, you know, an infectious, you know, agent in one country can quickly spread and impact the whole world, I think we have to actually think about AI in this context as well—that it’s not one country developing something that does not stay within its borders.

I think, finally, we have to find a way to do two last things, which is—one is to study and invest enough in studying the real-time impact of these platforms because right now the problem we have with social media is not only that we have a lack of transparency where independent researchers say they can’t get information about mental health impact from companies but we also have a major lack of investment in that research, right.

So you have a relatively small community of researchers, given the size of the problem and the almost universal nature of utilization, right. So that’s something we need to front load research funding in this space and, look—and, finally, we have to engage the people who are users as well, right?

Sometimes we think we know what the impact is or we think it’s not really a problem. But then when you really study this and talk to people in communities about, hey, how is this impacting your life, how are you using this technology, we may realize very different things.

I spent seven years before I was surgeon general doing, among other things, building a technology company and one of the things—you know, when you’re part of a tech startup you do things that are way outside your job description because you have to because there are only a small group of you.

So I was actually one of the people who was focused on user interface and design, right, and so I just had to learn, you know, about that, you know, sort of area. But it involved, actually, a lot of interesting conversations with user groups and I remember how often we were surprised that we would build a tool that we thought would help people do this—they would react a certain way.

We would take it to a user group, people would react completely differently. Like, no, actually, I didn’t like that or I really liked that, even though we thought that was a throwaway feature. Or I used it for this purpose, which is completely different from what we thought they would use it for.

I think we have to stay close to the ground there because some of the uses that people may engage in may end up being problematic for themselves or others, but there also may be innovations there in terms of how they’re using it even though those uses were not intended.

So I think we just have to be much more thoughtful about how we do this and we have to work together with the public, with industry, and with government partners. But I don’t—what we cannot do is just put our head in the sand and say, let’s see how this shakes out in five to seven years, or say, well, let the market take care of it and people will essentially help drive us toward the solutions that ultimately work.

That did not happen with social media and this is not a problem that the market alone is going to solve. It’s a place where we need scientists and researchers. We need thoughtful regulators working in concert with the public and industry.

BOLLYKY: Great. We have a few minutes left. I’m going to take a couple of questions and then give Vivek a chance to answer both of them.

The gentleman over there and then the gentleman in the center table.

Q: Dr. Murthy, thank you. My name is Balaji Narain with the Congressional Biotech Commission.

I want to go back to your earlier comments about trust versus skepticism about ulterior motive and ask you in the course of your work what are some of the challenges that you and your team have faced in building trust among the constituencies and stakeholders, and how did you work to dispel that distrust and what lessons do you draw from that for other institutions to learn from?

Thank you.

MURTHY: Thank you, Balaji. I appreciate that.

BOLLYKY: The gentleman over there.

Q: Hi. My name is—my name is Jordan Reimer. I am senior manager for North America at the Strong Cities Network. We are a global network of city governments dedicated to addressing hate, extremism, and polarization.

Between your loneliness report and your gun violence report those topics really delve really closely to what we work on, which is a public health informed approach to targeted violence prevention, and right now the DHS center for prevention programs the partnership owns that portfolio for the U.S. government and they are working with the CDC’s violence prevention team.

I’m wondering to what degree is your office involved in targeted violence prevention or to what degree just brainstorming can your office help advance the mission of targeted violence prevention? Thank you.

MURTHY: Thank you. These are great questions.

You know, in terms of trust I think, you know, over time as we’ve worked on this, particularly in the early days of the pandemic, I mean, that was pretty hard—you know, the pandemic time period—because, sadly, you know, the issue of COVID became very polarizing and very politicized in the country and there was a lot of misinformation that was flowing as well and IT made it hard for people to know, like, who to trust, what to follow, who cared about them versus about some ulterior motive. Like, these are very, very, very hard.

What I found, at the end of the day, is that there weren’t any simple fixes for this. Sometimes, like, I think that in large shops we try to think, oh, what’s the right message that we could form in. If we just get the right message, and then we put that on poster boards everywhere, and billboards, and then on digital, you know, sort of channels, then people will see the light.

And it’s rarely about having the exact right message, right. It’s about having the right relationship, and the hard part about that answer is that relationships are hard. They take time to build. They take real investment, and you can’t, despite the—despite, perhaps, the myth that we may be sold by social media you can build relationships en masse, you know, with thousands and thousands of people.

Even when we think about celebrities, right, and there’s also, I think, a tendency sometimes among organizations that think, ahh, if we just get a celebrity to say what it is that we want then people will do it, right?

But people are actually smarter than that, right? They may love a celebrity for their music or they really appreciate, like, how they act in a movie. But that doesn’t mean that they’re taking medical advice, you know, from that person.

And so I found that there were real limitations to this thinking that it’s just about the right message or it’s about getting the celebrity messenger. Really what it was about is finding the people actually who folks have some trust in and in the case of COVID the people we were thinking about, well, were nurses and doctors in communities, faith leaders, teachers, right? These are people who—firefighters, cops. Like, these are folks who—I’m not saying everybody trusts these individuals, like, you know, in a community but they have far higher degrees of trust than most other groups.

And so then the question was, well, how do we work with those groups then to help them understand what our intentions are, to ask them if they’d be willing to invite us into their communities so that we can speak alongside with them, you know, about some of the public interventions that we want to talk to people about or the concerns that we want to share, and that is a tough strategy.

You know, we had to build something called the COVID community corps which had many, many organizations and individuals like this who were trusted in their communities and then we had to spend time working with them to see how we could jointly, you know, engage with their communities but allowing them to really take the lead because they’re the ones who had trust.

So, you know, again, these strategies are not simple but it also underscores why local public health is so important. You can’t have one federal organization that’s trying to build relationships in every community across America, right.

You need local organizations where the people can recognize, they can see, they trust them and build relationships with them over time, and then federal agencies can work with those organizations to provide them with support, to learn from them, to work as a team collaboratively.

But large sort of state or federal agencies I came away feeling like they have an important role but they can’t play the entire role and this fundamental lack of investment that we have made as a country in public health—local public health—I think has really hurt us and it particularly hurt us during the pandemic.

You know, when the 2008 financial, you know, crisis happened when we were in the Great Recession that was really tough. A lot of people lost their budgets, and the money eventually came back, you know, and the economy came back and the stock market came back. You know what didn’t really come back were the budgets of local public health departments, right, which still continue to struggle.

So, again, those are—public health is challenging because when public health does its job nobody notices because bad things don’t happen. It’s hard for people to get excited about the heart attack that was prevented or the outbreak of food-borne illness that didn’t happen, right? But when something does go wrong that’s when people notice and that’s a tough place for public health to be in.

And, finally, I’ll just say that with—you know, and we did, like, massively increase investment in public health through the American Rescue Plan, for example—one of the COVID-related bills, and others.

But what public health needs is sustained funding, right? Like, when you have short-term infusions of funding people get excited and it’s good and it’s actually helpful in a crisis. But, interestingly, people don’t build as much as you think they would because they’re worried that they can’t sustain it.

They’re thinking, why do I—if I hire a hundred staff where’s the budget going to be in year three? Year four? Year five? I’m going to have to lay everyone off. Like, that’s going to be hard. Should I build this expensive new center or set of technologies or infrastructure I need? It’s going to be a two- to three-year build, but is the money going to be there to support it afterward? So you need sustained funding.

And then, finally, when it comes to violence prevention overall, the reason that we issued this surgeon general’s advisory on gun violence recently was because this is an issue, gun violence and violence more broadly, that has been highly politicized but which needs to be taken out of the realm of politics and put into the realm of public health.

If you approach it the way we did other public health challenges, whether it’s HIV, tobacco, car-related—car accidents and related deaths, in those cases we took a public health approach of saying let’s understand, you know, what the full price is that we’re paying, what’s the cost of this problem, who is most affected.

Let’s put in place solutions that we can start to experiment with and then learn from and study. Let’s scale those solutions up so they can benefit more and more people. That we take a very methodical approach to public health problems.

That’s not the approach we’ve taken with gun violence, right. We’ve starved it of research, right, and one of the things we laid out in our advisory is that if you look at a condition that causes a comparable number of deaths as gun violence, and one of those conditions is sepsis, right—bloodstream infections that can be fatal—gun violence receives 1 percent of the research funding as sepsis does.

Now, most people in the country probably—may not even know what sepsis is, yet, you have an area that’s receiving a hundred X of the funding as an issue that people are deeply worried about, right, and when you have 54 percent of people in America saying that they have been touched by gun violence, either themselves being directly injured or losing a family member or friend that tells you that the ripple effects of gun violence are profound and widespread.

And what I believe and what I’ve seen not just in studies but through stories is that the politics in our, you know, perhaps—you know, among our elected leaders I think sometimes belies a surprising amount of agreement in the general population that this is an important issue and it’s surprisingly an agreement in the general population about what the solution should be.

We laid out a number of those strategies in our advisory, steps that policymakers can consider, that institutions and communities can put in place. And communities include community violence intervention programs, which I’m sure you are familiar with and you work on, but also hospital violence intervention programs, which can be really powerful in interrupting the cycle of violence. We talked about the role that health-care systems can actually play. Advocacy as well, which is important.

But if we fundamentally shift how we see this and look at it as for what it is, which is a kids issue, that I think is what has the power to fundamentally change our approach as a country. In the 1990s when tobacco was a problem and, you know, people—a lot of people just said, look, we’re trying to work on this but this is just part of a thing—culture. You know, people like to smoke. Like, this is not going to change.

But people like David Kessler, who was the FDA commissioner in the 1990s, said, you know what? This is a kids issue. This is—our kids are the ones who are getting introduced to this at a young age. They’re the ones who are getting addicted and they’re the ones who are growing up with tobacco-related disease and losing their lives. We’ve got to protect our kids.

That fundamentally changed the conversation about tobacco in the 1990s and here, too, when we realized that gun violence is the number-one cause of death in America among children and adolescents ages one through nineteen, when we realize that 51 percent of children say that they are worried about a shooting taking place in their school, when we see that a majority of parents are scared about sending their kids to school because they’re worried about gun violence, we start to see that this is, in fact, a kids issue.

And I will just leave you with something I just firmly believe, not just as a doctor but as a parent, which is that our most sacred responsibility as a society is to take care of our kids, full stop. Is to take care of our children, and the moral measure of a society is how well it does that, and by that measure we are falling short.

And we have in other areas made it a point to protect our kids, right, whether it’s around cigarettes, whether it’s car safety, whether it’s making sure that the products that kids use have safety standards associated with them with the exception of social media, which has been a glaring exception and a problem.

But on this issue, on gun violence, I believe this is our—we need to step up and fulfill that sacred obligation, which is to look at it for what it is, a children’s issue and one that we, all of us, regardless of what party we are affiliated with or our beliefs, I do believe that the vast majority of Americans can come together around protecting our kids and that’s what we have to do now.

BOLLYKY: Great. A wonderful answer, and I think that agenda around correcting these failures for—of protecting our kids resonates through so many of the themes we talked about tonight—loneliness, social media, this issue around gun violence, too.

I hope you’ll join me in thanking the surgeon general for his really thoughtful remarks here tonight. Thank you for staying a few minutes late. This transcript and video will be posted on CFR.org so feel free to share more generally.

And, again, thank you so much for coming.

MURTHY: Thanks so much, Tom. Thanks, everyone. Appreciate it. (Applause.)

(END)

This is an uncorrected transcript.