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

Before the conversation proper, the transcript carries a disclaimer that it 'is not in its final form and will be updated,' and Huberman frames the episode around a specific agenda: nutrition and the obesity crisis, food additives allowed in the US versus other countries, the youth and adult mental health crises, the 'global crisis of loneliness and isolation,' corporate influence on the research and decisions behind public health directives, and the 'current and future landscape' of how to 'restore faith' in public health officials, policy and science. He introduces Murthy as a medical doctor and acting Surgeon General who 'oversees more than 6000 dedicated public health officers,' and says the podcast is separate from his Stanford roles but part of an effort to bring 'zero cost to consumer' science information to the public. The framing matters because it sets up the tension that runs through the whole exchange: the public-facing scope of the office is presented as very broad, while Murthy will repeatedly insist that his formal authority, channels and resources are narrow.

Asked what a top Google hit would miss, Murthy describes 'two primary roles' rather than one: - Public engagement: making sure people know about critical public health issues, 'so they know what they are, how to protect themselves and their families.' - Oversight of one of 'the eight uniformed services in the US government,' the United States Public Health Service, which 'has 6000 officers' including doctors, nurses, physical therapists, pharmacists and public health engineers. The operational evidence he offers is concrete: when Ebola came to West Africa in 2014, 'we sent hundreds of officers to West Africa to set up the Monrovia medical unit in Liberia'; officers are dispatched for hurricanes or tornadoes to strengthen public health infrastructure and provide direct care; and 'We deployed thousands of officers during COVID.' Huberman probes whether these are full-time careers or a 'side hustle,' and Murthy answers plainly that 'they are full time government employees and members of the public health service,' embedded day to day in public health agencies, 'extraordinarily well trained,' and bringing 'a combination of skill and heart to their work.'

Murthy later separates the two roles procedurally, which is where the independence claim becomes testable. Deployment of the 6000 officers is 'collaborative': the office works with colleagues throughout the Department of Health and Human Services, with 'people in FEMA across the administration,' and with states, which often ask 'we need support here, can you help?' before a team is sent 'collectively.' He cites officers 'helping in Maui right now, particularly with mental health needs' that he worries are 'only going to continue to grow over the weeks and months ahead.' Deciding which issues to engage the public on works differently: the office is 'open to suggestions from the public' and members of Congress sometimes ask it to explain an issue, but 'the decision about which issues to focus on' is its own. That split - shared operations, guarded agenda - is the hinge for the argument that follows.

Huberman opens the substantive discussion by refusing the 'lack of health' framing: people hear about 'the mental health crisis' but are really discussing 'the lack of mental health crisis, aka mental illness,' and rarely hear 'what constitutes mental health,' whereas physical health comes with abundant guidance on cardiovascular exercise, resistance exercise, yoga-type exercise and mobility. He asks directly whether any areas of physical or mental health improvement in the US over 'the last, let's say, five to ten years' can be attributed to public health initiatives. Murthy concedes the premise rather than producing a victory list: 'you're absolutely right that we have operated primarily through an illness frame,' which is 'in my mind, that's only one half of the equation.' His evidence is clinical and concrete - a doctor learns to 'diagnose and treat someone with diabetes, or with high blood pressure, or with coronary heart disease,' yet a person with no diagnosable condition may still be unable to 'walk around the block without getting short of breath,' play with their kids, or lift luggage at the airport.

Murthy extends the same logic to mental health: preventing and managing diagnosable illness is 'one goal,' but there is 'a whole other half of the spectrum' of people not 'operating optimally in their lives,' which detracts from fulfillment and functionality 'not just at work, but also in their communities and in their families.' Huberman agrees and voices the hope that the same officers who rush into crises would also transmit everyday, weekly and monthly guidance on how to make life as healthy as possible. Murthy partly grants this - 'many of our officers do focus on this broader rubric around well being' - but locates the deeper failure in training and system design: in medical school 'the vast majority of the focus was on diagnosing and treating illness,' while what people actually say they want is to 'walk their child down the aisle,' stay independent, and carry their groceries or luggage. He grounds the shift in his own biography: he had not planned on government, trained in medicine, 'spent seven years building a technology company that was focused on health,' and grew worried that 'People who needed care couldn't get it,' that care was often too expensive, and that the system was 'on treatment solely and not enough on prevention.'

we're not just aiming for lack of illness, we're aiming to optimize our physical health.

Later in the segment Murthy names the positive program that follows from this framing: 'the core pillars of a healthy life, which are sleep, our nutrition, our physical activity, our social relationships.' He argues these are 'not teaching kids about this in school' even though school should 'lay a foundation for a healthy life going forward,' and makes the deliberately strong claim that learning 'how to build and maintain healthy relationships in their life' is as important, frankly, as learning to read and write, judged by contribution to 'their happiness, their fulfillment, their health and their success.' He immediately flags that this is 'a strong statement to make.' The limitation is stated just as plainly: 'there's more that needs to be done, more issues that need to be tackled,' and some of 'the hardest decisions' in the office involve 'putting aside issues that we know deserve a lot more time and attention' because 'we just really don't have the resources.' He lists what the team has managed to raise awareness on - social media and youth mental health, isolation, clinician burnout - which is a record of priorities chosen, not of capacity available.

Murthy's central structural claim is that the Surgeon General is 'supposed to be an independent position': 'in 2013 is when President Obama's team reached out to me,' he says, and the agenda 'are not determined by a president or a party. They're determined by science and the public interest.' He says the same principle guided his first term and 'when President Biden asked me to come back and serve as Surgeon General a second time.' Huberman presses the point with concrete hypotheticals - memos about COVID messaging, deploying a team to Maui, 'who's your boss?' - and notes that long-arc tragedies get covered in a 'blast' of news and then forgotten even as physical and mental health crises keep overlapping. Murthy deflects the 'boss' question with a joke ('My boss, my wife and my two kids who are five and seven. I do what they tell me to.'), but the serious answer is the independence claim itself, and the rest of the interview is largely an exploration of what constrains it in practice.

Murthy says two things 'are really most important in guiding our choice about priorities': - 'One is data': 'what the numbers actually tell us about the impact these issues are having on the population, as well as the trajectory of rise,' since 'If something's getting dramatically worse and people don't realize, it might be an area for us to focus.' - 'what I hear from people on the road': town halls and community visits where he tries 'to, frankly, just listen to what's on their mind.' He attributes his loneliness and isolation focus to the second factor, explicitly not the first: 'It wasn't because it popped up in a report as being the leading public health issue in the country.' In 2014 and 2015 he kept hearing, from college students, retired Americans and parents in rural and urban areas, stories of people who felt 'all on their own,' 'invisible,' 'like they just didn't belong,' or 'if they disappeared tomorrow, no one would even care' - 'particularly heartbreaking to hear it from kids.' His first-term focus areas, by contrast, were 'the opioid crisis' and 'e-cigarette use among youth,' where he says the office 'issued the first federal report on e-cigarettes and youth' and worked with Congress and the FDA; on vaping he reports 'some improvements, but we still see way too many kids' without giving figures.

The reason independence matters, in Murthy's account, is trust: 'part of the reason over time I believe the public came to have some degree of faith and trust in the office' is that people hoped it functioned the way they hope a doctor does - 'being an independent source of information for you,' with their best interests at heart, 'not being pulled aside by political interests or by other agendas.' He frames priority-setting as an explicit triage under scarcity: 'where is the need the greatest here? Where can we make the biggest difference?' and 'we have to make hard decisions about where to put limited resources,' adding that not building an initiative on an issue 'doesn't mean that issue is unimportant.' Note the epistemic status he assigns this: it is 'I believe,' a claim about public trust, not a measured outcome.

So my agenda, the issues I choose to take on, are not determined by a president or a party. They're determined by science and the public interest.

Huberman's most sustained challenge is about communication infrastructure. He contrasts the flood warnings and 'test warning' alerts he receives near the coast with the absence, during the pandemic, of any email or public service announcement about maintaining circadian rhythm while indoors. He grounds the complaint in 'hundreds of studies now' that 'drifts in circadian rhythmicity are a precursor to mental health issues' and a 'new idea that many, not all, suicides are preceded by a period of disrupted sleep' - adding the qualification 'it's not causal, of course' - and asks why citizens did not get 'these are five things that you need to do every day' to stay stable. Murthy calls it 'a really good question' and 'a reasonable and a very good suggestion,' offering a hospital-safety analogy in which 'there would be an email sent to all the hospital staff members.' But he then names the structural gap: 'over the last 20, 30 years on health issues, there hasn't been sort of an agency or an entity that has sent emails out to everyone,' and 'how to send an email out to everyone in America is not a simple proposition either' - 'Technically, it's challenging,' and 'There's some legal issues you'd have to deal with as well.'

Huberman proposes a single apolitical media event - one night across CNN, Fox, NBC, ABC, New York Times and Wall Street, 'one video just where they all agree' - so the message is 'So apolitical.' Murthy replies that 'that kind of messaging... through traditional media, certainly has happened, and it happened during COVID,' noting that 'in the first year of COVID I was a private citizen in the prior administration' and watched officials go in front of cameras with 'here are three things you need to do to keep yourself safe from COVID.' He then gives two reasons this is insufficient: 'even if you hit all the major network and cable news shows, you're still not reaching everyone' because 'increasingly people are not watching TV, they're getting their news from other sources,' and 'attention shifts quickly in traditional media also from issue to issue,' so a Sunday-show clip is gone the next day along with people's attention. Despite 'we've logged probably thousands of interviews' with concise three-things messages, he says 'we actually don't have a quick, efficient way to reach everyone in the country with a health message,' calling it 'a bit of a health infrastructure challenge.'

The historical and current workarounds Murthy cites are all partial and ad hoc: - 'in the 1980s, when C. Everett Coop was surgeon general,' he 'sent a letter, a physical letter, to all households in America about HIV,' working with a member of Congress to find funding - 'a very unusual move and one that was never replicated since,' because 'there was never infrastructure or funding to do that again.' - Murthy himself sent physical letters to the medical community twice: first on 'the opioid use crisis' and '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 second on COVID therapeutics, so that data on medicines like Paxlovid reached patients, because 'many people weren't getting offered life saving medications, even though they were in high risk groups.' Both required 'creatively cobble together resources, funding.' - What the office relies on today is 'traditional channels,' 'online channels,' and 'creative partnerships' with people who reach different audiences - 'it's a patchwork and it's not always ideal.'