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Speaker A: Welcome to the Huberman Lab podcast, where we discuss science and science based tools for everyday life.

Speaker B: I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today, my guest is Doctor Vivek Murthy. Doctor Vivek Murthy is a medical doctor and acting surgeon general of the United States. As surgeon general of the United States, Doctor Murthy oversees more than 6000 dedicated public health officers whose job is to protect, promote and advance our nation. Public health doctor Murthy received his bachelor's degree from Harvard University and his medical degree from the Yale University School of Medicine. Today's discussion covers some of the most important issues in public health, not just within the United States, but worldwide, including nutrition and the obesity crisis, as well as food additives, and why certain food, chemicals and additives are allowed in the United States versus in other countries. We also discuss mental health, the youth mental health crisis, the adult mental health crisis, and the global crisis of loneliness and isolation. We also talk about corporate interests, that is, whether or not big food and big pharma industries actually impact the research and or decisions that the us surgeon general takes in his directives toward public health. And of course, we discussed some of the major public health events that occurred over the last five years and the current and future landscape of how to restore faith both in public health officials, in public health policy and science more generally. By the end of today's episode, you not only will have learned a tremendous amount about public health and why you hear the particular public health directives that you do, but also how to better interpret future public health directives. You will also come to learn that as surgeon general, Doctor Murthy has both an extremely challenging job, but one that he meets with a tremendous amount of both rigorous and compassion. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast. Our first sponsor is element. Element is an electrolyte drink with everything.

Speaker A: You need and nothing you don't.

Speaker B: That means plenty of salt, magnesium and potassium, the so called electrolytes, and no sugar. Salt, magnesium and potassium are critical to the function of all the cells in your body, in particular to the function of your nerve cells, also called neurons. In fact, in order for your neurons to function properly, all three electrolytes need to be present in the proper ratios, and we now know that even slight reductions in electrolyte concentrations or dehydration of the body can lead to deficits in cognitive and physical performance. Element contains a science back to electrolyte ratio of 1000 milligrams. That's 1 gram of sodium, 200 milligrams of potassium, and 60 milligrams of magnesium. I typically drink element first thing in the morning when I wake up in order to hydrate my body and make sure I have enough electrolytes. And while I do any kind of physical training and after physical training as well, especially if I've been sweating a lot, if you'd like to try element, you can go to drink element. That's lmnt.com huberman to claim a free element sample pack with your purchase. Again, that's drinkelement lmnt.com Dot Today's episode is also brought to us by waking up waking up is a meditation app that includes hundreds of meditation programs, mindfulness trainings, yoga Nidra sessions, and NSDR non.

Speaker A: Sleep deep rest protocols.

Speaker B: I started using the waking up app a few years ago because even though I've been doing regular meditation since my teens and I started doing yoga Nidra about a decade ago, my dad mentioned to me that he had found an app, turned out to be the waking up app, which could teach you meditations of different durations, and that had a lot of different types of meditations to place the brain and body into different states, and that he liked it very much. So I gave the waking up app.

Speaker A: A try, and I too found it.

Speaker B: To be extremely useful because sometimes I only have a few minutes to meditate, other times I have longer to meditate. And indeed, I love the fact that I can explore different types of meditation to bring about different levels of understanding about consciousness, but also to place my brain and body into lots of different kinds of states depending on which meditation I do. I also love that the waking up app has lots of different types of yoga Nidra sessions.

Speaker A: For those of you who don't know.

Speaker B: Yoga Nidra is a process of lying very still but keeping an active mind. It's very different than most meditations, and there's excellent scientific data to show that yoga nidra and something similar to it called non sleep deep rest, or NSDR, can greatly restore levels of cognitive and physical energy, even with just a short ten minute session. If you'd like to try the waking up app, you can go to wakingup.com huberman and access a free 30 day trial. Again, that's wakingup.com huberman to access a free 30 day trial. And now for my discussion with Doctor Vivek Murthy.

Speaker A: Doctor Vivek Murthy, welcome.

Speaker C: Thanks so much, Andrew. And please call me Vivek. I'm informal.

Speaker A: Okay, Vivek. My understanding, based on my Internet search, is that the role of the us surgeon general is to provide scientific information on how to improve health and reduce risk of illness and injury. Do I have that correct?

Speaker C: That is correct.

Speaker A: What are some other roles that you play that perhaps would not come up in a top hit Google search that I ought to be aware of and that our audience ought to be aware of?

Speaker C: Well, here's how I generally explain to people. There are two primary roles the surgeon general has. One is to engage with the public and make sure that people know about critical public health issues so they know what they are, how to protect themselves and their families. The second role of the surgeon general is lesser known, but it's equally as important, which is to oversee one of the eight uniformed services in the us government, and that is the United States public health Service. Many people are familiar with the army, the navy, the air force. We also have the US Public health service, which is 6000 officers. They include doctors, nurses, physical therapists, pharmacists, public health engineers, a whole range of healthcare folks. And their job is to protect our nation from public health threats. So when Ebola came on the scene in 2014 in a major way in West Africa, we sent hundreds of officers to West Africa to set up the Monrovia medical unit in Liberia to treat people with ebola domestically. When there are hurricanes or tornadoes, we dispatch officers and deploy them to go help strengthen the public health infrastructure, but also to provide direct care. We deployed thousands of officers during COVID So these officers, I'm incredibly proud of them. They could be doing lots of stuff outside government in the private sector, probably making a whole lot more money and getting working a lot less hard, but they're really committed to protecting the public health of the nation. So I have the privilege of overseeing that services, surgeon general. And those are the jobs that I've signed up for in this role.

Speaker A: Got it. I was not aware of that role. And if I understood correctly, these people, these public health officers that presumably are made up of physicians and I, licensed psychologists and nurses and so forth, you said they could be making substantially higher incomes in the private sector, but the work that they're doing with you is their sole career at this point. They're completely devoted to that or they're doing this as a side hustle.

Speaker C: No, they are full time government employees and members of the public health service. Their day job is often in public health agencies, where they're embedded in communities helping day to day to advance public health. And during times of emergency, we deploy them. And they're extraordinarily well trained, they're experienced at dealing with adversity, but they bring a combination of skill and heart to their work. And you really need both to be effective at public health.

Speaker A: I'm glad that you mentioned the word emergency, because in preparing for our discussion today, it occurred to me that in this list of roles that your title assumes, that scientific information on how to improve health comes first. Then you mentioned emergency. So what I'd like to talk about first is health. Not lack of health, but health. So often we hear about the mental health crisis, but what we're really talking about is the lack of mental health crisis, aka mental illness. And rarely do we hear, for instance, what constitutes mental health. We hear what constitutes mental illness, whereas in the domain of physical health, there's a lot of information out there about how to be more physically healthy, cardiovascular exercise, resistance exercise, yoga type exercise, mobility, et cetera. And of course, some people have physical health ailments, and there's a lot of information in terms of how to deal with that as well. But what I would like to know, before we get into the long list of issues that our nation confronts, everything from obesity to food additives to mental health issues, what is going well? In other words, in the last, let's say, five to ten years, have there been any areas of physical health and mental health improvement in the US at large that we can attribute to some of the public health initiatives directly.

Speaker C: So that's a really good question. And let me just also say about the very first point you raised, that you're absolutely right, that we have operated primarily through an illness frame when we look at health, and in my mind, that's only one half of the equation. So when we are talking about physical illness, for example, as a doctor, I learned how to diagnose and treat someone with diabetes, or with high blood pressure, or with coronary heart disease. But we also know that even if I don't have diabetes or coronary heart disease or high blood pressure, even if I don't have any diagnosable medical condition, I may not be at an optimal level of physical health. Right? I may not be able to, for example, walk around the block without getting short of breath. I may not be able to play with my kids, because my physical fitness and stamina is insufficient. I may not be able to lift my luggage when I go to the airport because I don't have enough strength in my body yet. I wouldn't have a diagnosable mental illness. So I think it's easier to understand there with physical health, that we're not just aiming for lack of illness, we're aiming to optimize our physical health. The same is true with mental health. And I think when we talk about mental health, people think we're just. The sole goal here is to prevent diagnosable mental illness. That is one goal to both prevent and to manage mental illness when it arises. But we also need to recognize there's a whole other half of the spectrum where there are people who may not have diagnosable mental illness but are not operating optimally in their lives. And that's detracting from their fulfillment, from their functionality, like in not just at work, but also in their communities and in their families. And so I think part of the conversation that I want us to have as a country is about how to optimize mental health and well being, and that includes preventing mental illness, but it is much broader and bigger than that alone.

Speaker A: Great. Yeah. I think it's so important that we recognize that treating disease is critical, obviously, but that there's a lot that can be done to improve one's health, even in the absence of any known disease. And you've got all these officers, these incredible physicians and nurses and people at your disposal. My hope is that they would also be accessible for and currently carrying out efforts to transmit information to people about, hey, here are the things that you can do every day, every week, every month in order to make your life as healthy as possible, as well as rushing in under conditions of public health crisis.

Speaker C: Yeah, it's a good point. And it certainly many of our officers do focus on this broader rubric around well being, but it's part of how we need, I think, the broader health system and public health system to operate, even outside of government. And this, I think, will require significant change and shift in how we think about our jobs. Like, when I went to medical school, the vast majority of the focus was on diagnosing and treating illness. It was much, much less focused on thinking about how to enhance well being. And when you ask and talk to people in their lives, it becomes clear that they want to do more than just prevent diagnosable illness. They want to be able to walk their child down the aisle. They want to have the endurance to do that they want to be able to be independent often and carry their groceries or carry their luggage. This is why I think we've got to broaden our focus in public health. And, look, when I came into this role, by the way, I was not expecting to serve in government. This is not part of some 510 30 year plan. When I was a kid, I was interested in medicine, but I always thought I was going to practice medicine like my dad did and like the clinic my mom ran, you know, set up, put up a shingle, see patients, and be a primary care doctor and feel good about the work I was doing. But what happened to me along the way is, you know, I trained in medicine. I got interested in technology, spent seven years building a technology company that was focused on health. I got. I was. I became increasingly worried about the way we were delivering healthcare, and it felt like our healthcare system was broken. People who needed care couldn't get it. It was often too expensive to get care. We were focusing on treatment solely and not enough on prevention. So I started getting involved in advocating for a better healthcare system with doctors around the country when, despite all that, I still never thought I would work in government. But in 2013 is when President Obama's team had reached out to me and asked if I'd be interested in considering the position of surgeon general. And what was interesting to me about this position is it's actually very different from most positions that are appointed by president and government, in that it's supposed to be an independent position. So my agenda, the issues I choose to take on, are not determined by a president or a party. They're determined by science in the public interest. And that's what's what guides me, you know, and that's what. That's what guided me in that first term when I served, and when President Biden asked me to come back and serve as surgeon general a second time. That's what's guided me here, too.

Speaker A: So Biden is not sending you notes saying, hey, could you put some effort into getting messages out about COVID Or could you put more effort into getting your team over to Maui to deal with the tragedy there, which is a long arc tragedy. We get the news in a blast of this happened, the next blast comes in about something else, and we forget that there are physical and mental health crises that are ongoing. And then I have to imagine, then start to overlap with one another. So is it your decision where and how to deploy the financial and human resources? Like, okay, we're gonna put ten people on Maui, we're going to put five people in the central states, you know, going around talking to major organizations about what they need to do to prepare for this winter. Is that how it works or are you getting memos? And in other words, who's your boss? Everyone has a boss. At some level. Mine are the listeners of this podcast. At some level, I work for them. It used to also be my bulldog Costello, but my boss, my wife and.

Speaker C: My two kids who are five and seven, I do what they tell me too.

Speaker A: Got it? Got it.

Speaker C: But how we make our decisions in the office, actually it's a bit different with those two roles. So with the second one with overseeing the commission corps, our 6000 officers, they're the decisions about how and when we deploy. Officers are collaborative, right? So we work with other colleagues throughout the Department of Health and Human Services. We work with people in FEMA, across the administration, but we also work with states. So sometimes states, often, often states will put in a request and say, hey, we need support here, can you help? So we'll work with colleagues across our department to say, okay, we can mobilize our commissioned corps officers, what assets can you mobilize? And then collectively we will send a team out there. So for example, we have officers helping in Maui right now, particularly with mental health needs, which are, I worry, only going to continue to grow over the weeks and months ahead on the other side of the house, when it comes to deciding which issues we engage with the public on, like in this case, mental health has been a big focus area for me on that front. While we certainly are open to suggestions from the public, members of Congress sometimes say, hey, can you help the public understand about this issue? A lot of people have ideas and opinions, but the decision about which issues to focus on, those are our offices. And to me that's important because part of the reason over time, I believe the public came to have some degree of faith and trust in the office is because they hoped that the office was functioning the way you hope your doctor is functioning, which is being an independent source of information for you and a source that has your best interests at heart. That's not being pulled aside by political interests or by other agendas, but the primary agenda is how can I help your health? And so for me, we have to make an independent assessment there and say, okay, where is the need the greatest here? Where can we make the biggest difference? Sometimes we may not build an initiative on an issue and that doesn't mean that that issue is unimportant or that it's not affecting a lot of people, but we have to make hard decisions about where to put limited resources. And so when I was surgeon general, the first time, one of the big areas I focused on was the opioid crisis that we were dealing with, as well as the e cigarette use among youth, because we were seeing a dramatic increase among kids in e cigarette use.

Speaker A: Can I just ask you. Sorry to interrupt, but I think it's relevant here. Has that increase continued, or e cigarette use, aka vaping?

Speaker C: Yeah. So we still see, unfortunately, there's been some improvements, but we still see way too many kids who are using vaping devices early on. And part of what we did from our office is recognizing that we actually issued the first federal report on e cigarettes in youth. We call the country's attention to the fact that this is a crisis. We worked with members of Congress to talk about the kind of action we needed from a legislative and regulatory perspective, and worked with colleagues at the FDA and in government as well. But there are two things that are really most important in guiding our choice about priorities. One is data. We look at what the numbers actually tell us about the impact these issues are having on the population, as well as the trajectory of rise. If something's getting dramatically worse and people don't realize, it might be an area for us to focus. But the other critical factor is what I hear from people on the road. So I try to spend as much time as I can visiting communities across the country, doing town halls, meeting with community members, and just trying to, frankly, just listen to what's on their mind. And that's where I actually get a lot of information as well. That's actually how I came to focus on the issue of loneliness and isolation. It wasn't because it popped up in a report as being the leading public health issue in the country. It was because everywhere I was going in 2014 2015, whether I was talking to college students, talking to retired Americans, talking to parents in rural areas and urban areas, I kept hearing these stories about people who felt like they were all on their own, or they felt invisible, or they felt if they disappeared tomorrow, no one would even care, or they felt like they just didn't belong. And it's heartbreaking to hear that from anyone. It's particularly heartbreaking to hear it from kids who you hope are entering life and looking forward to what comes. But many kids weren't feeling that way.

Speaker A: That is very useful context, and we will get back to the isolation crisis, such an important initiative that I just will. Thank you now for having put out the message on social media and elsewhere about that, because I think one of the questions I have, in light of what you just said is it's clear that you've got your ear to the ground, you're talking to different people, but it's also critically important that people hear from you and know not just what's happening, but that you perhaps want to know where the issues lie and what the actionable steps are that people can take. And I think that we now live in a hyper connected world. So, in fact, I'll just say that one of the reasons I launched this podcast is in 2020. I was going on podcasts talking about things like maintaining sleep and circadian rhythm and stuff from my lab related to trying to adjust anxiety under conditions where I think everyone was anxious and sleep rhythms were disrupted, etcetera. And I was somewhat surprised that I didn't get a warning on my phone, hey, make sure you're getting morning sunlight. I'll get a flood warning. I'll get a warning that I might get a warning, but it's only a test warning. I'll get three of those. Yesterday, living here near the coast, I don't think once during the pandemic did I get a email or a public service announcement saying, hey, you know, if you are going to be indoors a lot, you're going to have to be mindful of maintaining your circadian rhythm, because if you're not, we know, based on hundreds of studies now, that drifts in circadian rhythmicity are a precursor to mental health issues. I mean, in fact, there's a new idea that many, not all, suicides are preceded by a period of disrupted sleep, which kind of makes sense, and it's not causal, of course, but how come during the pandemic, we each and all, as us citizens, did not get an email or a text message saying, hey, these are five things that you need to do every day to try and stay as stable as possible in this very uncertainty landscape that we're in.

Speaker C: Well, it's a really good question, and I think it's a reasonable and a very good suggestion to say that, hey, look, there should be a clear and comprehensive way that we can get messages out to everyone. Like, if we were working in a hospital system and there was a safety issue that came up, there would be an email sent to all the hospital staff members saying, hey, this is something you need to be aware of. So I think it's a reasonable expectation practically, if you go back, though, over the last 2030 years on health issues, there hasn't been sort of an agency or an entity that has sent emails out to everyone. First of all, how to send an email out to everyone in America is not a simple proposition either. Technically, it's challenging. There are some legal issues you'd have to deal with as well.

Speaker A: But you could do a night where you go, CNN, Fox, NBC, ABC, New York Times, Wall street. You could hit the right wing, the left wing.

Speaker C: So that's, yeah, that's really interesting suggestion.

Speaker A: But one video just where they all agree, like, hey, this is important information. So apolitical.

Speaker C: Yeah. So I would say that that kind of messaging, I would say, through traditional media, certainly has happened. You know, and it happened during COVID It happened, for example, when, you know, during the first year of COVID I was a private citizen, you know, in the private prior administration. But I watched both then and at the beginning of the Biden administration, many officials would go out in front of cameras and say, here are three things you need to do to keep yourself safe from COVID And that was a big question people had. How do I keep myself safe? Okay, here are three things you can do. A couple of challenges, I would say here is that. Number one, even if you hit all the major network and cable news shows, you're still not reaching everyone. Right. Because we're living in a society where increasingly people are not watching tv, they're getting their news from other sources. The other thing that's important to know is that attention shifts quickly in traditional media also from issue to issue. And so you might get a clip out at a certain day, or you might get on all the Sunday shows, for example, but the next day that message isn't necessarily there. It's gone. And people's attention has also switched off, too. I can count, and we've logged probably thousands of interviews at this point that we've done with mainstream media, with sort of concise messages about three things you can do to protect yourself, etcetera. And I'm glad we did those. We got to do them. But I think one of the things we don't have right now in the country, and this is, I think, a bit of a health infrastructure challenge, is we actually don't have a quick, efficient way to reach everyone in the country with a health message. Just like what you said, if you wanted to get that message about three things to protect yourself from, let's say, Covid, or three things to do to support your health and wellbeing during a.

Speaker A: Time of crisis or during a time of health. I mean, again, like not just the flood warning, but the daily. Because I do think that most of mental and physical health is the result of daily practices that are, you know, that build on themselves, sort of like compounded, compounded investments. And then, of course, there are acute challenges and chronic challenges that people face. Things of that sort, too.

Speaker C: I think those kind of messages in time of health are absolutely important as well. And I think in the sort of, I think, fast paced, crisis driven environment that we live in, unfortunately, people are often less, are paying less attention to those maintenance and improvement messages than they are to managing the crisis messages. But I think that they're equally as important. But I do think that what you're pointing out is an infrastructure piece that that needs to be built, which is a way for health authorities to reach people with information quickly and comprehensively. I'll just tell you that in the 1980s, when C. Everett Koop was surgeon general, one thing that he had done which was interesting is he had actually sent a letter, a physical letter to all households in America about HIV. A physical letter, a physical letter.

Speaker A: Some of our listeners won't know what that is.

Speaker C: This thing you read about in the history books or something shows up in your mailbox and you open it, and hopefully it's something you want to read. But in this case, he was worried about HIV, about the fact that people didn't know about it. So he worked through, as I understand it, with a member of Congress, found a way to do this from a funding perspective. But it was a very unusual move and one that was never replicated since. And there was never infrastructure or funding to do that again. When I was surgical last, some years ago, and then this time around, one of the things I did do is I was able to send a physical letter to the medical community. The first time, it was about the opioid use crisis and about changing our prescribing practices in medicine so that we exposed fewer patients to the harm of opioids while making sure people who needed them actually got them. And the second time, it was about COVID therapeutics. It was about making sure that when we had data about medicines that actually work, like Paxilvid, that we may actually offer them to patients, made them available to patients, because we were realizing that many people weren't getting offered life saving medications, even though they were in high risk groups. So we were able to find, and again, there, too, had to sort of creatively cobble together resources, funding. This is all sort of behind the scenes government stuff. But the bottom line is what you want in an emergency and what you want I think in the long term is a simple, clear, comprehensive way that public health messages can get out to people. And to this day, what we still have to rely on are one traditional channels, like traditional media, to cover the initiatives we put out, whether it's on social media and youth mental health, or on loneliness, or on youth mental health more broadly, we have to rely on online channels, which we do as well, or we have to look to creative partnerships that we build with people who reach different audiences. And then together we try to get our messages. Our office does all three of these, but it's a patchwork and it's not always ideal, but it's what we do now. I think part of what this reflects is a broader challenge, like in government, but also in society more broadly, which is that we have valued historically prevention and health communication very little. We put the mass majority of our resources into treatment strategies, into getting medications to people, into diagnosis, and that's very important, don't get me wrong, but we are now seeing with mental health just as one example, that if we only focus on expanding treatment and deepening our well of knowledge there and we don't do anything to help people stay well, that we just can't keep up.

Speaker A: Right, because one problem feeds the other.

Speaker C: Exactly.

Speaker A: The kids that are staying. Listen, if I would grown up in today's era, I'd be on my phone and tablet late at night. Cause I was up reading magazines and talking to friends on the phone late at night. So it's not a criticism, but disruptions in sleep, disruptions in circadian rhythm, disruptions, lack of physical activity, poor nutrition, social isolation, I mean, these are all piling the sand much higher in this other side of what you do in terms of. And here I'm obviously stating the obvious, you know, so it's just going to create a mountain of issues on the other side, which presumably has a larger budget, is what I'm sensing, but doesn't. But there's no way that budget is large enough to deal with that. I mean, if somebody's kid, for instance, is trying to address the issue of whether or not to go on prescription medications and or by the way, folks and or change their dietary intake because they feel they might have ADHD, for instance, I mean, what are they going to do? They're going to Google, they're going to listen to podcasts. They should be able to write first to your organization and say what is the highest level stringency data say about these issues? And AI should be able to tell them accurately. And maybe you have somebody chime in for them. I mean, we all pay taxes. I pay federal and state taxes.

Speaker C: Me too.

Speaker A: And to some extent, happily so, because it pays for public works and many important things, police officers, firefighters, et cetera. But if you don't have a channel to communicate with people about what they and their kids and their relatives can do, then to some extent, it feels like it's a cul de sac. It's like, how in the world can we get healthy again or healthier as a country?

Speaker C: The part that keeps me up at night is, and one of some of the hardest decisions I have to make in the office are putting aside issues that we know deserve a lot more time and attention, but we just really don't have the resources to deal with the issues that we have dealt with. Certainly proud of my team that we've worked hard to try to raise awareness of the issues we have taken on, whether it's around social media and youth and mental health, or whether it's around isolation or clinician burnout or other issues like that. But the truth is that there's more that needs to be done, more issues that need to be tackled, and we have to get to a place where we can talk about what I think of as the core pillars of a healthy life, which are sleep, our nutrition, our physical activity, our social relationships, these are all vital elements to living a healthy life. Right now, we're not teaching kids about this in school, but if you think about education and school as a place and a force that should prep kids for the rest of their lives, it should lay a foundation for a healthy life going forward. These absolutely are important elements for kids to learn about. I think it's as important for kids to learn about how to build and maintain healthy relationships in their life as it is, frankly, for them to learn how to read and write. And I know that's a strong statement to make, but it is true in terms of its contribution to their happiness, their fulfillment, their health and their success.

Speaker A: Yeah, I could not agree more. We have a series that's out now with a psychiatrist, Paul Conti, about mental health, not mental illness, about self inquiry and how to use self inquiry and practices that do nothing require a therapist in order to bolster mental health. Of course, therapists can be very useful, but not everyone has access, and not everyone feels comfortable doing that. But we are but one channel. I mean, you are the governing body for this. You're the army, navy and marines, so to speak, of health.

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Speaker A: There's lots more to explore there. We may have to do several of these together, but to touch on all of them, but maybe we could talk about a few of the things that our listeners asked about. When I solicited for questions, I got more than 10,000 responses across social media in a very short amount of time. But there was some redundancy. One of the things that I'm very.

Speaker C: Curious, can I just say on that point, though, I'm really glad that you asked folks to submit questions, and I was really excited to see how many people actually wrote in. But I think it's also just a testament to how you've done such an incredible job of building a channel to the public to let people know about these topics that are so vital to our health and well being, whether it's sleep or physical activity or mental health. And so I just want to thank you for all the work you're doing trying to help people understand more about health. And clearly the fact that folks are engaging, they're sending questions and they're sending comments to you means that you're building a relationship there with a lot of folks. So just kudos to you for doing that.

Speaker A: Well, thank you. The audience of the Huberman Lab podcast is the only reason we do it. I mean, I love learning and teaching, but that's the truth. So they are the podcast. The podcast is them. So thank you for that. There were a lot of questions, and I also wonder about why is it that many food additives and preservatives and dyes and things of that sort that are not allowed in Europe, are allowed in us food products?

Speaker C: That's a really good question. And decisions around food and food safety in particular, are made by the Food and Drug Administration. So that's the FDA. It's a separate independent agency. It's not one that our office is involved in directing in any way. And so we're not involved in those decisions and don't have insight into how they're making, their drawing, their conclusions, but they do it in a process that's guided by scientists, like they do with medications, with devices, et cetera. With that said, I am concerned that dietary practices, the food that many Americans are consuming, are, in fact, not supporting their health and wellbeing, and in many ways are detracting from it. When we look at highly processed foods, one of the concerns I have there is we often see sodium content is very high, we see the sugar content is very high, and there are certainly additives in there as well, that I think, I would love to have more data on the actual health impacts of those. But the bottom line is that a significant portion of our diet is comprised of highly processed foods in America. And that worries me. The other piece of this that worries me are just how much refined sugars are being added to so much of our foods. And most people think that sugars are only added to things like desserts, et cetera. But you look at spaghetti sauces, salad dressings, salad dressings, a lot of these things, which we think of as savory products, have sugar added to them as well. And so we are consuming, I think, unhealthy levels of sugar in our diet. We're consuming a fair amount of additives, given the processed food composition in our diet. And I think part of the reason this is happening, and I want to be very clear, I don't fault individuals out there for the composition of their diet, necessarily, because we have also made certain decisions in our country about what we subsidize, about what's cheaper and more expensive for people. And the cheapest foods, unfortunately, are often the most unhealthy foods, the most highly processed foods. If you are somebody who lives in a low income neighborhood. A number of these neighborhoods don't even have grocery stores in them, which is a tragedy because you can't get fresh produce, et cetera. A lot of times, your shopping, your grocery shopping may be done at a local convenience store, at a 711, or somewhere else that may not have the array of fresh fruits and vegetables that you and your family need.

Speaker A: I don't even think they have vegetables. I think they'll occasionally have some lemons or apples or oranges and bananas. But when I walk into a convenience store, what I see is a pharmacy. I really do. I see alcohol, caffeine, energy drinks that have a number of different things in them designed to stimulate different neuromodulators like dopamine and serotonin. I see nicotine products. I see high sugar, high, highly processed foods. And keep in mind, I was a teenager. I mean, I drank my slurpees, I had my butterfingers. I wasn't Bart Simpson, like in my love of butterfingers, but I liked them. But it was a smaller fraction of what we ate. And when we were at home, those foods were either not available or we certainly weren't allowed to eat them in ad libitum. Okay, so what's clear to me is that the FDA makes decisions about what is safe, what's not safe. But for instance, okay, this last year, there were several papers published in high quality journals showing that if people eat just high, just sweet and savory foods combined, that neural circuits in the brain rewire through process of neuroplasticity. That drives increased appetite and changes the response to healthier foods so that they don't taste as satiating. Okay, that's sort of a duh to a lot of people. But I think it was an important set of findings because it said the brain actually changes in response to the very rich, flavorful foods that are associated with highly processed or even moderately processed foods. That's just a couple of studies. There was nothing in those studies that said if you eat these foods, you're going to develop cancer. But at some point, one has to. As a citizen, a tax paying citizen, speaking on behalf of many other taxpaying citizens, I have to sort of take a step back and say, how long do we wait? Do we have to get a randomized clinical trial about the 500,000 sick kids that grow into sick adults and then run a trial where they go on an elimination diet where they're eating only unprocessed vegan or unprocessed meat and vegetable or unprocessed starch and vegetable. I mean, then we're talking about a 30 year health crisis before we intervene. Why not? I mean, if I were in charge, which I'm not, and clearly I wouldn't survive in a government organization because, well, I got the uniform down. I always wear the same thing, but a uniform. But I wouldn't, because I would want to say, wait, why not err on the side of caution? Why not send out this AI generated text message that tells everybody, in all the languages that Americans speak and can understand, you get to make choices about what you eat. But you should be aware that making your diet comprised of more than 15% to 20% of these foods is potentially going to lead to serious issues down the road. And those serious issues are extremely serious. I mean, the obesity crisis is really a crisis of both body and brain, metabolic challenge that we can talk about. So who sets the thresholds? In other words, why is it that in this country, we have to wait until people start to get really sick and dying and really struggling before something is done in the direction of their health? And I'm not blaming you, I just want to understand, because.

Speaker C: Good question.

Speaker A: The wealthy people I know care a lot about their food sources, and they pay a lot of attention to it. And why aren't we allowing everyone the opportunity to make better choices?

Speaker C: So this is the right question. And this is something I think about a lot because I'm conscious about what I eat. But I also talk to folks around the country and realize a lot of people don't have either the information or the resources to actually purchase healthy food and to know what's going to be good for them and for their families. This is why I mentioned we have a list of issues that we would work on if we had more resources. This is actually one of them, because to me, one of the most common questions people ask is, what should I eat? That's simple, but it's vexing. It's complicated. It's incredibly confusing if you go online and just try to search for information. And it's a classic example of where it's important to have an objective scientific authority that can come in and speak on broad principles around diet, that can talk about what we know and don't know. So here's an important thing. I think a lot of times people may see something as, on the market, they might read lists of ingredients. They don't recognize half of them because they're additives, but they figure, well, if it's there, then it must have been studied for 30, 40 years, and there must be no harmful consequences. But sometimes things are put out there because we have short term data that says that they're okay. And there might be, but there may be a need for more long term data helping people understand, what do we know? What do we not know is important so that people can make decisions for themselves based on how much risk they want to take. The other thing, though, that concerns me here, Andrew, is, look, I'll tell you, I have a bias here. And my bias is that I am worried about the additives and other products we have in food that don't have long term data that's clear in terms of health risk. And so because of that, my bias is generally to think, how can we get people minimally or less processed foods, and how can we get them more fruits and vegetables? How can we make sure that they have that more available to them? But we've got to not only make the information available, but we have to make it accessible. From a cost perspective, if you don't have a grocery store in your community, if vegetables and fruits cost three x, what other foods do, that's going to be a problem to change diet. The other thing we have to keep in mind is that food companies, a lot of them, do a great job of actually trying to get healthy, nutritious food out to people, and kudos to them. But I worry also that theres an incentive also to just try to sell more and more and more of your product. And one of the ways to do that is to try to hack the body to kind of figure out, okay, well, what kind of synthetic additives could I put together here? Or what kind of combination of nutrients could I put together that will get people coming back for more and more and more.

Speaker A: And we saw this in the nicotine industry.

Speaker C: You saw the nicotine industry. You also, I would say another in parallels, you see it in social media as well, where the business model of the social media platforms is built on volume of use. Right. How much time am I spending on the platforms? It's not quality of time, it's quantity of time. Right. So if that's the business model, then you're going to design your platform to maximize how much time someone spends on them, regardless of whether it's detaching from sleep, detracting from in person interaction, detracting from anything else that's healthy, regardless of whether that may be causing certain harms. The business model dictates in many ways how these things are designed. And that applies, I think, to food as well, which is why I think it's incumbent upon us to be particularly cautious with highly processed foods, foods that have additives, and to understand how is this impacting our brain? How is that impacting our satiety? How is it leading potentially to greater ingestion that is healthy, and leading to things like obesity, which have a whole host of other medical conditions, from cancer to arthritis to diabetes and heart disease associated with it? Those are the questions. As a citizen, as a father of two young kids who's trying to bring them up with a healthy lifestyle, those are the questions that I would want to know the answers to. And it's one of the reasons I think these kind of objective reports are so important for the public.

Speaker A: I'm starting to see the scope of the problem, and the mechanics involved in trying to alleviate these issues are complex. I see that they aren't also.

Speaker C: One of the things that is important to do that, though, is you need to have authorities that can speak to these issues, that are insulated from political retribution to explain this.

Speaker A: Amen to that. Yeah, I mean, listen, forgive me for interrupting, but somebody who from time to time, will make not recommendations, but will offer information about potential actionable items, things that people could do or not do, according to a couple of studies that have come out. I mean, I've come under intense scrutiny from my colleagues who are like, wait, that's not a randomized controlled trial. How can you do that? And yet, I know from being in this field for a long time that, for instance, the emerging therapies for PTSD and depression that are now based on federal funding for things like. And I'm not recommending this, by the way, for children or for everybody, but, for instance, the macrodose psilocybin, therapeutically supported legal use of psilocybin for major depression. The data there, they're not perfect, but they're pretty darn good compared to the major SSRI's. But for years, if an academic said the words I just said, they'd lose their job almost instantaneously because they're controlled substances. That's a to do. But then there are a number of things that we're talking about here that are just about making better choices about things to avoid. Right? If people understood, I think that is sugar poison. Well, some of my audience will say sugar is poison. It's as addictive as cocaine. Look, it is not as addictive as cocaine or heroin. It is not, however, if a child or adult is eating very sweet or very savory foods of any kind, consistently if those are not healthy foods, or if they contain unhealthy additives, over time the brain will rewire so that healthy foods don't taste as good, they won't be the choices that people make. And you're going to end up with a sick individual, period. And I don't think we need one more clinical trial funded by federal tax dollars to support that statement. What I'm starting to gather is that you're a very rational, grounded, broad thinking individual. I'm not just saying that because you're sitting here and you're trained in medicine and you understand the science, but that you don't have the means at your disposal to put out a call that says, hey folks, having some sugar, every once in a while it's treating the kids to ice cream, great. But if 80% or more of the diet of our kids isn't made up of minimally or non processed foods, their brains are going to be rewired in unhealthy ways. And you can almost expect that they're going to have some health challenge in the future that may not be autism or schizophrenia, but is going to be a major health challenge, and that is serious. And now is the time to intervene by avoiding certain things. And if you don't want to do it, look, it's a free country at that level, you're welcome to do it, but you'd be better off spending x number of dollars on these healthier foods, because there's also, and we know this from my colleague Ali crumbs laboratory at Stanford, that even the mere knowledge that certain foods are nutritious can lead to more satiety from eating those foods at the level of hormone release, not just psychologically. You're telling yourself, the orange is as tasty and filling as a candy bar, but the understanding of the fact that it is nutritious actually leads to shifts in patterns of ghrelin secretion, et cetera. So people can feel better on a healthier, slightly lower calorie, nutrient enriched diet of healthy proteins and fruits and vegetables. And it's not a mind trick, it's physiology. Anyway, I think I feel your pain.

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

Speaker A: The, you're welcome on my social media channels anytime, really, to get their word out to millions of people.

Speaker C: No, I appreciate that, and I may take you up on that. But I'll tell you that one of the reasons, one of the things we always do, recognizing that when we put out statements that people, one they trust, it's coming from a scientific authority and that it's been vetted. Right. So we put the effort and time into vetting this thoroughly. We check sources, we look at the data, we talk to experts. We think about how to communicate this in the right way. That's the work, the behind the scenes work that we do before we put out sort of reports and initiatives, because we want people to have confidence in what they're hearing. We also know that when we put out initiatives that other people build on them, philanthropists and foundations will then think about, should I fund work in this area? Schools and workplaces will think about shifting some of their practice. Policymakers will also think about legislation that they may want to design based on that. So we want to make sure it's really solid. But the point I was making when I said also that we have to make sure that not just our office, but folks who are in public health and who are in medicine, who are trying to speak to the public about their health, that they are protected from retribution and attacks. This is what I meant, which is that saying things about diethyde, saying things about tobacco, these can be challenging for some folks because there are industries built around these which may not always like what you have to say if it hurts their business model or their bottom line. And they may then lean on political leaders, elected leaders, others to then try to silence you or shut you up. And I'll tell you, I've experienced this in the past. I was surgeon general during my first term. I had issued two key reports. One was on alcohol, drugs and health, about the addiction crisis, and the other was about the e cigarette crisis among youth. I will tell you that there were plenty of people who were very unhappy that I was issuing the first federal report on e cigarettes, folks who felt that, hey, this is going to make folks unhappy. It's going to create political pressure. It's going to create a lot of problems. Similarly with alcohol, drugs and health, there are many folks who said, hey, if you do this, you're really going to upset the alcohol industry. Do you really need to have alcohol in the report? Why don't you just focus on other drugs? Why don't you take alcohol out of the title? All of these sort of concerns are raised.

Speaker A: Are you telling you this? These are people who get paid by the alcohol industry?

Speaker C: No, these are people in government who are reading the tea leaves and who are supportive of the work we're doing, but are saying, hey, you're going to really upset a lot of people and.

Speaker A: Industry, and you're also going to help a lot of people.

Speaker C: Yeah, well, this is what it comes down to. They say, well, and if you upset folks, then they're going to try to fire you. They're going to try to do all these things to which, honestly, like my response to a lot of these and the reason we just put them out anyway was because I said, well, the worst thing that can happen is I get fired. And that's okay. If I go out knowing I did the right thing here, then I'm fine with that. I'm not looking to build a lifelong career in government. I'm not doing this job to get to the next thing on the ladder. This is about serving for the time I can. I want to be able to go to sleep at night, look myself in the mirror and know I did so with integrity. So that was an easy decision for me. But my point is that we have to be thoughtful in these issues, that there are going to be headwinds. I'm sure in your case, for example, you've probably gotten pushback from folks about talking about certain things that may have rankled folks who may have had an interest in those issues. And that's okay. You keep talking about them as you should, and I'm grateful for that. But this is especially important at a time where I think public trust in our institutions more broadly and in science and in medicine have taken a hit over the last few years. And I think it's a time where we have to be even more vigilant, those of us in medicine and public health, to make sure that what we do is based on data, that we're transparent about why we're saying what we're saying, that we're also clear about what we know and what we don't know. So that if recommendations change over time, people recognize that this isn't necessarily flip flopping. You should change your recommendations if the data changes, if the circumstances change. So anyway, this is all part of the work that we've got to do. But to me, this is a really important part of the work. The integrity behind our work in public health is not just about the issue we're taking on today. It's about the trust that we need to rebuild in the field more broadly.

Speaker A: So if I understand correctly, if you were to, for instance, put out a call that says, look, you know, there are food additives that are allowed in the US that are not allowed in Europe, that may be of risk. We don't have enough data at present to say to avoid these things. But here's a kind of a yellow zone, known to be safe, red, clearly known to be unsafe, yellow. We just don't know yet. Not enough data. So here's what my recommendation would be for my children. Yeah, it's free country. There are people that argue it's not, but at least at the level of which foods you want to buy with your own budget, it's a free country. So you're saying that you get messages that warnings about certain things could lead to pushback. But if I have to imagine that there's something, and I'm not a conspiracy theorist, but there has to be either the people that are saying, look, there could be problems are just friction averse. They just don't like anyone to be angry at anyone, or there must be some incentive for things to remain quiet. I mean, certainly the government has not had problems saying to do things or to not do things that upset companies or shut down companies or elevated companies and their success. So I'd like to know more about the back contour of this.

Speaker C: Well, look, I think, and this is not too dissimilar for, I think, what happens in other industries, but it's, whenever you do something, whether it's in the private sector and government, people weigh, what are the pros cons? What's the pushback I'm going to get? How do I deal with that pushback? And pushback isn't always a bad thing. If you get pushback from the public people, hey, that doesn't make sense to me, et cetera. You should listen to that and use it to inform your approach.

Speaker A: But that's the public who your job is to serve. I'm talking about pushback from companies is different.

Speaker C: Right. So when pushback comes from people who have a financial interest in the product that you may be commenting on, then you've got to be, you need to know about that, number one, so that you know how to mitigate it. And while people may take different approaches to this, my approach as a public official, as surgeon general, has been to say, at the end of the day, like, I'm happy to hear from anyone in terms of their concerns or pushback. But the end of the day, what's going to guide my decisions? About what issues we take on, what decisions we make, and what we say to the public is going to be what is in driven by science, in the public interest. And if that means it's politically inconvenient, that's okay. If that means that, you know, something happens, you know, to my job, that's okay, too. You know, like, we look, the bottom line is, life is short. We don't know how much time we have here. We may as well make the time we have count. We may as well do the things that are right and that are going to serve people. That's my simple philosophy my parents taught me when I was growing up. So that's the approach I bring to this. And that's why, if we were to do, let's say, an initiative on diet, I have no doubt that some of the things that we would say would be perturbing to folks who had a financial interest in industry, because I don't think that the current setup in the industry is serving the public well. I think we have made unhealthy foods cheap. That's a problem. We've made healthy foods expensive. That's a problem. We put health, from a dietary perspective, out of reach for millions of Americans. That is a fundamental problem. And we've also disempowered people, but that by not giving them the information that they need to make decisions. So even if you have resources, I guarantee you there are people listening to this podcast and many more people out there who go to the grocery store and just feel confused, like, what on earth should I buy? What's healthy? What's okay anymore? It's just hard to know. And so I think we've done a disservice by not doing more to help the public understand and access healthy foods. And again, it's why it's an issue that was on our list of issues that we would want to work on, because I think that the public health need here is immense.

Speaker A: I have a question about trust in big institutions and public health initiatives in general. The question is about masks. Early in the pandemic, as I recall, we were told that masks were not necessary. Then we were told they are necessary. And I think for a lot of people that flip in messaging landed like a parent telling their teenage kid to always wear a seatbelt. But then you look into the front seat and mom and dad aren't wearing seatbelts. And has anyone who's been around teenagers or has been one, you make that mistake once, you're not making again, and you may never recover. From that particular example. In other words, the public felt like there was a switch of messaging. But what I don't recall happening was a, like a, hey, we got that one wrong. So sorry on us. You know what the new data say? Blank. What I recall was a message of don't and then do. But there wasn't a lot of kind of acknowledgement of how challenging the situation was. It was just a lot of top down mandates. And in my opinion, and this is just my opinion, I think that led to a pretty rapid distrust of subsequent messages from which we still haven't really recovered. And so why do you think it's so challenging for public facing officials to just say, look, doing the best we can at the moment, screwed up before, changing the message now may change again? We're navigating this in real time. It's dynamic. Please stay with us because it goes without saying, there's been a huge chasm around this and related issues.

Speaker C: Yeah, look, it's an important question. And look, I'm always, I want to be thoughtful about, you know, how I comment on what was done in the first year of the pandemic. I was a citizen as outside government, and I don't know what was happening inside government in terms of the decisions that were made there. But I do know sometimes from my experience in Ebola and in Zika, during those experiences we had as a country, that in the fog of war, when everything's coming at you, sometimes it's hard to make the right decision all the time. So I want to give some of those folks who were there in the first year of the pandemic some benefit of the doubt. But I do think that the important thing, the principle, I certainly try to follow. But one, I think that, and we can all do better. I can do better, certainly, too. But I think an important principle for us in public health communication has to be that we're clear that we're transparent about what we know and what we don't know, and then we explain the why to people. So if we're telling someone to do something, why? Is it because there's a lot of data behind it? Is it because it's a sort of expert agreement, best practice? Because sometimes, as you know, in medicine, sometimes when we don't have enough data to guide us on a therapeutic approach, but when the problem is imminent, then sometimes experts will get together and put together expert informed guidelines to say, okay, look, based on our best judgment and the limited data we have, here's what we would recommend. And as the data evolves. We will change and modify those recommendations. We do that with hypertension. Evolve and update recommendations. We do that with lipids here, too. I think that has to be a key part of the approach. I think one of the challenges that I saw many public health officials encounter was even when they went out with comprehensive messages like that, which are hard to fit into a soundbite or into simple posts on social media, often a lot of that wasn't covered. What gets covered is the top line. You know, this is what's being recommended, that's what's being required, et cetera. All the explanation is lost. It's missing. Right. And I think we also are living in a time where people are reading headlines like they're living busy lives. Right. They're not necessarily, you know, always hearing all of the nuance, you know, that's being explained. But I think that that's a challenge. Right. It's like, I know many public officials struggled with how do you deliver nuanced information at a time when there isn't a clear black and white answer to things? But I think the last piece around this is, I think something I was taught early in medical school is to approach your patients with humility, recognizing that even though you have more training than they do, you aren't living their life. You don't necessarily know what they're going through, and you shouldn't assume things about them. Approaching with humility means that you've got to recognize that not everyone's going to be able to follow your guidance. And if they aren't able to, that doesn't mean you criticize them. It also means recognizing that people may have ideas or suggestions for you that may actually improve your recommendations or how you communicate. And so these are the principles, I think, that are important in public communication. But I think that both the challenge of translating nuanced arguments into what's actually covered, that was tough for many public health officials. I think the other thing, honestly, just on a human level, that became hard for many of them. And I'm thinking particularly about local and state public health officials who are on the front lines that I talk to a lot, was they ended up getting attacked a lot and abused a lot during the pandemic. And I don't just mean, like attacked online. I mean, people showing up at their houses, people harassing their children, people threatening their safety. And this was often people who were upset about some of the requirements that were being put down from local departments of health. And you can understand, look over as stressful a time as we've seen recently people lost their jobs. People were losing loved ones. I mean, talk about a stressful time. But I think at a human level, public health officials who were exposed to that kind of abuse and who started to worry about their children's safety, many of them stepped out of the arena and said, is this really worth it to put my family at risk? And that was hard because we lost a lot of good public health people in that respect. So I think in addition to having sort of these core principles of public health communication in place, I think what we also need to restore is an environment where we, frankly, of humility and civility, where we don't attack people who maybe have different views or are coming out with recommendations that are not palatable to us. And I think it's also incumbent upon our leaders in society to not stoke that kind of resentment and violence as well, because that happened during the pandemic as Covid got increasingly politicized. And while that may have been at times done for political reasons here or there, the people who suffered were both the public health leaders who were trying to do the right thing for their communities and the public themselves who weren't able to have a clear, direct channel and a dialogue with their public health officials, because a lot of that ended up getting closed off.

Speaker A: Yeah, I feel like there was a lot of talking down to the dissenters in the general public, and I totally agree that getting violent or harassing people with whom you disagree is totally inappropriate.

Speaker C: Andrew, the one thing just to say about the humility piece, and I'll give you an example here of where I think this could have and should have been done better, is in an effort, for example, around masks, to recommend that people wear masks. And one important thing just to know, is that when it comes to schools requiring masks, those are decisions that are made on local levels. The federal government doesn't mandate masks in schools. It doesn't have the authority to do that. So those are local decisions. But at the end of the day, they were people who did not want their children to wear masks. Right. For a variety of reasons. Some worried about their development, social development. Some worried that it was adding stress to their kids. People had different reasons why they may or may not have wanted their children to wear masks. And one of the things I think that was not helpful was that when there were parents who made the decision, they didn't want their kids to wear masks, I think some of them received a lot of criticism without people necessarily stopping to understand why they may have been making that decision. Because I'll say as a parent whose children were in school, my kids are five and seven. And in the first year of the pandemic, they were doing preschool virtually, which was a nightmare. It was incredibly hard for us, even when they got back to school and the fall of 2021, it was a really tough adjustment for them. And I could understand some of the concerns that parents were having, wondering about, hey, how are these precautions affecting my child's experience and social development? So on the whole, this recommendation may still be, hey, improve ventilation in your classrooms, recommend masking, recommend testing, et cetera. But those recommendations, I think, have to be made in a way that acknowledges, like, the humanity of people who are, may have a different point of view or may make a different decision for their child. And I know that when localities made the decision, in many cases, to require schools and their kids in their district to wear a mask, that puts some parents who didn't want that. I put them in a hard place, right? But I think that our failure to actually have an open, honest, respectful conversation about this, where we didn't feel like we were each being attacked, you know, as parents for our decisions or as community members for the decisions we were making, I think that not only hindered, I think, the response, but I think it actually contributed to this division, the sense of black and whiteness that, hey, it's us against them. And then suddenly, if I was against one measure, then I was against all of them, you know? Or if I was for one measure, I was for all of them, because we just started segregating into sides. And this became a polarized experience at a time where really it should have been a crisis that brought us together as messy as it was. And that, honestly, Andrew, is what I worry about most for the next pandemic. I think we've learned a lot from this pandemic about how to manufacture vaccines and how to develop them quickly, how to distribute them efficiently. It was one of the, I think, most historic and effective vaccine distribution efforts in this country, even though it certainly could have been better. But it was historic by all measures. We've learned a lot about how to do vaccines, therapeutics, a lot of the nuts and bolts of a pandemic response well, but I worry what we are still struggling with is how we build trust, how we communicate with the public, and how we stay together as a country in the face of adversity. Because if we're divided the way we were during COVID during the next pandemic or the next threat that may come from a foreign adversary. That's a huge national security issue for us. And so that's what keeps me up at night when I think about the next pandemic that may come, two questions.

Speaker A: Related to what you just said. First of all, as it relates to vaccines, in my opinion, and I think the opinion of many people out there, that the response to the next pandemic will be heavily contingent on at least some sort of acknowledgement that there are people who at least feel that there have been vaccine injuries, right. To simply say, okay, the previous round with COVID went this way, and now there's now virus x, right? Let's hope not, God forbid, but it sounds like it's coming at some point, and people are going to think to the last time and they're going to immediately say, well, the last time we were told to take a vaccine, some people had a good experience with that, other people didn't. And in this empathy model of acknowledging and letting your moral compass guide and understanding the why behind what people are, are doing and how they're reacting, it seems to me that now would be the time to at least try and understand where they're coming from, even if one disagrees, maybe even. Especially if one disagrees and try and get people aligned now before the next pandemic. And so what efforts are being made, if any, to try and acknowledge that some people really do feel as if they were harmed? I'm not saying if they were or not, but clearly there are people who feel that they or people they know were harmed. Is there an effort to present them with data, to have discussions with them, to try and get people aligned so that the next time around we can be more of a unified front, whatever the necessary response happens to be?

Speaker C: Yeah. No, it's a really important question. And to me, I always go back to sort of first principles from practicing medicine, right. Which is if there is a medicine, you give a patient, and even if it helps 99.99% of patients, but this one particular patient happened to be harmed by it, you go in, you acknowledge it, you talk about it, and you together trot out a path for how you want to move forward. And the path forward might be, yes, let's get rid of that medication, but let's use an alternative. Let's try it, or we can't use that medication anymore. Here are the risks you may sustain, but we'll find other ways to protect you. That's what we would do in medicine. Right. That's what I've done with patients over the years. I think here, too, similarly, when it comes to tracking adverse events from vaccines, this is an area where the CDC and the FDA track and collaborate. And tracking means not just not only collecting reports from the public and from clinicians when they see an effect that may be related to a vaccine, but it also involves analyzing those to see were they correlated or were there actual causation there. Because if today, for example, I felt unwell and I traced back what happened yesterday, and it turns out, hey, I ate this burrito that was out in the sun for way too long, the question is, am I feeling sick because the burrito, or did the burrito just happen to be something that happened? But it's independent of how I'm feeling. Maybe it turns out somebody was actually sick with a GI bug around me, and that's the reason that I'm feeling the way I am today. So the analysis that needs to be done on cases that are reported is important, and it's something that the CDC and the FDA do together. Now, that analysis, I think, is essential to communicate clearly to the public. And whenever I engage with folks in the public, which we do often, and people will talk to me about their experiences with vaccines, I do think it's important to acknowledge what people have gone through. Like some people, for example, like when I got vaccinated for Covid, for example, I felt like I had mild flu like symptoms for a couple of days. It wasn't great. I would have preferred I didn't have those feelings, and then I felt better a couple of days later, and then I moved on. But I acknowledge it didn't feel good to feel that way. There are other people who may have had experiences where they felt that they had more serious side effects. And there may be a question, was that related to the vaccine or not? So I think we have to both hear and acknowledge those. I certainly try to do that. I think it's important to keep doing that across all of government. But I also think it's important for us to help people understand the process that we have to go through to understand whether those are related or not. If you go online and the CDC's site, where they collect a lot of this information and you just purely look at reports that are given of potential adverse effects, you can't sort of take that and say, ah, those are all related to the vaccine. Look at this rate of harm. It's extraordinarily high because we don't actually do that with any other vaccine or medicine. Right?

Speaker A: Sure.

Speaker C: We start there, we do the analysis, and we try to understand what's actually related or not. So I think that's what we've got to do here, too. One last thing I'll say is that it's important, I think, also for us to help put this in context of other vaccines and medicines and interventions that we use. So, for example, just take Tylenol, for example. Most people think, oh, well, Tylenol, it's safe. There's nothing bad happens if you take Tylenol, etcetera. But people who track the data know that Tylenol, by and large, is, generally speaking, a safe medication. But there are people who experience adverse effects from Tylenol, liver damage and other adverse effects, and that data is available. But what has happened in the case of that medication is that the risks and benefits are both analyzed, and then a recommendation is put forward about a generally safe way to use it. And then there's data put out about the side effects, common or rare. Right. But I think sometimes we also forget that a lot of the medicines that we have come to take and just see as normal part of our life, just like any other vaccine, like there's some rate of rare side effects that will happen. I say that because what I worry about in the black and white environment that we're living in is sometimes people will take an anecdote about a potential adverse effect, and we'll portray that as the rule, right? And we'll say, well, look, I know somebody who had this side effect, so nobody should take this because this is what's going to happen to you. If we did that, nobody would ever take Tylenol, no one would ever take ibuprofen. No one would take Nyquil, like, no one would take any of the common medications that we pick up at the drugstore and that we commonly use. So that's how I think we have to approach this, with a combination of, of clear communication, empathic listening, and data and context. Again, that doesn't fit neatly in a social media post, per se, but I think part of what we need to do as a country is rebuild the relationship honestly between the medical and public health establishment and the public. And I think it starts with this kind of communication.

Speaker A: The other question I had about the next pandemic, and the one we just had, is, why not have committees of people of diverse backgrounds, socioeconomic diversity, racial diversity, every aspect of diversity, rather than individuals standing there telling us what to do? For several reasons. One is we are a country of many different people. I think there are dozens, if not hundreds of scientific papers showing that patients follow the advice of doctors that look like them and sound like them or to whom they would aspire to be like, we know this, and yet public health officials typically are unitary. One person telling us, do this, don't do that. This is a good idea. That's a bad idea. I'm but one citizen, but I'm putting up both hands, both feet and all toes and saying that committees, small but diverse committees that people can relate to and feel as if the messages that they're getting are vetted through a common understanding.

Speaker C: Yeah, so it's a really good suggestion, and I couldn't agree with you more that a diversity of voices is really important to get a message out. And during COVID actually, that's one of the things that our office actually was helping to build, was something called the community corps, where we actually, we recognize so very clearly. And this is something I. I came to see as a doctor. Sometimes I was the right person to message to a patient. Sometimes I wasn't. Sometimes it was the nurse. Sometimes it was the medical student. Sometimes it was an administrator or the social worker who had different background, different life experiences. Part of this work is knowing when to step up, when to step back. But the community corps that we were building was a really diverse group of people. A lot of them had public health backgrounds, but a lot of them were community leaders who understood health, even though they didn't have formal training. But they're people who knew their communities, and they had the trust of their communities, and they understood what was going on. They wanted to be helpful. So we brought them together to say, okay, look, here's what the science is telling us. Here are the general recommendations. Here's what we would provide. You ask us any questions you have, like, if there's something we don't know, we'll go back and look it up. But you're the leaders in your community. They should be hearing from you about these messages. And then those folks went out and actually, we worked closely with them, collaborated with them. They would design the messages for their community based on what they thought made sense. They weren't taking what we said word for word, and we didn't want them to. But to me, that kind of diverse approach is what we need more of. Now, I'll tell you what I would have liked. I would have liked if more media networks put those folks on tv and got them on the radio, because it's important that many of them were showing up in their communities, were knocking on doors wherever, doing local podcasts, etcetera. And that was great. But I would have liked more of their faces I carried on tv. Right. So that's a place where when we talk to media, and when I talk to folks in media, one of the things I encourage them and push them to do also is to say, look, if you can take more of these diverse faces and voices and put them out there, that's actually good for the community. And it also helps people see that it's not like one or two people who are sort of pushing an agenda here. This is like a, the public health community is big. It's broad, it's diverse. It has a lot of voices. And the more voices we can hear from as public, the better off we are.

Speaker A: Yeah. Hear, hear. Again, I genuinely hope and pray that we don't have another pandemic. But if and when we do, I hope there will be committees rather than individuals. I know we, this is a thing in this country. We like the idea that one person's going to save the climate, one person's going to save transportation, one person, the coverage, the person of the year type approach. But then we get frustrated when that person does things or makes decisions that we don't like in their public or personal life, and then it all seems to fall into division. And I just feel like we're not talking about groups of hundreds of people, but small groups. So I think we're aligned in that way.

Speaker C: Yeah. And look, there's, I think, a notion that I think sometimes we do want, like the one person who can not only necessarily have all our trust and we can look to, but also who we can hold accountable if something doesn't quite work out, if we don't like something. And while I get that sort of mentality, I think that in this moment, especially when we're trying to rebuild trust, I think it's important for people to know that what they may be hearing in terms of medical or public health recommendations, it's important for them to know how broad an audience that's coming from, or broad a group of experts. Right. There was a lot more broad agreement, for example, during COVID and during Ebola, during Zika, on public health recommendations. But you wouldn't always know it if you turn on the tv because you were seeing the same couple of faces. So I think we have to certainly diversify that. One other thing I'll tell you that's important here is I think we have to also think about how we fund groups on the ground that are doing the, the hard work of getting public health messages out. Because one of the things that those groups often would tell me, and these are, I might say, the groups I'm talking about the community organization that spent years in a neighborhood getting to know families, where folks recognize them when they're walking down the street. They're like, oh, yeah, that's the person from organization x. They understand us. They get us. They're looking out for us. A lot of those organizations had spent their resources helping the community, getting to know the community, but they didn't have sophisticated mechanisms to apply for grants. For example, they didn't have grant writers who had done this a thousand times. So historically, those groups have a hard time getting support and funding. So I'll tell you one interesting thing my wife did, which I certainly was very proud of, is she was helping to build an effort and to build a nonprofit organization with a couple of colleagues. That organization of people who knew how to get money, how to apply for grants, how to get foundation support, but who also had the wisdom to know that the most important they could do was to give portions of that money to groups on the ground. So they saw themselves as an organization that channeled money to groups that had trust, and they executed their mission that way. And that was very effective. And I think we need more of that. When it comes to disseminating funding, one thing I think many people may or may not appreciate is that when you, it's actually hard from government to put out a lot of money at once and to do so quickly. Right? Like when you've got a lot of funds that you need to get into communities, what happens is the federal government often will give it to states. States will then give it to local communities to, like, the local department of public Health, potentially. And then they will look to distribute it to others. That takes time, but it also means if you're not connected to that network, if you don't know your local department of health or you're not connected to the state department of Health, sometimes it can be challenging to figure out how to get the money. So I think we need more operations like what my wife and others have been building to try to get those funds directly to the folks who don't necessarily have the most fancy grant writing operation, but they have the relationships, because at the end of the day, it's those relationships that create the trust. It's a trust that allows life saving information to get to people. And that's the link that's missing.

Speaker A: Very interesting. Pharma. Big pharma. I got a lot of questions about whether or not big pharma is on the take for every public health initiative. Now, as somebody who understands a bit about and certainly believes in the use of certain prescription medications, I find most questions about, quote unquote Big Pharma to overlook the fact that there are thousands, if not hundreds of thousands of medications that save lives and enrich people's lives that are prescription drugs. I also believe my audience knows, I say it over and over again, that better living through chemistry still requires better living. We still have to get our sunlight, get our sleep, social connection, good nutrition, exercise and all those things. There's just no pill that's going to replace those. But I think it's a valid question that people are asking, is there a direct relationship between big pharma and public health initiatives in a way that should have us concerned about the messaging that we're getting at times and the fact that the United States consumes the vast majority of drugs for mental health, for instance, as compared to other countries? So that's one question, and then I want to dovetail into that question. And what are your thoughts on the fact that there's a history of the tobacco industry being very interdigitated, shall we say, with government policies in ways that had us basically injure, if not kill, millions of Americans, and then eventually say, you can't smoke near a hospital, you can't smoke anywhere, there's very few places where you can consume tobacco products. That kind of relationship and financial incentives and then a lot of backpedaling later, I think war on people's trust. So how should we frame the relationship between the pharmaceutical industry, government, and public health initiatives in a way that is at least halfway functional?

Speaker C: Look, I understand where the concern and suspicion comes from, right. Look, I think it's important that public health initiatives and medical advice is independent of the influence of industries that may seek to profit from what's being recommended or from medications that are being prescribed. And we, look, we have a history in medicine, right, of doctors who were given gifts and vacations and all kinds of fancy things by pharma companies in an effort to influence what they prescribed. That was really problematic. And now we're seeing a lot less of that, which is good. A lot of rules are being put in place by medical societies and professional societies and by academic institutions to say this is an unacceptable way to practice. And that's really important, because I do think that human psychology is that sometimes we underestimate how much we're influenced by incentives. We think, yeah, I'm getting that, but I know how to make independent decisions. But at the end of the day, we're human and we're influenced, or it's a great drug.

Speaker A: It could be. Wow, this is a drug that's really helping my patients. I'm happy to recommend it to them.

Speaker C: Yeah. So I want to separate one thing, though, like taking money from pharma companies. As a physician, I think is highly problematic. I think it's hard to say that it doesn't influence practice. Maybe it doesn't for some people, but it's really hard to know who those people are. I do think that separate from that, you can be a physician who prescribes medications because you believe they work. Look, as a doctor, I have prescribed many antibiotics during cases of infection that have helped my patients, and I would prescribe those again. I am glad that those exist. In many cases, they've saved the lives of patients I was caring for in the hospital. So that's what should drive us, is does the data show that they work and does our patient need them? Right. That's what should drive our decisions when it comes to public health recommendations. Here, too, I think a similar principle holds, which is that I don't think that pharma money should be influencing our public health decisions, which means that it shouldn't be funding our public health organizations that are making recommendations. Certainly, I know this is obvious to you, but I'll say, just to be clear, for everyone who's listening, our office doesn't take any money from industry. Not just pharma industry, from any industry. The money that we get is allocated by Congress. At the end of the day, it's taxpayer money, and that's all we get. And that's important. We don't want money from pharmaceutical companies, but that's important because people need to know that these decisions are not being made for financial gain. That's being said. There's a broader concern I have, Andrew, which is I think that we have become a pill for every problem society where we look for a quick fix of a medicine for every challenge that we may incur. And sometimes, yes, I'm a believer that if science helps us create medications that can help solve disease, we should use them appropriately. But I think we discount heavily the behavioral changes that we need to make, the more broader societal and environmental changes that we need to make that influence our health. Like our food environment matters for our health. Our decisions about how physically active we are matter for our health. Whether or not we sleep matters for our health. And all of these impact our mental health and well being as well. And so when I think about that bias, that to me, is not always stemming from money that came from a pharmaceutical company, although I think it, the ads that we see all the time from pharma companies, I think, try to convince us that, hey, just take this pill once a day and all your problems will go away. But I think it's more complex than that. And I think that even in the healthcare setting, if you're seeing a patient who has pain, who's having intense pain, it feels easier sometimes to prescribe a medication for that pain rather than trying to deal with non medication based approaches or try to get the deeper origins of the pain. I'm not saying that's what doctors do all the time, but I'm saying that we're living in an environment and a broader culture where we, I think, increasingly reach for something that we see as a quick, immediate fix. And again, don't blame people for that. We'd rather take a quick fix over something that's going to take a long time. But I think it is selling us, I think, sometimes a false hope, which is that that's all we need to solve our problems. And I think a lot of times you need more. You need the behavioral changes, you need the environmental changes. That's one of my big concerns in terms of how we communicate about health.

Speaker A: Would a potential solution be this idea of small committees? So let's say somebody is experiencing chronic pain, localized or general, that they would go to their general practitioner, but in the room would also be somebody who understands somatic medicine, trained clinical psychologists who understand somatics, that the body and the brain are linked through the nervous system, and could also assess possible psychological roots of the issue. And then somebody in the room who can make behavioral, nutritional, maybe even supplementation based, safe supplementation based recommendations, and then the physician who can say, and in addition to that, I think the person should have on hand a five milligram dosage of a prescription drug that if they need it, they could take. And I think it would provide a lot of protections against potential adverse effects of any one of those things. In isolation. There's great protections in having people meet in groups for lots of reasons, and the person would feel very well cared for. So again, small committees of people with diverse expertise pooling together to treat people from, for lack of a better word, a more holistic perspective. Why not?

Speaker C: I mean, you're describing the dream. I think that's exactly what we need. Interdisciplinary teams that can provide integrative care, recognizing that in this day and age, there's not one person who has all the expertise to help us figure out a how to best manage our health challenges. I think what we have not figured out are a couple of things. Number one, who are all the right people who need to be in the room, or the sort of virtual room, if you will. The second is how do we create a structure, a healthcare system, where that can actually happen with efficiency, where it can be reimbursed appropriately, but that's what we should be doing. And then the third leg of that is the group experience for patients. And there's increasingly more clinics and healthcare systems around the country that are working on creating group experiences where patients who all, let's say, are working on their diabetes come together, let's say, once a week, and they meet with the healthcare practitioner. That might be in addition to their individual appointments. But there is so much power in groups coming together, groups of patients who can find community, who can help each other, learn from each other as a experiences that's highly underutilized right now in medicine. But to really do this well, Andrew, I think, means that we have to pull back from the model we have had for years in medicine, which has been a very highly individual type model, which says, okay, you go to your doctor, you see your doctor one on one, you get everything you need. Maybe you need to go see a specialist, okay? Then you wait a few weeks, get another appointment, drive 30 miles, go see somebody else. Maybe they're connected to the electronic health system, maybe they're not. Maybe they know what was discussed, maybe they don't. Maybe they'll call and talk to their primary care doctor, but maybe they won't because they're too busy. And then you as a patient are stuck trying to piece all this together.

Speaker A: While often in pain.

Speaker C: Yeah.

Speaker A: In physical and emotional anguish. I'm not referring to my own experience, although I've had mild examples compared to what other people have dealt with. But people with chronic pain are irritable for understandable reasons. I mean, it's. Or maybe somebody's close veering towards suicidal depression. Then there's the interpersonal effects. I mean, I feel like the crisis is one of a lack of efficiency and thoroughness. And again, I'm not throwing stones at the medical profession. I, like you, believe that it's a collection of mostly well meaning people trying to do their best. But the specialist model and the referral model is incredibly cumbersome.

Speaker C: It really is cumbersome. And like you look, having worked with many medical professionals over the years, these are colleagues who I deeply admire. I mean, they're there for the right reasons. They want to help people alleviate suffering, but they, too are feeling burned out and frustrated by the inefficiencies of the system. Because I'll tell you, one of the greatest contributors to burnout for doctors and nurses is a lack of self efficacy. It's seeing a patient who has a problem in front of you and feeling like you can't get them the help that they need. That is the greatest paper cut, if you will, to the sort of spirit of clinicians. And many find themselves in that circumstance where they either find that they know what's needed, but the system is throwing up prior authorizations or other insurance hurdles and preventing their patient from getting that care, or they are kind of at the edge of their expertise. Right. This happens to pediatricians and primary care doctors more broadly, all the time with mental health. Right. Most of the mental health care that's delivered in this country is delivered in primary care offices. Now, primary care doctors didn't necessarily train specifically and only in mental health, yet they find themselves having to manage a lot of that, including increasingly complex substance use disorders and treatment resistant depression. And they need help figuring that out. But if you don't have a lot of resources to get that referral, collaborate with mental health professionals, and you're stuck on your own figuring that out. And so I think the pain is being experienced mostly by patients, but also very much so by clinicians. And that's why that overhaul is needed. And I think, look, a lot of this is, you know, I'm not a healthcare economist per se, but I will say that a lot of this, I think, is tied into the business model that we built around medicine. The notion that, you know, we're paying individual people for individual services and individual procedures that are done. And while that has some merit in some cases, what we really care about is that the person is getting efficient, integrated, multidisciplinary care overall. When health systems, for example, come together and say, okay, rather than focusing on the amount I'm getting reimbursed for every procedure, we're going to take more of a value based approach here where we say, okay, we've got a certain amount of money to care for certain people. What's the most efficient way for us to provide them care? Recognizing if we don't do that, it's not only bad for them, but our costs in the long term will go up because we're not getting reimbursed for every procedure. We're getting reimbursed for the care overall care that we're taking for a patient. So there are more of these value based models that are being adopted. Certainly in 2010, when the Affordable Care act was passed and when other measures were taken in the Obama administration in Medicare, that really pushed valuable payment models forward. And again, they're not perfect. They need their own tweaks. But I don't think that the existing financial structure that we had in medicine was serving us in terms of delivering the kind of multidisciplinary, integrated, efficient care that we increasingly need.

Speaker A: Tough problem. But through recognition of tough problems comes good solutions. That's my belief. I'm an optimist. At the end of the day, you mentioned mental health. Lately, you've been increasingly vocal about the crisis of isolation.

Speaker C: Just 1 second, Andrew, before we go there, one thing about the tough problems, you're exactly right. And the problem is the longer we take to acknowledge and address these tough problems, the more entrenched the interests become that profit from the status quo. So if you look at the private insurance industry right now, there are so many challenges we have right now. Patients and clinicians saying that they know what care is needed, but it gets denied. They know what care is needed, but prior authorizations get thrown up there and required even for a medicine that clearly your patient needs urgently. I've had the experience myself of having a family member who has needed a medication for an urgent situation and then being told that the pharmacy will not fill it because it requires a prior authorization. But that can't be processed until the weekend is over because no one's in the office to approve the prior authorization. And you're thinking to yourself, does this make any sense? Like, this is an urgent situation. My family member needs this medication. I've also had the experience as a doctor of fighting for my patients who have been denied care by an insurance company, being on the phone saying, I'm sitting here in front of my patient, I know that they are sick. I know they can't go home. I know they need to be in rehab. There's nobody literally to help them at home. But then not having the rehab bed approved by somebody who's not even there. Right? And there's also just a practice that we've seen time and time again where insurance companies will also just burden clinicians with more and more requests for information before they will agree to reimburse for services that have already been delivered for a patient who needs them, which is just creating more and more barriers, hoping that if you're a small time doc out there who's got a shingle that you put up, you don't have a lot of resources. How are you going to keep fighting all of this and sending more and more paperwork, and eventually you'll just give up? We have a lot of problems right there. In an industry that should be delivering care often is doing good things, but too often, I think, is allowing barriers to be put up to the care that's needed. And this is particularly true with mental health. I know we're going to talk about that, but mental health care has just been such a difficult thing for people to get in our country. And part of the reason, there are many reasons, but one of them is that insurance companies historically did not reimburse adequately or in the same level for mental health care as they did for physical health care. Or if they did, they would only reimburse for a limited number of sessions that you could have. But how, if you're a mom out there who sees her child struggling with depression, you're really worried. You don't want to be told, you know what, you can only get three sessions. That's it. What are you supposed to do after three sessions? What has happened is that even though in 2008, there was a law passed called the addiction equity and mental health parity law, even though that was passed to try to close that gap, there were many ways that insurance companies were skirting it. One, the law wasn't even being adequately reinforced for many years. But two, insurance companies sometimes would say, okay, we're reimbursing adequately. But when you look in the network, they had very few providers, so you really couldn't access somebody. That was a problem for patients. And then the other challenge is that they would say, okay, you can see somebody, but you've got a complete this prior authorization, have that completed by your primary care doctor, et cetera, again, throwing up more and more barriers. So very recently, in fact, just a few weeks ago, President Biden just announced that we are from, as an administration, putting out a proposed rule to actually strengthen the mental health parity law to prevent some of these, what I think of as abusive practices because they're preventing people who need care from getting it. And if you've ever been, as I know many people have been who are listening to this, if you've ever been in a situation where you or somebody you love has struggled with a mental health concern, what you need in that circumstance is help. You don't need to be filling out paperwork. You don't need to be waiting three months to actually get care. You don't need to show up and be told only, you only have two more appointments. You need to know that help is there when you need it. And a lot of these denials are being issued to people who have done their part of the bargain. They paid their premiums. They've held up their end of the bargain, and care should be there for them when they need it. So anyway, this is something that upsets me a lot because I have seen too many patients over the years struggle without the care that they deserve and should get because of barriers that are being thrown up by industry. But I say all that just to say that when you take on big problems, you will run up against entrenched interests. And that's a fight we have to take on. We can't shy away from it. We can't say, you know, this is politically too difficult. Like, one of the things I'm very proud of is that we're finally negotiating on drug prices through the Medicare program, something that should have been done decades ago, but it's finally happening now. The administration just decided this has got to happen. It was passed by Congress. This is good. And it just, it makes no sense that we would pay more than we need to and pass the cost on to taxpayers when we can negotiate. And we got to get, look, you got to, if you're collecting taxes as government, you should be doing your best to make sure every one of those dollars is being spent well. Right? Because somebody took money out of their paycheck, didn't use it for their family, didn't use it for their kids, and they gave it to the government for good reason, because that supports first responders, police officers, a whole bunch of services that we need. But the response being in government is to make sure that money is being used well and to pay more for medications than we should. Makes no sense at all, especially for patients and taxpayers.

Speaker A: So clearly some steps in the right direction are occurring. While on the topic of mental health, let's talk about the isolation crisis. What is the isolation crisis? What aspects of mental and physical health is it impacting? And then perhaps most importantly, what can we each and all do about it?

Speaker C: Well, this is one of those issues that if you had told me, Andrew, ten years ago, hey, you and I are going to be sitting here talking about loneliness and isolation, I would have said, I don't think so, but I was really educated by people I met across the country about the fact that this was a real problem. And the truth is, it was familiar to me because of my own personal experiences as a child. I struggled a lot with a sense of loneliness and isolation. I was really shy as a kid. I was pretty introverted, and I wanted to make friends and hang out with other kids. But it took me a while to actually build those relationships. So I spent a lot of time feeling left out. You know, there were times when I would, like, in elementary school, there were days where I pretended I had a stomachache and so my mom wouldn't make me go to school. And it wasn't because I was scared of a test or a teacher, because I didn't want to walk into the cafeteria one more time and be scared that there was nobody to sit next to or that no one would want me to be at their bench, as I know what it feels like. And I also know what the shame is like, because I never told my parents about this. I never told anyone about that, because even though I knew my parents loved me, I just felt like, hey, if I'm feeling this lonely, it means that something's wrong with me. I'm not likable. I'm not lovable. It's got to be my fault in some way. It was only years later, Andrew, when I talked to friends from grade school, that I realized that a lot of them were feeling the same thing. We were all struggling by ourselves. No one really knew it. And I came to see a lot of this as a doctor when I was taking care of patients. And I never took a class on loneliness in medical school. It wasn't part of our residency curriculum. Yet when I showed up in the hospital, I found that the patient who had come in with a diabetic wound infection or who had come in because they had had a heart attack, when I sat down and talked to them, often in the background, they would talk about how lonely they were. Sometimes I would ask them, hey, I need to have a difficult conversation about your diagnosis. Is there somebody you'd want me to call to be with you during this time? Too often, the answer was, I wish there was, but there's nobody. I'll just have the conversation by myself. But it was when I was surgeon general. I realized that those experiences weren't limited to me and my patients, but they were incredibly common. And two things I learned when I dug into the data, Andrew, was number one, that loneliness is exceedingly common, with one in two adults in America reporting measurable levels of loneliness. But the numbers are actually even higher among young adults and adolescents. The numbers among youth, actually, depending on the surveys you look at, are between 70% to 80% who say that they are struggling with loneliness. So that's the first thing that I learned. But the second thing was how consequential loneliness was. I used to think loneliness was just a bad feeling. What I came to see in digging into the scientific literature was that feeling socially disconnected, being lonely and isolated, was actually associated with increased risk of depression, anxiety, suicide, but also an increased risk of cardiovascular disease, of dementia. And these are not small risks. We're talking about 29% increase in the risk of coronary heart disease, 31% risk. And the increased risk of stroke, 50% increased risk of dementia among older people, increased risk of premature death. And the mortality impact of loneliness, by the way, and loneliness and isolation is comparable to the mortality impact of many other illnesses. In fact, it's even greater than the mortality impact we see associated with obesity, which is something we clearly recognize as a public health issue. So you put all this together, and for me, one of the key takeaways is that loneliness and isolation are critical public health challenges that are hiding behind the curtain, behind this wall of stigma and shame. And unless we talk about it and address it, unless we reconcile what's been happening to us over the last 50 years, where fewer and fewer people are participating in community organizations, where more and more people are feeling isolated, then we're not going to be able to repair the fraying foundations of society, which are grounded fundamentally in our connection to one another.

Speaker A: You mentioned community organizations. Could you elaborate on those? Growing up in the seventies and eighties, I was exposed to, like, community soccer teams, swim team. There was a community pool. These were all public things. There were churches, synagogues, and mosques. Are we not seeing as much participation in those types of organizations anymore? And what other types of organizations are out there that come to mind when you think about the isolation crime?

Speaker C: Yeah. So there are several factors that have led to us being as isolated as we are. One of them, as you mentioned, is the decline in participation in community organizations. This isn't a recent phenomenon. This has been happening over the last half century in America. We've seen lower participation in faith organizations, in recreational leagues, in service organizations, and other community groups that used to bring us together. I think we can talk about the reasons why that has been the case, but one of the key consequences of that is that people don't have places where they can come together and get to know one another, especially across differences. So we actually associate more and more with people who are like us. But this has also been fueled by a few other factors that are going on at the same time. One is that just from a cultural perspective. As modernity has arrived, not just in the US, but in other, other countries, we've seen that people are more mobile, right? They move around more. We don't always stay in the community that we grew up in. We tend to. Even if we move somewhere else for a school, we may go somewhere else for a job. We may change jobs and move somewhere else. We are leaving behind communities that we grew up with, that we went to school with, that we worked with. And I'm not saying that's all a bad thing, right? We have more opportunities, and that's a really good thing. But I think one thing that we have not accounted for is the cost of these changes. If we know what the costs are of certain actions, we may still take those actions, but we may find ways to mitigate the cost. We may, in this case, invest more in our relationships, be more conscious about reaching out to other people, going to visit them. But that has been a quiet but devastating consequence. The other pieces with modernity is that we have more convenience in our life, which means that we also don't need to see other people to get certain things done, like buying groceries or mailing an item out or getting something from the store. I can sit in the comfort of my home and have everything just come to me now. On the one hand, that's incredibly efficient, right? But I think efficiency is an interesting thing because it's only one factor we should be considering in our lives. There, too, we have to ask the costs. And one interesting thing about COVID as many people in the first year of COVID when we were all separated from one another, when we finally came back together, and I had so many people who said to me, you know what I expected to miss? My parents and my siblings and my friends not being able to see them. What I didn't expect was missing the strangers that I saw at the coffee shop or the folks who I ran into at the grocery store, or seeing neighbors as I walked down the street, like, I actually miss that more than I thought I would. So we have lost out on some of those interactions and those loose ties. But the final thing to keep in mind also is about what is happening with how we are using social media technology, which I think has fundamentally transformed how we interact with one another and how we see ourselves and each other. And this is particularly true for young people who are growing up as digital natives. But what has happened there, I worry, is that, and it's not that social media is all bad. Just to be clear, technology. Look, I'm a believer that in technology, broadly speaking, user of technology. I spent seven years building a tech company. I'm a believer in tech, but I think whether technology helps or hurts us is about how it's designed and ultimately about how it ends up being used. And what we've seen with social media as well is that for many people, it ended up leading to in person connections being replaced with online connections. We came to somehow value and almost seek out more and more followers and friends on social media, feeling like somehow that made us more connected. But the nature of dialogue also changed. Like, as human beings, we evolved over thousands of years to not just understand the words someone is saying, but to hear the tone of their voice, to see their facial expression. Like you and I are sitting across, and we're both processing our body language, right? And I'm seeing you nod your head, and I'm seeing your eyes focused. Like, all of that matters to how we communicate. But also like, you and I are less likely to say something hurtful right now to one another because we can see each other. If I said something hurtful to you, I probably see the pain or consternation on your face, and that might give me pause, right, when you're communicating online with other people without any of that information or with any of the sort of barriers, if you will, that make you pause before you hurt someone, it leads to a very different kind of communication, one that can be quite hurtful at times. And I also think that one thing many people don't recognize is that to communicate with somebody else and reach out and build a relationship with someone, it actually takes a certain amount of self esteem to do that. You have to believe the other person's going to want to hang out with you. They're going to see something valuable in you. And for many young people, what has happened, and I think, frankly, for many older people, too, is their experience on social media has shredded their self esteem, as they're constantly comparing themselves to other people. Like when you and I were growing up in the eighties, we compared ourselves to other people, too, right? People have for millennia. But what's fundamentally different now is that in a given day, you can compare yourself to thousands of images that you see online. That's actually literally what young people tell me. I do roundtables with college students and high school students all the time around the country, and the three things they tell me most consistently about their experiences, social media is it makes them feel worse about themselves, worse about their friendships, but they can't get off it because the platforms are designed to maximize the amount of time they spend on them. So you put all of this together, and I think what has happened is that we're talking more, but we understand each other less. We have a lot of information, but we're lacking in the wisdom that comes from human relationships. And I think that that's really hurt us. We see it certainly in the data that tells us about mental and physical health outcomes. But there's also the human suffering component. Andrew. It's really heartbreaking for me to travel around the country and to hear from people of all ages, often in quiet whispers about their struggles with isolation, about how they feel like they just don't matter at all, about how they feel like they just don't have a place where they belong. And these are people on the outside looking perfectly fine, right? They're posting happy things online. To the folks at work, they're seeming like everything is going great. This is what I always tell people. Loneliness is a great masquerader. It can look like withdrawal and sadness. It can look like anger and irritability. It can look like aloofness as well. And so it's only when we stop to ask someone how they're doing, when we take pause for a moment to maybe reflect on what's happening in their life, that we realize that, wow, the majority of people in our country are actually struggling with loneliness.

Speaker A: Yeah. I'm a firm believer that our nervous system evolved under conditions of close interpersonal and direct connection. And to suddenly throw a technology in front of ourselves that deprives our nervous system of its normal development is clearly going to lead bad places. It's also clear to me, based on what you just described, that when we go on social media, we see something, but they don't really see us. Hence, perhaps why people get aggressive in the comment section. They want to be heard. We want to be seen. I think all of us want to be seen and see other people, and social media doesn't allow for it so easily. I also know that a lot of young people will congregate with their friends to play video games online. But that's different. You're essentially showing up as an avatar. And when we were kids, we also played different characters in our games, but, oh, so different. Now, do you think that there will be a youth rebellion movement against these kinds of technologies? I mean, there's a long history of young people rebelling against the stuff that's been put in front of them, and they're like, nope, no more. We're going to rebel. In fact, that was the way that youth overcame the. The nicotine epidemic, if you recall, it was the advertising pitching them against or pitting them, excuse me, against wealthy, cackling older men in chair, in rooms, counting their money. That was what actually was successful in getting kids to not smoke, because kids have a rebellious streak, as opposed to when they were told, hey, smoking is terrible for you. Your lungs are going to fill with cancer. Kids didn't stop smoking. Teens didn't stop smoking. Rebellion has been baked into our nervous system in the adolescent and teen years. So do you see a rebellion against this social isolation? Are kids going to start putting away their phones and hanging out together again? And that's going to rescue us? And that's a way of saying, what can we do for them? What can they do for themselves, and what can we do as adults? Because there are a lot of the silent suffering is the thing I also really worry about.

Speaker C: Yeah, so it's a good question. And I think there is already a movement that's building among young people to create distance between themselves and their devices, and particularly social media. And it's cropping up in different ways. I'm meeting more and more, some of these are organized efforts, but I'm also meeting more families where the parents and kids together have decided that they're going to delay using social media and, you know, till past middle school or in some cases even later, or where they're deciding that they're going to draw boundaries around social media use, or they're going to replace their smartphone with a dumb phone that allows them to do things like text and make phone calls and use maps and all that stuff, but doesn't necessarily have social media apps on it. Now, this is still a small minority, and we're dealing with a bit of a network effect here. Right. Because if you're the only one who's nothing on social media in your middle school class, and you might feel left out, which is why it's so important for parents and kids to actually do this together. But I do think that, to use your analogy with smoking, that one thing that I think many young people bristle against is this notion of being manipulated and used for the profit of a social media platform. And the reality is that, again, we've talked about how the fundamental business model, or most social media platforms, is built on how much time you spend on those platforms. That translates to ad revenue, and that translates to the bottom line, whereas what I care about as a parent, as surgeon general, is about how well that time is being spent. Is it actually contributing to the health and wellbeing of a young person, or is it not, is it actually harming them? And this is where I think, when I go out and talk to young people about this. Number one, I'm so impressed by a lot of young people because they already have a lot of these insights. They're the ones living it. They're not thinking that this is all perfect and it's all a pure benefit here. They're the ones telling me that it makes them feel worse about themselves and their friendships. But they are also having a hard time getting off of it, because, again, of how these platforms are designed, about a third of adolescents are saying that they're staying up till midnight or later on weeknights using their devices. And a lot of that is social media use. And this takes away from sleep, which we know, and you know better than anyone, is so critical to the mental health and wellbeing of all of us, but of young people in particular who are at a critical phase of development. The other thing that is very concerning to me is nearly half of adolescents say that using social media has made them feel worse about their body image, as they're constantly comparing themselves to others online. And we used to think of, this is just girls who are experiencing this. And yes, it is a lot of young girls who are experiencing these body image issues, but now it's increasingly boys as well. So this is happening across the board. But the other piece, I think, that concerns me, thinking about mental health symptoms, is that when you look at how much time kids are using social media, on average, adolescents are using it for three and a half hours a day, on average.