Dr. Vivek Murthy: Author and doctor. 19th Surgeon General of the United States

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I'm Guy Kawasaki and this is remarkable people. This episode's remarkable guest is Dr. Vivek Murthy, the the former Surgeon General of the United States. Usually we release the Remarkable People podcast on Wednesday mornings, but this is a special time. This is coming to you on Monday morning. That's because tomorrow is Election Day in the United States and I want you to hear this podcast before you vote. Vivek has an undergraduate degree from Harvard and both an MD and MBA from Yale. His residency was at Harvard Medical School. He started Doctors for America, a group of 15,000 doctors and medical students supporting high quality, affordable care. He also started a company called Trial Networks. This company increases the efficiency of clinical trials. Barack Obama appointed him surgeon general in 2013. While in this position, he issued the first surgeon general's report on alcohol, drugs and health and the first Surgeon General's Report on the use of e cigarettes by young people. He also launched the Turn the Tide campaign to address opioid addiction. In April 2017, Donald Trump fired Vivek. I would assert this is a badge of honor. At that point, Vivek started addressing the medical impact of loneliness and published a book called the Healing Power of Human Connection in a Sometimes Lonely World. This episode of Remarkable People is brought to you by Remarkable the the Paper Tablet company. Yes, you got that right. Remarkable is sponsored by Remarkable. I have Version two in my hot little hands and it's so good. A very impressive upgrade. Here's how I use it. 1. Taking notes while I'm interviewing a podcast guest. 2. Taking notes while being briefed about a speaking gig. 3. Drafting the structure of keynote speeches. 4. Storing manuals for all the gizmos that I buy. 5. Roughing out drawings for things like surfboards, surfboard sheds. 6. Wrapping my head around complex ideas with diagrams and flowcharts. This is a remarkably well thought out product. It doesn't try to be all things to all people, but it takes notes better than anything I've used. Check out the recent reviews of the latest version. I'm Guy Kawasaki and this is remarkable people. And now here is Dr. Vivek Murthy.

Can I tell you something that before we begin, just on a personal note. So I, I started reading some of your books when I used to visit India as a child and I would be sitting there during the summers and hanging out with family and have a lot of downtime. And I came across some of your books during that time and I just found them to be fascinating. So it's, it's just wonderful to be speaking with you because you had a presence in my, in my childhood as a important author.

Thank you. What city were you going to in India?

Bangalore.

Yeah, I've been, I have been to India several times and it is just a mind boggling experience. I mean, it's just people go to New York and they think, oh, New York is so hectic and all that, and then you get off a plane in New Delhi, Bangalore or Mumbai and it's, it's an order of magnitude more intense.

Absolutely.

I like to tell people from India because this always blows their mind. My favorite part of visiting India are the Dobby Ghats. I just love the Dobie Gods.

Oh, yeah.

Yeah. The colors and just the logistics. I've never experienced that whole thing where people deliver lunches. But the Dobie Gots. I don't know how they, how do you. They know that the, the sheets came from this place and the shirts came from this place?

I.

That's just amazing.

It's really extraordinary how they keep track of everything that. And the lunch deliveries you said are similar. It's like how on earth they keep all that information in their head about where to deliver things to, how to get the right containers back to the right people. It's truly amazing.

Yeah. And there's no chips in those containers or in those shirts or sheets. My first question is, I have to get this straight. Okay, so you have an undergraduate degree from Harvard, you have an MD from Yale, you have an MBA from Yale, you had a residency at Harvard Medical School. Are you some kind of underachiever because you haven't gotten a law degree yet? Are your parents disappointed in you?

You're funny. No, I mean, I think they, my parents, it's interesting. They, they dreamed, you know, when they came to this country of their kids having opportunities. And one of those were educational opportunities. And when we came here, we didn't have much in the way of money or connections. And so but we were, they were powered by these dreams of what America could be. And we feel really grateful that even though our life here hasn't been perfect and we've encountered challenges and racism and other struggles along the way, that we've been really blessed to have had good teachers in public schools and opportunities that have allowed my sister and me to go to some great schools. And so my parents and all of us, we just feel really grateful that we've been able to live a bit of that American dream that inspired my parents all those decades ago.

Walk me through the details of they were living in Bangalore or something and they just decided to move to America. How did that happen?

Yeah, so it was interesting. My mother grew up in Bangalore. She was born there and brought up there. Brought up in a modest family, middle class family, and she studied English literature in school. My father grew up in a small farming village about three hours or so outside of Bangalore. It was very rural there. I mean, his father and the other farmers grew sugar cane and rice and coconuts and mango tamarind. But you know, my just give you a sense of how poor they were. When they made dinner. They used to boil dal or grain and they just would just keep diluting it and diluting it with more and more water until they could fill the bowl of each child around the, the dinner table. That's how poor they were. My father never had any shoes or slippers or anything to, to wear because they couldn't afford anything. And the first time he had footwear was when he was 15 years old and he got a blister actually because he just wasn't used to wearing shoes. So they grew up in really in very modest sort of circumstances, so to speak. And my father in his village, no one had ever graduated from high school, much less gone to college. But somehow, and this is truly remarkable to me, somehow he had this vision of not only becoming a doctor, which is what his father had dreamed of for him, but of actually leaving India. And at that time the place to go shortly after Indian independence was ironically England. That's where people went for a better education and, and for better job opportunities. So initially they went to England after they got married, my mom and dad, and that's, that's where I was born and my sister as well. And then eventually they made their way to Canada and then to the United States. But about from where we started when I was a small child, family didn't know anyone, didn't have much to where we've come in terms of a family that's been had the opportunity to go to great schools and participate in public service at a high level. And I think, despite how much of a Delta, how much of a jump my sister and I have made from where we started to where we are, that will never, ever come close to the jump that my father and mother made from where they started to where they came. And that's why I think about that often, because I think that's not unique to my story. That's true of so many immigrants and so many people, whether they came here a generation ago or 10 generations ago, that we stand on the shoulders of. Of our families and those who are there to support us and show us the way. And I'm certainly no different.

I'm almost afraid to ask, but what does your sister do?

So, my sister is a primary care doctor. She and my dad actually practice medicine together here in Miami. And she's also the godmother to. To my kids. So she's. She's a really important part of our life, and, yeah, really grateful for her.

So when you were Surgeon General and people might ask your mother or father, what does your son do? And they would say, well, he's Surgeon General. Did people think, oh, he's a surgeon. He's like pediatric surgeon, orthopedic surgeon.

So.

Maybe you can explain. There's a funny story that somebody told me that he worked for Apple and he was in tech, and his parents were disappointed that he didn't go into medicine. He must have been Asian. But anyway, so his parents were disappointed he didn't go into medicine. And so one day, because he was at Apple, he was in charge of the relationship between Apple and Dr. Dre. So he told his parents, yeah, I'm working with Dr. Dre. And they said, oh, finally, you're working with a doctor. You realized our dreams. Anyway, we're going on so many rat holes, so I'm not sure I understand either. What exactly does the Surgeon General of the United States do?

It's a great question. And I realized that you're not alone in not fully understanding. I realized when I got into the role that even people in government didn't fully understand what the Surgeon General did. But the Surgeon General's job falls into two categories. And this is somewhat ironic, actually, because people recognize the title Surgeon General. They're used to seeing these warning labels on alcohol bottles, and they know they're on cigarette cartons, et cetera. But here's what the job actually is. So the first job is as a public facing job, and it's to provide the best possible scientific information to people so they can make good decisions for themselves and for their families when it comes to health. And that could be in anything from a current crisis like the opioid epidemic, or in this case, COVID 19. Or it could be on more chronic health issues like mental illness and obesity and other chronic health challenges. But there's a second and lesser known duty of the Surgeon General. And it actually has to do with why the Surgeon General wears a uniform. And that's because the Surgeon General is actually the commanding officer of one of the uniformed services in the United States government, and that's the United States Public Health Service Commission Corps. And These are about 6,500 uniformed officers who are doctors, nurses, physical therapists, pharmacists, public health engineers, and a host of other public health and medical professionals. And what they do in their day job is they help advance the public health of the country through their jobs at the CDC and the FDA and nih. But during times of emergency guide, we actually deploy them to various sites in the United States and sometimes around the world. So for example, during 9 11, we sent groups of officers to help provide medical care and strengthen the public health infrastructure. In New York City after hurricanes and tornadoes, we send in officers. During the Ebola outbreak a few years ago, we sent hundreds of officers to West Africa where they set up the Monrovia Medical Unit to help take care of people who were struck with Ebola. So in this way, these public health officers really are an invisible force that serves as a public health backbone for our country. And so that's. Those are the jobs of the Surgeon General. People have heard of these reports, Surgeon General reports that the Surgeon General sometimes issues on critical topics. I issued several when I was Surgeon General on substance use disorders, on e cigarettes in youth. And these are all part of the many tools that the Surgeon General uses to help advance the public health of the nation. The most important factor in picking a surgeon General is you need somebody who understands and really not only understands science, but actually has a deep affinity for it and is willing to preserve the integrity of science even in the face of politics. Because unlike many other political appointee roles in government, your job as Surgeon General is actually to be independent. It's not to execute the agenda of the president or a political party. Your highest fidelity is science in the public interest. And if that means you have to contradict your president, if they say something that is harmful or incorrect, that is what you're supposed to do. That's the job.

Do you think that's possible today?

I think if you do it today, you have to be prepared to be fired. That's, that's the reality. And you hope it doesn't get to that point. But that means you've got to do a lot of work sometimes behind the scenes to, and you've got to understand how to build relationships, how to dialogue again behind the scenes to try to get people to recognize the, the importance of leading with science and preserving the integrity of the office. Because, you know, during all administrations in history, like politics is politics, people want their agenda moved out and they don't want you to stand in the way of your agenda. Now I was fortunate because I served in the Obama administration and President Obama. There was never a single time where I felt that I was being asked to either say something that was not science driven or that I was being asked to suppress information or my views on a topic because it was politically inconvenient. I think there was a recognition from President Obama himself that science has to not only lead in the way in addressing public health crises, but also that the integrity and power of the Surgeon General's office comes from its independence. And interfering with it would only diminish that power in the moment and also for future presidents. So I never fortunately, was in that, that situation. But I think that a number of my predecessors have been in sticky situations. And currently we find ourselves at a time where the current administration's approach to COVID 19 has not always been consistent with the science based approach. And so that, that creates some real challenges. If you're a medical authority serving, whether you're the Surgeon General or whether you're the head of the NIH or whether you're the head of the Food and Drug Administration. And it, it does create this situation where you have to ask yourself, what is my red line? Every Surgeon General has to have a red line, a line that they're not willing to cross as they execute their jobs. And if they're asked across that, they either publicly refuse or they step down. Because at the end of the day, integrity matters not just for the individual, but of the office. And I always used to tell my team that, yes, I may be the Surgeon General now, but our job as a team, as an office, is to be custodians of an office that's much bigger than us and to leave it stronger for the people who come after us. And, and that's why it's so important to draw those red lines and to stand up and for science and for the public interest.

So there is what you just described sort of the independence you have to speak your mind, perhaps get fired. But is silence now, being complicit? When you hear the president saying something that you know is not scientifically sound and you remain silent, is that complicit?

It's a good question. And I think there. It depends really on the circumstance. I mean, you have to. If you, I'm just think thinking about the current moment in COVID 19, if you're Dr. Tony Fauci or if you're the Surgeon General or if you're the head of the nih, you've got to. You've got to be judicious about which battles you pick. You've got to make sure you're using your. Your power and your voice at the best possible moment, because you may only have one chance, you know, to do that. If you raise an issue that's incredibly important, you may get fired for it, and that's your one chance. So I think in those jobs, you have to be. You have to be thoughtful and measured. But that doesn't mean that you jump on board with supporting statements that are incorrect. And it also doesn't mean that if you're asked questions directly that you evade them. Right? So if, for example, if a political leader goes out and says something incorrect about COVID 19, you may choose not to make that the hill that you die on, so to speak. But if you are asked about it, you absolutely cannot avoid that question, or if you think that the consequences of misinformation there would really be harmful to people's health. So this is. These are tricky, tricky situations. And this is why we actually find ourselves in a very unusual situation. Guy. Because while there has always been tension between politics and science, I think it has been magnified to such a great degree right now. Because in the past, in both Republican and Democratic administrations, during times of great public health crisis, when there was a major outbreak or a pandemic or some other public health threat, generally, you saw politicians come together with scientists, and at least, even if they had slight disagreements here and there in the approach, come together around the general principles and emphasize common messages. And the fact that that is not actually happening as consistently right now stands as a departure from much of our recent history and also creates extraordinary problems for the scientists in government who find themselves operating in roles in which even stating the truth can be perceived as political.

If you were currently surgeon General, would you have been fired or resigned by now?

Well, it turns out I was appointed during the Obama administration, but my term carried over into the Trump administration, and I was actually fired by President Trump. So perhaps that answers your question. But, you know, in my case, I mean, something I had just believed from the time I got into the office is my wife and I remember us talking about this before we accepted the. The role. Like, I wasn't doing the position because I was looking for the next step up. I wasn't trying to use it as a ladder to get to be a cabinet secretary or to run for office myself or something. Like, I was doing this because, you know, is an opportunity to serve. And it. To me, it didn't matter so much if I upset some politicians or ruffled some feathers. What mattered to me is I was doing the job I was supposed to do. That meant leading with science. I mean, leading with the public interest. And that meant that there were some issues I took on which. Which made certain groups unhappy. And those included, for example, taking on the issue of e cigarettes, which now, since, you know, I issued a report in 2016 on E cigarettes on youth, there's been much more data that's even come out to support some of the fundamental points we made, that these are, that these are essentially products that are deeply concerning, especially to our children. They may have a place in cessation, but we need more data to actually prove that. But they were groups, you know, many groups that sort of petitioned the incoming president at that time, President Trump, because they were upset that I was taking on issues that were, in their mind, not aligned with their positions and interests. And so I told. I used to tell my team, I was like, we're going to issue this report and the next president may be upset with us and may fire us, but that doesn't mean it was the wrong thing to do. We've got to do it. So, you know, some people ask me sometimes, like, what if I had to do things over again, would I. Would I soften my positions, would I choose not to issue certain reports, etc. And the answer is absolutely not. I feel like I would have much rather served the time I did and done so knowing that we stood up for what we believed in than served an entire term, having to hold back on stating the truth and having to muzzle. Muzzle myself.

I think that on your LinkedIn profile, you should say fired by President Trump. I mean, in a few years, maybe in a few months, maybe in a few weeks, that's going to be a badge of honor. So I would put that on your business card. Anyway, so you actually also founded a company to optimize clinical trials. Right. And so what's your Analysis of where we are with clinical trials of vaccines right now.

I think that the accelerated path of vaccine development that we've seen over this last seven, eight months has been really extraordinary. And you know, I do give credit to the current administration for the work that it's been doing to help accelerate that process. It's not easy to do. Good news is that we have new technologies now that we didn't have three, four, five years ago. And all those are all coming together along with global collaboration to help us develop. Well, looks like there will be a cadre of vaccines that I hope will be effective. Look here, here's where we are though. We've got multiple vaccines right now that are in advanced stage clinical trials. It is possible, and I say possible, not definite, but it is possible that we may see a candidate that gets an emergency use authorization by the end of the year. But to do that, it would mean that it would need to have data from those late stage trials that showed that the vaccine candidate was both safe and effective. But I think that's within the realm of possibility by the end of this year or by early next year. I think in all likelihood, as 2021 progresses, that we will have multiple vaccine candidates that will have some degree of efficacy. We don't know at this moment whether those vaccines will be 90% effective or 60% effective. Time will only tell. But I do think that we will have options. And the real challenge that we're going to face is a challenge that's just as daunting as the development of a vaccine, and that's the distribution of a vaccine. Because the logistics, the sheer logistics of mounting a national campaign in order to get 70% or so of our population immune to COVID 19. That is a herculean task that we have not undertaken in our lifetimes. Just to be clear. We will be attempting to do something we have not done in our lifetimes at this scale. But it also requires overcoming a big deficit in trust. Right now, according to surveys that were done in early September by the Kaiser Family foundation, little over 50% of people say that if a vaccine was available today, they wouldn't take it. That's extraordinary. Think about how COVID 19 has turned our lives upside down. It's our kids can't go to school, so many people have lost our jobs, so many of us have lost loved ones. Yet half the population says they wouldn't take the vaccine if it was available today. Why is that? Well, it's because people are skeptical and worried that the process of approval has Become politicized. And so that is something that we need to do better at. That means putting being very transparent what the standards are for a vaccine, being transparent with the data itself, allowing scientists to speak directly to the public and make a decision about approval as opposed to trying to rush that decision for political reasons. There's got a lot of work that has to be done to rebuild public trust. And this is why, as I think about it, I, in retrospect, we may find that developing this vaccine was perhaps slightly easier than overcoming the challenges of distribution. But it can be done. It's just going to require a really focused, thoughtful effort and it's going to require us to bring our A team.

Well, the amazing talk about the world being upside down. So there was a group of people who were anti vaxxers because they thought it caused autism, Right. And many people thought they were on the fringe. But now, as you say, I think there are many people who won't take the vaccine because they don't trust the approval process. And that's a very different. So anti vaxxers and liberals are not going to agree on something. This is hard to wrap your head around.

You're raising an important point which is, I think, and I want to make a distinction between people who were distrustful of vaccines long before COVID came onto the scene and people who had, I think, unfortunately, been misinformed into thinking that the measles vaccine somehow causes autism, which we now know definitively does not. I wanted to draw a distinction between that community and people who in recent times, in the last several months have become skeptical and or distrustful about the vaccine approval process. Because I do think that the former group is actually, despite all the publicity we and the news that we hear about people who are against vaccines, that is a silly, relatively small percentage of the population. Whereas the group of people who have become skeptical or concerned about the approval process is a much larger group and a group, frankly, that includes a number of medical professionals who are worried. These are medical professionals who have prescribed vaccines for years and years and years and believe in the integrity of vaccines in general. But at this particular moment are worried about the approval process being politicized. What's interesting if you look at some of the polling, is that if an approval happens after the election, many people, it turns out, would feel better about that because they feel like it's not being rushed to try to hit some artificial election deadline. They also, if you, if you're transparent about the data and people are able to hear directly from scientists about the Data and whether they believe an approval is warranted on safety and efficacy basis. They would also feel better, you know, about taking the virus, I mean, the vaccine. And so I think, I think distrust can be re. Regained, gained. I think people can be brought back into recognizing that a vaccine has value. But look, I think that we've got to, we've got to be honest and upfront and transparent in it to a degree that perhaps it didn't happen in times past, but it's what's going to be necessary to regain trust.

How do you ever do a vaccine test? I forget the technical term for this, but there's a kind of vaccine test where you get volunteers and there's two groups, placebo and the treated group, and you purposely expose them to see if they get it. Now that's Russian roulette, no pun intended. That's Russian roulette with the group that's getting infected on purpose if there is no treatment. Right. So can you ethically do that kind of test yet?

Yeah. So that, that's complicated and has been a source of discussion and controversy. The good news is that the vaccine trials that have been done so far, the vast majority of them are not taking that approach of trying to intentionally infect someone. In fact, what they're doing is they're, they're actually conducting their trials in parts of the world where there is a lot of infection spreading, which is bad in general for the population. But it turns out that it actually helps you study the vaccine because you, you need a situation where a lot of people are getting the virus so you can see if your vaccine actually protects people or not. If, if no one's getting the virus. Right. If they're not contracting COVID 19, then you really don't know if your vaccine's working or not. Right. Because there's not going to be much of a difference between your experimental group and your placebo group. So you've seen. It turns out the United States, sadly, is one of the parts of the world where the virus is spreading rapidly. So trials are being conducted here. They've been conducted in Brazil, India. These are again, all regions of the world which are seeing unfortunate spread. And now, sadly, we're seeing a resurgence in Europe as well. So, so, but your point is well taken, which is that we've got to be like really thoughtful about the design of these trials because some of the mistrust that people have around vaccine trial participation and even the results have to do with historical experiences that have been bad, frankly, where we have intentionally and Knowingly either not afforded treatment to people where we knew it existed, and in doing so, we've exposed them to unnecessary harm.

How exactly does the President's physician work? I mean, is it. I don't even know how to begin this question. So he's miraculously cured after 10 days and his physician says he's no longer contagious. Are we supposed to believe that?

This is complicated. And I think I always hesitate to comment on patients when I haven't seen their primary data or examined them. Obviously I haven't done that with the President, so I can't exactly say what his situation is. But what I can tell you is this. When you're trying to determine whether somebody is, quote, unquote, safe to engage with the public, what you're worried about is are they infectious, are they still spreading the virus? And if you look at the CDC guidelines, the CDC guidelines generally say is that if you've had a mild or moderate infection, that the vast majority of people, after 10 days it should be safe to re. Engage with the public. But if you've had a severe or critical infection, then that that timeframe should be closer to 20 days. And what we used to do in the early days of, of COVID 19, the early days, it sounds like years ago. I'm talking about like five, six months ago. What we used to do early on in Covid, in the early part of the year was, was require two negative PCRs. PCR is a very sensitive test for Covid. But to require 2 PCRs 24 hours apart in order to quote, unquote, clear somebody. Right. For various reasons that we moved away from that. But that standard of two negative PCRs is sometimes still used in very high risk situations. So the question is, if you wanted to know, is the President safe after 10 days or does he require 20 days? Some of the information that you'd want to know is does he fall into the mild to moderate category or into the severe critical category. And one of the, one of the parameters that helps determine that is how much oxygen support you need and what your oxygen levels are on room air. And so because we don't have a lot of clarity on some of those questions, people have wondered what category does the President fall into if you try to infer just based on the medications that the President used? Well, let, let's think about that for a moment. He received three particular medicines that are of interest. These monoclonal antibodies, which are synthetic antibodies. Antibodies are proteins your body makes to help tag invaders, bacteria and viruses and tag them for destruction by your immune system. But these monoclonal antibodies are synthetic antibodies that essentially replace or boost your immune function for a short, temporary period of time. So he received those. Those are still being studied. He also received Remdesivir, which is an antiviral, and received dexamethasone, which is a commonly available steroid medication, a potent one. But dexamethasone and Remdesivir are indicated for people who have severe infection. Right. So some people looked at that and they said, well, if he received those medications, he probably had severe infection. Because to give dexamethasone, a steroid medication to somebody who just had mild infection is actually would be a questionable decision, because when people don't have severe infection, when it's just mild, in fact, you can potentially do more harm than good because you can actually suppress the immune function. But when somebody has a severe case, when they have a high level of inflammation in their body, then those steroids, on balance, will help you more than they will hurt you. So again, this is all a game of trying to guess where, what level of severity the President's illness is based on tidbits of information and his therapies. But the bottom line is, this guy is that the President won't necessarily be treated like a regular patient because of the circumstances around a President's health and because of. Because of who the President actually is. And they will receive just a much greater attention, medical attention, than most people would typically receive. And. And they may receive medications with a lower threshold than you might use for the average patient. I'm not saying that that's right, but I'm saying that that's always a risk when you're treating people who are of great importance, like. Like the President. So the bottom line is how the severity of his illness. So we don't know how long he should generally be outside of contact with the public for safety purposes.

If he called you up and said, vivek, come fly with me on Air Force One to Florida, you probably wouldn't get on that plane.

Right? I'd ask for more information before I got on the plane, put it that way. Like two negative PCRs, that would be nice.

I want to get off this subject, believe me. But, you know, I would be remiss if I didn't ask you some of these things that I'm sure many Americans are curious about. So let's go to the future here. So let's suppose that Joe Biden wins and he calls you up and he says, vivek, come back Be the Surgeon General again. And let's further suppose that your wife and family are okay with this. So you say yes, because I don't know if you would say yes. But anyway, let's suppose you agree. What would you immediately do?

Wow. Well, I'll frame this in general terms because again, who knows what will happen? I sometimes don't even know what I'm doing tomorrow, much less in a few weeks with my two kids, who are 4 and 2. They've like, forced me to think very short term. So I'm just like, okay, when's the next meal for the kids? How are we getting them to bed? Who hasn't taken a bath yet?

I can hear. I believe. I believe I've been there and done that four times.

Oh, my gosh. Yeah, you're. You're an expert. I'm just. I mean, just have two. And I'm struggling to make it. To make it all work. But wait till the wait.

Wait till the kids outnumber the adults. In fact, that's when it gets interesting. Right now, you're man for man. Wait till you go to Zone, baby.

I don't know if I have it in me to go to zone. I think I've just got to stay where I am. But look, here's what I would say, though. If Joe Biden has the opportunity to serve, here's what his team's got to think about from day one. And the Surgeon General's got to be a big piece of this, is they've got to think, number one, how do we put together a plan for addressing this virus, a multifaceted plan that will involve how to prevent, spread, how to accelerate the development of treatment, how to distribute a vaccine, and how to provide economic support for people who have been hit hard by this virus. The second thing they've got to do is to figure out how to communicate clearly, transparently, regularly and accurately with the public. Right? Part of how you rebuild trust is by being open in your communication, not just communicating with people when things are going well, but telling them your plans, being honest with them when things aren't going well. And the third thing that they're going to have to do is we're going to have to build really strong partnerships. And there's a particular way to build partnerships in the time of crisis. Building partnerships when you're the federal government in the face of the biggest pandemic we've had in a century is not done by simply hoisting responsibility onto others and saying, businesses, go take care of yourself. States Figure it out. That's not partnership. That is transferring responsibility. But to truly build partnerships, what you have to do is you have to bring people together, key stakeholders, including the states. And you have to say, look, here is the problem as we see it. You've got to gather input from them, and you've got to map out in clear terms what you will provide as a federal government in terms of support and guidance and resources and assistance. And you've got to be ready to listen to that feedback from states and from employers and from schools and from parents, because that's actually how you work together. And the thing of is, you know, guy about partnerships is that they're hard to build in the middle of a crisis. Ideally, what you do is you're building those partnerships all along. One of the advantages actually, that. That Joe Biden had, having served actually for eight years in the White House, is that he was actually building partnerships all along, not just during the H1N1 crisis, not just during Ebola, not just during Zika, but. But in between as well. And so he has strong relationships with leaders in a number of states. He's got strong partnerships with employers. He's got great relationships with teachers and with communities of parents as well, and with educational institutions. Those are all of the relationships he's going to need to draw on, like in this moment. So the truth is that dealing with this pandemic on January 20th will be one of the hardest jobs any president in modern history has taken on. It will dwarf, I believe, the difficulty of the challenge that President Obama and Vice President Biden took in took on in 2009 when they inherited an extraordinary economic crisis and had to help halt or slow down an economy that was in freefall and ultimately help that economy heal. This will be a much, much bigger challenge. But I'll tell you this, though. I spend time briefing the vice President on a regular basis on COVID 19. We talk about the plans that he wants to develop. And what has struck me about him is that. Is that he is. He's really focused on the practical and the personal. I would say those are two sort of themes that guide him. And when I say the personal, what I mean is he grasps numbers with great dexterity. He understands key concepts. He knows what the big drivers are of spread, et cetera. He knows a lot of that stuff, but he's anchored in the personalization that he always wants to know. How is this affecting an everyday mom or dad? How is this affecting small businesses on the street? If I'm a child, who is in high school, how is this going to actually affect my learning experience if I go back to school in the midst of COVID Like, he's very focused on the personal, but the practical is also at the heart of how he thinks. At the end of the day, he cares less about labels and titles and structures. He cares about getting results and getting the job done. And so he's always pushing us in these sessions that we have these briefings to say, okay, practically, how are we going to solve that problem? We're talking in a given day about. About the challenge of reopening schools. He wants to know, okay, what are the steps to solving that, to getting schools the resources they need to ensuring that the guidance is really clear to schools? I can think of a few other times where it's been more important to have a focus on the personal and the practical, because we just. We got to get results, but we also have to make sure that we're letting the stories of individuals really guide us and that we're not just trying to get the numbers right. We're not just trying to sharpen the, you know, the parameters on a dashboard, so to speak. But our success is gauged by did we make the lives of moms and dads and boys and girls better in the United States of America? And if the answer is yes, then we will have succeeded in their COVID 19 response.

I want to talk about loneliness.

Sure.

Finally. Okay, so first of all, how do you define loneliness?

That's a great question. Loneliness is a subjective state of being. It's not an objective descriptor of how many people you have around you, but it's a subjective feeling that the character connections that you need in your life are greater than the connections you have. And in that gap, we experience loneliness. What's also really important to recognize is that loneliness is a largely invisible phenomenon in society today. A lot. You know, a lot of times, if you're experiencing loneliness, you might look around you and you might think, gosh, I'm. I'm the only one. Everyone seems to be living this extraordinarily social life. If I look on their social media feed, they're going to parties, they're hanging out with friends, like, they have great birthday celebrations. Life couldn't be better.

Gender reveals.

All kinds of things happening, right? But the truth is that many people are, in fact, struggling with loneliness. And even though we know that people post selected curated images of themselves and their families on Instagram and on social media more broadly, still, when we look at their feeds, it's hard not to look at their posts and to compare it to our lives and to feel like we come up short. And so that, interestingly, can compound that feeling of lonely. What's worse than being lonely is feeling like you're the only one who's lonely. And that is, sadly, the experience a lot of people have today. I should lastly also just say this. Look, another reason that loneliness is hard to see is that there's a stigma around being lonely. This sense that somehow if we're lonely, that means that we must be broken in some way or socially deficient or a loser or what have you. And as a result, a lot of us may feel a sense of shame around even admitting that we're struggling with loneliness. I say that from personal experience because as a child I struggled with loneliness for many, many years and have certainly dealt with it many times during adulthood as well, including during and after my time as Surgeon General. And I have felt, especially as a young child in school, that shame. I was so ashamed, in fact, of being alone and being lonely in school that I never told my parents, even though I was very confident that they loved me. And I felt, definitely felt like I belonged at home. My parents, my sister, they were just the absolute best. And they still are. But I was so ashamed that I never told them. And so this is partly part of the reason I wrote this book on loneliness is not only because it was a journey of exploration for me to understand the prevalence, the consequences of loneliness, but I also wanted all of us to know. I wanted to tell other people and remind myself that if you are feeling lonely, you are not the only one. And it does not mean you are broken. And if you are lonely, in fact, you are experiencing what all of us do at various points in our life, which is a natural reaction, a signal, if you will, that our body sends up when we're lacking something we need for survival, and that's our connection with one another.

So there is a medical impact of loneliness.

This is fascinating. I went through medical school and residency, Guy, without knowing much at all about loneliness, including the health consequences. But when I was Surgeon General, I came to hear in so many of the stories that I was fortunate to be able to get on the road. From people in town halls and in their living rooms, I was hearing these threads of loneliness crop up again and again and again. People would often say to me, they wouldn't come up to me and say, hi, my name is Vivek, or Guy, I'm lonely. They would say things like they would say you know, I'm dealing with a lot of stuff in my life right now, and I just feel like I've got. I'm dealing with it all by myself. There's nobody really around to help me out. Or they would say, you know, if I disappear tomorrow, I feel like nobody would even care. They wouldn't even notice. Or they would say, I feel invisible. And keep in mind, I wasn't just hearing this from the people we stereotypically think are lonely. People who are older, living by themselves at home or in an institution. I was hearing this from college students who are surrounded by thousands of other students on campus. I was hearing this from moms and dads, you know, who were. Had busy lives, weren't involved in their. In their communities. I was hearing this from CEOs, from doctors and nurses, even from members of Congress who would tell me behind closed doors that they, in fact, were also struggling with loneliness. So as I dug more into it, I came to recognize that there were interesting, interesting sort of tidbits about the impact on health that our science and research were already telling us. So, for example, it seems that people who are lonely, that loneliness is associated with a shorter lifespan, with premature death, with a greater incidence of heart disease and dementia, and depression and anxiety and sleep disturbances. And the list goes on. And there are. The more I dug into it, I started to recognize that these are really substantial consequences. Like the mortality impact that's seen and associated with loneliness is similar to the mortality impact associated with smoking 15 cigarettes a day. It's greater than the mortality impact associated with obesity or sedentary living. And I'm saying this to you guys, it's a surgeon general who came from a tradition of surgeons general who focused actually on those three issues, tobacco use, obesity, sedentary living, but never did, I think, until I encounter this issue of loneliness, that loneliness itself would be as perhaps important a public health issue as these others that our office had focused on over the years.

Wait, so I just want to make sure I heard this right. So you're saying that loneliness has a medical impact equal or greater than smoking and heart disease?

Yeah. So what I'm saying is that loneliness is associated with a mortality impact that's similar to that of smoking 15 cigarettes a day. Yeah. And what I'm also saying is that people who struggle with loneliness seem to be at higher risk of heart disease and a host of other medical conditions. If you want to understand why, if this seems really peculiar, like, why would a bad feeling lead to, like, physical health results? There are two Things to say here. One is that the more we've learned in medicine, we've learned about this deeper connection between our mind and our body, that the fact that how we feel impacts in fact, how our health actually develops. And the other thing to note here is that loneliness seems to trigger a stress response in our body. And stress states are interesting because when they're short lived, they can actually motivate you to do things that can be quite helpful. They can be adaptive in some ways. So imagine, for example, the night before a big test, you're feeling stressed. That might motivate you to study harder, right? It might motivate you to stay up, make sure you've learned all the concepts, let's say before a big speech, you feel nervous. I might motivate you to prepare more. So in the short term. And also just imagine you're, you walk onto the street and all of a sudden a car, you know is hurtling toward you that you didn't see, and suddenly you turn around, you see it, you immediately enter into a state of stress and that actually propels your body to move fast and to get out of danger, right? So stress responses in the short term are actually beneficial for us. The problem is in the long term. It's like what happens if that stress persists not just for a few minutes, but for days and weeks and years, Then that cortisol surge, that surge in hormones that we experience in our body, when they're persistent, they can actually start to do damage. So we know, for example, that chronic stress can lead to elevated levels of cortisol, it can ultimately lead to damaging tissues and blood vessels and can lead to the increase in chronic illness that we commonly see in our clinics and hospitals. And so the stress, I would say if there's one thing that I have learned since my first day in medical school, if I had to pick one of the a handful of things that I have a much deeper appreciation and respect for now. It is the impact of stress on our health because. And the more we learn, the more we recognize just how many systems in our body are affected by stress. And now it makes sense why loneliness would have such an impact on health. Because it is a form of stress, and when it is long lived, it is a form of chronic stress. And that is not good for us.

What if a person's reaction to loneliness is to seek out groups that become tribal, to go from one extreme to the other? Do you now join some kind of tribe that is dangerous, negative, destructive? Can't that drive you into the Opposite extreme.

It's a really interesting question and very relevant today in particular, because the drive to be connected to one another is extraordinarily strong. As human beings, we were wired for social connection, and that's why when we lack it, it has such a profound impact on how we feel and on our health. But the drive to recapture connection once it's lost is powerful and can lead us to do things that are sometimes healthy. For example, like if we are lonely and we pick up the phone to call a friend or get in the car and visit a loved one, that's wonderful. But if instead we join a group that might have bad intentions or might ultimately be bad for us, but they provide a sense of belonging and companionship, and we lack that, then that could be quite destructive for us. In. In the book, I talk about two extraordinary men that I. That I met who at a place in LA called the Anti Recidivism Collective. And these two men were amazing because they had. They had both been incarcerated for many years and they were members of. Of a gang, and they had engaged in acts of violence that had led to their incarceration. And they ultimately got out and turned their life around. But when I sat down to talk to them, what they told me is that what drove them to those gangs was loneliness, was that they felt so by themselves, so abandoned when they were younger. They didn't have the support they needed from families. They didn't know who they could trust. And the gang presented itself, yes, sure, as problematic, as dangerous, but as a place where there was immediate belonging and where you had a family, a surrogate family, if you will. So I do absolutely worry that if we do not address loneliness in the right way, if we don't make it an issue that we can talk about, that we can help people understand how to address in a healthy way, that it can absolutely lead to disastrous consequences in our life. And it's why, in fact, I just, on a very personal level, why I decided to focus on this issue when I came out of government, because I was asking myself, and what could I do that would help to address the deeper underlying causes of so much of what I was encountering in office, whether it was the opiate epidemic or violence or depression and anxiety. And I came to see that this issue of social connection or social disconnection was in fact, a driving force behind so many of these challenges. And this is how to think about it. Think about loneliness not just as a source of stress, but as a source of pain. Right. If you think about that Emotional pain of loneliness, which is not just the pain of feeling like nobody is with me, but it's a pain of feeling that I am unworthy. Because the longer people are lonelier, the more they come to feel that I'm lonely because I'm not likable or I'm not lovable. And that pain can get to be quite excruciating. And as human beings, we will seek to relieve pain when we experience it. Now, if I reach for something healthy, the phone or my car keys to go see a friend, then that's one thing. But if I reach for a bottle of alcohol, if I reach for drugs, if I reach for violence, whether that's in spoken word or in physical action, if I reach for connection through a gang, if I do reach, if I reach for connection through ways that ultimately harm my mental and physical health, that can actually assuage some of my loneliness pain in the short term, and in the long term, it can have profound impacts. And that's why, like when I, you know, issued in 2016, the Surgeon Dental's report on substance use disorders and alcohol, drugs and health. One of the things that I really tried to emphasize clearly here is that while we do have many things we can do to help people who are struggling with addiction, one of the most important things, one of the things which has to be part of our solution is community and connection. Because of all the thousands of people I have met who have come through that dark tunnel of addiction and emerged on the other side, just about all of them had a person or a group of people that they pointed to and said it was because this person or this group was here, because they believed in me, because they supported me. That's why I was able to make it. That's why I'm in recovery. That's the power of social connection. Our connections heal. And this is a time in our world where we need great healing.

What if you reach for Facebook, Instagram, or TikTok? Is that reaching for a good social connection? Or does it take you deeper, darker, into another kind of hole?

So now you're asking the question I get asked most often, and I think it's the right question, right in this day and age, not just for our kids who are on social media a lot, but for all of us, because we're all on social media a lot. And the answer to your question is it depends how I'm approaching and using social media. So I'll give you an example. If I am feeling lonely and I decide, you know, I'm going out to LA for a business trip. So I'm just going to post on Facebook that I'm coming out to LA and see if any of my friends might be free for lunch or dinner. Right? And then we actually, I meet up with a couple of friends because they saw my post. That's actually a great way of social using social media to lead to offline connection. If I'm, let's say, a member of an underrepresented group, either because of my race or because of my disability or because of my sexual orientation or any other life experience. And there just aren't a lot of people around me, like in my school or in my workplace or neighborhood who've had shared experiences. But I go online and I find communities have had shared experiences and we can actually talk to each other and they can understand each other. That too can be really, really powerful. My, my, my wife Alice is a doctor as well, and she's part of a. An amazing group on Facebook called the Physician Moms Group. This is a group started by an extraordinary woman, Dr. Hala Sabri, who I write about, actually in the book in detail, because this is such an extraordinary story. But what Hala Sabri did is she managed to create this community of, of just an extra tens of thousands of physician moms who don't know each other personally in the sense that they've not met, but they had a common need, which is to find people who understood their unique experience as doctors who are also jugg moms. And now this group does so much in terms of helping and supporting one another. People give each other advice on patients. People give each other advice on what dress to wear on a day. People give each other advice on, on, you know, how to deal with particularly challenging developmental stages for their children. One of the extraordinary stories that Hala shared with me is that one day a physician who is a member of the group came home and posted that she had just delivered a baby for one of her patients that day in the hospital. And she was heartbroken because the baby was okay. But the mom ended up having a rare complication which she experienced, something called an amniotic fluid embolus. And that's when some of the amniotic fluid that surrounds the baby escapes and gets into the bloodstream of the mother. And it can be disastrous, it can cause a stroke, it can be fatal. And the mother was not doing well at that moment. And she was really worried about her, but just felt like resigned to the fact that this may not go well and this poor child would Grow up without a mom. And after she posted that, there was a tremendous response from the community. And it wasn't just people saying, commiserating with her and offering her emotional support. It was also people saying, well, hold on, let's try to understand more about what's happening here. Is it possible that there are solutions here that maybe you know, have been overlooked or maybe that are just recently developed that we can learn more about? And long story short, they put their heads together, identified actually a new treatment strategy that was not available at the current hospital this mom was hospitalized at, but that was available at the hospital that one of the other physician moms worked at who was participating in this online discussion. And so together they actually arranged for the patient to be transferred to the other hospital. She was able to get the treatment she needed, she survived, and that child now has a mom in their life. And that is a power of what happened because of this community that was built on social media. So can social media be helpful to us during times of loneliness? Absolutely. But you know, the truth is, Guy, is that what I describe to you are not the predominant ways that we're using social media. And what I worry about is that when you use social media in a passive way, when you're just scrolling through people's posts hoping that you'll feel more connected to them, that rarely works. You often feel worse about your life and more lonely. The second thing is when you're using social media so much, that's crowding out your high quality time with other people, whether that's online or in person, that's also problematic. And the third is when social media invades our interactions with other people. When we bring our phones to the table and we're checking social media while we're supposed to be catching up with our family, when we're talking on the phone to catch up with a good friend, but we're scrolling through our Instagram feed just on the side because we can, because it's in our pockets. Those are ways that social media can dilute our connection with others. And perhaps most insidious is the impact on our self esteem. I really worry, especially for young people about the message that they get from social media, which often is telling them that they're not enough, they're not good looking enough, they're not smart enough, they're not popular enough and they're not thin enough. And usually that's paired with somebody's posts where they're looking thin and popular and looking good in general. Or it's paired with an Advertisement for a product that'll help make them fill that void. But the truth is that too many young people, I think, and too many older people leave their experience with social media feeling worse about themselves than they did before. And that to me is fundamentally problematic because when you don't feel connected to yourself, when you don't feel confident that you are worthy, that you have value, it actually makes it harder to build connection with other people because you are constantly second guessing yourself. When you're interaction, interacting with others, you're wondering, do they really want to spend time with me? Do they like me? You're trying to position yourself and curate your words to be palatable to them instead of showing up as your authentic self.

From what I read in your book, it seems like retirement is overrated and I need to join some group who's making wooden benches or something. Tell me about retirement now.

So for men and women, but particularly for men, retirement is a particularly challenging time when it comes to loneliness. In fact, in men there in particular, there are three big triggers for loneliness. One is retirement, one is the loss of a spouse, and the third is illness. And so it's really important at all stages of life to think about how we are building our social connections, recognizing that when retirement happens, we lose an important community sometimes, which is our work community. And for a lot of guys, you know, and I say this is a guy who's been guilty of this as well, too often we don't pay enough attention to our social connections and to our relationships. A lot of guys rely on their, their partner, in fact, to kind of supplement supply a lot of their social life and their social interaction, which is why again, the loss of a partner as well as retirement can be so devastating. But that said, one of the things that I found to be really fascinating was I, I profiled in this book. It's amazing phenomenon, really is what it is more than a project, but something called the Men's Sheds project. And the Men's Sheds was this amazing. And projects started in Australia that brought men together, who are often older and retired, to do woodwork and metal work together. And this simple idea that they had years ago when this was started in Australia was, and this is their saying, not mine, is that men connect shoulder to shoulder and women connect face to face. And the idea was that for a lot of guys, if you put them in a group and just say, okay, talk to each other, talk about your feelings, you know, it may not go very far, but yeah, but a lot of guys actually will have conversation while they're doing other things together, maybe while they're watching a football game or while they're, you know, doing woodwork or while they're taking a walk or running together or. Or something else. And so it was this recognizing that this extraordinary woman, Maxine Chaseling in Australia, started the Men's Sheds project because she recognized that her father had struggled with loneliness, and she saw it and now in so many of the men in her community. And that idea of the men's shed has now spread all over the world. So there are nearly a thousand men's sheds in Australia, but also hundreds and hundreds in, in England, many others throughout Europe and the United States. Actually, there's a growing men's sheds movement as well. And the idea is super simple. It's that if you bring people together to work on something, something that gives them a sense of shared mission, shared purpose, that that itself can be a powerful lever for connection. And it has to do with. With one last thing I'll share with you here, which is about the types of connection and types of loneliness that we all experience. And this is really important to understand because if you don't understand this, then you might actually think when your partner is lonely that it's your fault and, and that it's your relationship's fault. But here's sort of what, how it goes. We experience intimate loneliness, relational loneliness, and collective loneliness as human beings. Intimate loneliness is when we lack close confidants that could be a partner or best friend, people who know us for who we are, with whom we can be ourselves. Relational loneliness is when we lack friendships, the kind of friendships with, where we can have someone over for dinner, the people we'd hang out with over weekends or have over for a birthday party. And collective loneliness is when we lack a community, a group of people with whom we have shared purpose and mission. That could be people at work, it could be a. A group, you know, a volunteer group, or part of it could be our faith community. And these men's sheds essentially gave these men that collective connection, that community that they needed. And over time, people can migrate between those different types of connections. They can start off as part of your community, can become really good friends, and that can become close confidants over time. But I think as all of us move through different stages of our life, it's become clear to me that we need to. We need some anchor that allows us to stay close to people, whether that's a men's shed type experience, a group, a collective community, whether that's the moai experience that I described in the book. A couple of friends that we make a commitment to staying in close touch with and checking on on a regular basis, or whether that's staying close to family and friends, including geographically, so that we have a lot of interaction with them. But part of what we need to do and part of why I have decided to work on this whole subject is I realized, guy, the more I understood about the consequences of loneliness and how common it was, and it' extremely common. More common than diabetes and more common than smoking in adults in the US for example. But the more I learned about it, the more I realized that the great challenge we face in our country, in the world today is how to build a people centered life and a people centered world. And the truth is right now we have a work centered life and a work centered world for most people, not for everyone, but for most people. But it is when we are living in a people centered way, which means when we are prioritizing our relationships and how we spend our time, our focus, our energy and our attention, that's when we actually derive the most joy from it. And the reason I know this is not just because I feel that myself, but it's because when I think back, guy on all the patients that I cared for in the hospital at the end of their life, long after we had medications to offer them in those last hours when all we had to do was to sit by their bedside and to hold their hand and witness their final moments, I think often to what they talked about during that time. And what they didn't talk about was how many followers they had on social media. What they didn't talk about was how much money they had in their bank account or what their most proud moment was at work or what their last title was in the workplace. What people talked about in those final moments of life were their relationships. The ones that brought them joy, the ones they wish they had spent more time with. I love you. I love you too. The ones that broke their hearts. It has become so clear to me in those conversations and in the years afterward that in the final moments of life, when all else falls away, what rises to the top are our relationships. And I don't think we have to wait until the end of our lives to build a life based on that realization, to put people back at the center of our lives. And if we can do that, if we can make that our mission, we will not only build a world that is more nurturing, that's more cooperative, that's more connected. We'll not only build lives that are more fulfilling and more healthy and resilient and strong, but we will build a kind of future for my kids, for your grandkids, and for all of our children that's worthy of them.

I hope you enjoyed this interview with Vivek. Clearly, he is a person who understands the medical challenges that we face in a pandemic, as well as the impact of loneliness. I hope that someday he is Surgeon General of the United States again. I'm Guy Kawasaki, and this is Remarkable People. My thanks to Lori Flynn for suggesting that I interview Vivek, and she helped make it possible. My thanks to Jeff C. And Peg Fitzpatrick for their everlasting and insanely great dedication to making this podcast what it is. Tomorrow is election Day in America, so get out and vote. And going forward, in the middle of this pandemic, remember to wash your hands, avoid crowds, wear a mask, and listen to Dr. Tony Fauci. And when he says, get a vaccine shot, get it. Be safe, mahalo and aloha. This episode of Remarkable People is brought to you by Remarkable the Paper Tablet Company. This is remarkable people.