Rethinking health priorities: A conversation with Vivek Murthy

Pooja Kumar: I’m Pooja Kumar, a partner in McKinsey’s Boston office. Today, I’m joined by Vivek Murthy, who served as the 19th Surgeon General of the United States. As America’s doctor, he created initiatives to tackle our country’s most urgent public health issues, including the Ebola and Zika viruses, obesity, mental illness, and tobacco-related disease.

He also worked on the Flint water crisis and the opioid crisis. Vivek is also the author of a new book, Together: The Healing Power of Human Connection in a Sometimes Lonely World. It’s great to have a chance to talk to you about the public health perspective on the COVID-19 pandemic.

Vivek Murthy: Thanks, Pooja.

Pooja: Vivek, let’s start from the beginning. Tell us a little bit about how you got involved in public health and how you found your path leading the nation’s efforts to address a broad range of public health concerns.

Vivek: Well, thank you, Pooja. It’s just really nice to be here with you and with the entire community online that’s joining. My path to public health was accidental, as many other things have been in my life.

I was never one who made five- and ten-year plans, because when I did try, they would quickly fall apart. And when I was a freshman in college, I actually got a call from my father. He said, “There’s this philanthropist in Florida who wants to give money to a worthy cause, but he doesn’t know what cause to give it to. Do you have any ideas?”

What he meant was, “Do you want to do something? Do you want to build a project?” I had not thought of that at all. I was starting college, but that got me thinking. This was in the mid-‘90s, when HIV was on the rise in India. So, my sister and I together decided to build an effort to train young people, students, to go to India to empower really the students there through community education programs. We spent our first summer after freshman year doing these education workshops, and we spent the next eight years building out this effort. Along the way, we built the Community Health Worker Program in a series of small villages in south India, and this became our introduction to public health. And what I realized then is that I really enjoyed the experience of bringing people together around a vision for how to improve health at scale.

That’s what began my journey in public health, which took me to building more nonprofits. Ultimately, it led me to building a technology company focused on improving research and collaboration on clinical trials. But what tied all of those efforts together was really this common desire to bring people together around ideas that could improve health at scale.

Pooja: Now you’ve had a very accomplished career, including several of the experiences you just mentioned, but let’s also not forget that you’re only 42. What was it like being the first Surgeon General of Indian descent, and the youngest active-duty flag officer in the federal uniformed service?

Vivek: Well, it was interesting. I didn’t feel young because I felt that what I was bringing with me were a set of experiences and perspectives that I hoped would be helpful. But the other thing is, that I had to get used to working with people who were in different stations of life. So, when I was 17 years old, my sister and I were building this nonprofit organization, I had to work with the principals of schools, superintendents, and philanthropists who were 30–40 years older than I was. So, the issue of being at different ages was less of an issue for me. But what I found and what I was really excited to encounter in government was that there were people of all ages and stages, who were extraordinarily talented and who were doing amazing work. We were there because of our ideas, and our willingness to work hard, and our creativity.

The last thing I’ll say about that, which I found to be interesting, during confirmation is senators rightly asked, do I have enough experience to do this job. It’s a question they should ask everybody for any major post in government. And I was able to make a case that I did. But I found that the interesting thing is that when we get older, I think we tend to forget what it’s like to be younger. And so, we discount, for example, what younger people are able to do and how they’re able to function. But I was blessed to have people, including a president who appointed me, who believed in my ideas and my experience. [They] paid less attention to other issues like my age. I’m very grateful for that.

Pooja: Real wisdom in your words there. You started a conversation about loneliness even before this era of physical distancing that we are all caught in right now. In your new book, you discuss the importance of communities and human connection. I’d love to understand more about why you saw loneliness as a major issue in healthcare then, even before all of what we’re experiencing right now.

Vivek: It wasn’t the case that at the very beginning I thought I would work on loneliness. In fact, when I testified before the Senate for my confirmation hearing, I was asked what my priorities would be, and I gave them a list of issues, and they did not include loneliness.

I needed to be educated frankly by people around the country, who through their own stories, helped me to realize that there was something deeper happening. Beyond the stories of opioid addiction, beyond the stories of violence in communities, and disparities in health, there was something deeper going on behind those stories. Something that was unsaid, that I came to realize was connected to this sense of loneliness and isolation that so many people were experiencing.

I found that in these stories, not just stories of one particular group. These were moms and dads across the country. They were people in remote fishing villages in Alaska. They were members of Congress that I was talking to. In so many of their stories, I was finding that people were speaking to this deeper emotional pain that they were experiencing.

The pain was often coming up as a sense of being alone. They would say “I feel that if I disappear tomorrow, it wouldn’t matter” or “I feel invisible.” And hearing that again and again reminded me of two things, Pooja. It reminded me of my own personal experiences as a child, struggling with loneliness in school. And feeling this sense of dread when my parents dropped me off at school because I was a really shy kid, who had a hard time building friendships. The scariest time of the day for me was lunchtime, when I’d walk into the cafeteria and be scared that there would be nobody to sit next to.

And, I was reminded of those experiences when I was on the road as Surgeon General. I was also reminded of one other thing, which were my experiences in medicine, where I was surprised to find that so many patients came into the hospital alone. And even when we had to give them really difficult diagnoses, I would say, “Is there somebody that we should call to come in, because this is a lot to deal with on your own,” and a lot of times they would say, “There is nobody. I’ll just have to handle this by myself.” Even Pooja, at the time of death, I remember so many cases where the only witness to someone’s final hours were myself and my colleagues in the hospital.

My experiences were not singular, I was being given a window into a much deeper well of loneliness that affected people, not just across the US, but really around the world. It had profound consequences, as well, for our health, given that we know now that loneliness is associated with their increased risk of heart disease and depression, premature death, as well as anxiety.

Pooja: It feels like a lot of the journey that you went through personally is now what a lot of others are experiencing through the eyes of COVID. How has COVID changed your thinking and what concerns you most about extended periods of physical distancing and isolation and its impact on society, if at all?

Vivek: You know, COVID has changed my world and it has changed my perspective. Long before the pandemic hit, I was deeply concerned about loneliness, but in the age of COVID-19, I’m worried that loneliness could deepen further. That we could see the physical distancing that we’re being asked to observe translate into social distancing as we feel more and more disconnected from the people that we need in our lives. The irony is that this is happening during a time of extraordinary stress. And so, I worry about what I think of as a social recession that we may incur with profound consequences for our health, for our productivity in the workplace, and for how our kids do in schools.

And I also think that this could be an extraordinary opportunity for us to step back and to ask ourselves if we’re leading the kind of lives that we really want to lead. This is our chance to ask ourselves where people fit in our priority list and whether there’s a gap between our stated priorities and our lived priorities.

I will tell you that there’s a gap in my life. If you asked me, “What are your top priorities,” I’d be very clear on that. My top priorities are the people I love—it’s my mother, my father, my wife, my sister, my two children, my brother-in-law. But then the harder question is, “How am I actually living my life? Are the decisions I’m making about where I put my time, energy, and attention consistent with those priorities?” If I’m honest with you, I would tell you that a lot of times it’s not.

So, there’s a gap between my stated and lived priorities. And this moment is highlighting for me just how important it is to close that gap. Because I think for so many of us, we are realizing something we already knew in our hearts, which is that our relationships matter deeply to us, that they’re not just nice to have; they’re necessary to have.

And the science behind it tells us that they affect our health and they actually affect our workplace performance. Sigal Barsade, a professor at Wharton, who along with others, has found that loneliness is actually extremely common in the workplace. It shows up as greater disengagement, which has downstream effects for their productivity, their creativity, and even their retention. The same is true with kids. Children who are lonely struggle when it comes to learning, and their outcomes overall are threatened.

So, if we use this as a moment to recognize that, to build lives that are centered around people. And to make the case for creating a people-centered society, one where we do think about human connection as we design workplaces and schools, a world where we think about human connection when we’re assessing the impact of policy as well. Then I think that we will put ourselves on the path to creating a society that is healthier, stronger but also more resilient than even before the pandemic began.

Pooja: I love the way you spoke about being intentional and actually calling ourselves to account about what we want versus how we’re acting. Are there other ways individuals can take steps to maintain their connections?

Vivek: Well, yes, because we don’t have the ability to be together, the question is what can we do to strengthen [our] connection regardless of that limitation? One of the great points of learning that I took from the extraordinary people that I met across the world in writing this book, was a simple lesson that small steps toward connection can make an extraordinary difference. Then to build a connected life, it’s not about necessarily transforming your life, turning everything upside down, quitting your job, and moving to be close to your friends. All of those things could be really helpful, but you don’t have to necessarily transform your life entirely in order to see more connection.

Here are some simple things that I think we can do during this pandemic. One is we can make a commitment to spend at least 15 minutes a day reaching out to someone we love. That could be videoconferencing with them, it could be calling them on the phone to just check in and see how they are. Fifteen minutes is not a long time. But when done consistently, it can lift our mood and can serve as a lifeline to the outside world.

The second thing we can do is we can focus on the quality of time we spend with one another. Even if you don’t increase the time you have with others by a single minute, if you are able to eliminate distraction when you talk to others, particularly from our devices, that can significantly boost how much you get out of the interaction and how much they get, too. If you’ve ever had the experience of talking to a friend when they were listening to you deeply, when they were fully present, where you were open and sharing authentically, you know that that feels incredible. It feels like you’re being seen, like truly seen.

And all of us, as human beings, we may be from different backgrounds and experiences but we have three core needs: we all want to be seen for who we are, we all want to know that we matter, and we all want to be loved. And so giving other people the gift of our full attention, is one of the most powerful things we can do right now. And it doesn’t have to take an additional minute in our life.

The third thing we can do is to look for opportunities to serve. It turns out that service is one of the most powerful antidotes to loneliness, and there’s a reason for that. It’s rooted in our biology. Because when we’re chronically lonely, what happens is we experience an elevation in our threat level. We also shift our focus inward because we feel unsafe. Service shortcuts that mechanism. It shifts the focus from us onto someone else in the context of a positive interaction. It also reaffirms for us that we have value to the world.

Service in an age like this might look like delivering food to a coworker, who you know is struggling to telework and homeschool their kids. It can even look like just offering to virtually babysit for five or ten minutes. Maybe I’m talking about something that I might enjoy. I know as a parent, when somebody else calls and just gives you just five or ten minutes because they are entertaining your children. And when you can just sit down and breathe for that five or ten minutes, that time is like gold. All of this is just to say that if we look around us, we’ll find that there are many opportunities to serve.

These are all simple pathways that we can take, thinking about the quantity of time, the quality of time, and the opportunities for service that can help strengthen our connection even though we’re not able to physically see each other right now.

Pooja: I think there’s a real idea in that virtual babysitting, I would be fully onboard with that as well. It’s been great to focus on what you see as individual things we could be doing.

I’d love to shift focus now and talk about the system’s response? I’d love to start by actually talking about frontline workers of which you are one and your wife is one as well, and likely a huge proportion of your colleagues and friends.

Paint us a picture of how things are for frontline workers. What types of solutions do you think we need to be thinking about to ensure that they are protected and treated effectively?

Vivek: That’s an important question. My wife and I are both doctors. I’ll be honest with you. We feel a tremendous amount of guilt in not being on the frontlines with a lot of our colleagues. There are times when we look at each other and we’re like, “Should we just go to the hospital? Should we just like help?”

And then we remember that there are other issues that we have to deal with. We have a grandmother who is 90. We’ve got parents who are aged. We have these other needs that we’ve got to fill at home. But I will tell you that it is really painful to see what is happening on the frontlines because we have seen now so many nurses and doctors, who are going to work each day and who don’t often have enough protection that they need. Things are getting better, but there are still many pockets of the country where people don’t have what they need.

One of the things I learned in government about pandemic response is there are a few core principles that you absolutely have to adhere to. One of them is to communicate transparently and truthfully, even when it’s hard, especially when you mess up. The second is you have to lead with science and with scientists, letting science guide your decision making even when it’s not popular. And the third is you have to get the resources to people on the frontlines, the resources that they need. In this case that’s nurses and doctors. It’s grocery store workers. It’s postal delivery people. It’s people, who are having to put themselves in the line of fire, so to speak, because they’re serving us and making our lives possible.

For healthcare workers, PPE is one piece of it, but the other thing to recognize is that many of them are going through a traumatic experience. Frankly, all of us are. But they are on the frontlines of it, so the mental health impact on healthcare workers is already profound but it’s going to grow.

What we know [from studying] hurricanes, tornadoes, and other natural disasters is that mental health challenges arise in the form of depression, anxiety, [and] post-traumatic stress disorder. But they don’t disappear when the last house is rebuilt, or the last piece of debris is cleared. In fact, they often persist for months and sometimes even years afterward. That means as we think about our healthcare workers and other frontline workers, we’ve got to make sure we have the mental health services for them.

The last thing I’ll say about frontline workers, it is not a specific policy that we need to take but it’s more about a trust or a compact that we have to build between government and frontline workers. I believe that in moments like this and frankly, in between moments like this, that the government’s job is to support people and that people’s job is to support each other.

By that measure, I see people all around America upholding their end of the bargain. People are stepping up to take care of each other. They are dropping food off at the house of neighbors, they are calling and checking in on friends. People are stepping up. From a government perspective, I think we’ve got a lot that’s swinging in a positive direction. But I think what we’ve fallen short in terms of implementation, and I think we’re seeing that in terms of where the struggles that our frontline workers are having not just with PPE, but also with testing. We need every healthcare worker to be able to get tested regardless of symptoms. We do not have that capacity yet, and that is a profound problem.

When we fall short, we damage trust. When we damage trust, then people are less willing to follow directives in the future. They trust less that you’re going to be there for them. In moments like this, in pandemic responses, public trust is everything. When you lose public trust, that’s when you start to lose the entire effort because then even when you’re telling people the right thing to do, they’re not going to do it because they’re not sure you are being level with them.

That doesn’t mean that you can never screw up because, trust me, in every outbreak response, something goes wrong, something gets broken. It happens in Democratic administrations, Republican administrations, and that’s why you have to approach these pandemics with humility. But the way that you deal with those stumbles is to be upfront and honest with people and to really deliver on what you say you’re going to get them. Right now, I worry that many of our frontline workers don’t trust [that] the government’s going to be there for them in the way they need because they’ve seen some shortcomings in the past.

I think we’ve got to repair that trust by delivering on what they need, in terms of PPE, testing, mental health services, and other support. It’s not just important for making this pandemic response work, but it’s also going to be critical for future response efforts.

Let me note this because it’s critical, I think we’re so focused on what’s to come in terms of COVID-19-related issues [but] there’s this whole surge of non-COVID-19-related care that’s going to start to flow right back into our healthcare system.

It hasn’t gotten a whole lot of attention, but I’m worried about the non-COVID-19 surge. All of the elective, nonessential procedures that were deferred yesterday will become urgent tomorrow. How do we take care of all those people? How do we restore faith in patients that they can come back to the healthcare system and not put themselves at high risk for getting infected? These are critical questions, in terms of how we take care of everyone who doesn’t have COVID-19. Yet another reason why we need to make sure that we’re taking care of frontline workers, we’re getting them the tools they need, and continuing to build trust by delivering for them.

Avoiding a ‘social recession’: A conversation with Vivek Murthy

Avoiding a ‘social recession’: A conversation with Vivek Murthy

Pooja: Yeah. I think there is some real fear about what it means to go into an acute care setting, in particular. As you mentioned, a lot of thought being put into what does that mean going forward, when will people regain that trust of being able to be safe when they go back to a healthcare setting.

A tangential, but related question is around vulnerable populations. You obviously issued a call to action in the first ever Surgeon General’s Report on alcohol, drugs, and health, to end the public crisis of addiction. I’d love for you to just talk about that a little bit.

Vivek: I’ll tell you that one of the most poignant parts of my experience as surgeon general was spending time with literally thousands of people, who had struggled with substance use disorders. Some of them had come through on the other side and were in recovery. Others were still in the midst of that deep struggle. I talked to so many family members who lost loved ones to addiction, including to opioid overdose deaths.

One of the good things that’s happened in the last few years is that we’ve slowly started to pull back the curtain on addiction. We’ve started to lift some of that stigma that still exists at too great a degree, but which I think is better now than it was 20–30 years ago. But what I worry about is what’s happening right now. Which is during times of extraordinary stress and trauma, and we should think about COVID-19 actually as a major stressor, as a source of trauma across a population, people who were living in recovery can sometimes, in this setting of severe stress and trauma, can slide back and can relapse. The second reason I worry though is because of what you said earlier, Pooja, the fear that people have with engaging with the healthcare system.

If you are someone struggling with substance use disorders, where does your care fit into the larger priority list? Is it essential care? Is it high-priority care? Well, I think most people would agree that if somebody is in the throes of crisis with COVID-19 and they are on the verge of needing intubation that they come first. But after there, it can get murky. I think what’s happened in different communities around the country is that care itself has been interrupted for people with substance use disorders. Some of them are finding it harder to get the counseling care that they need. Some of their healthcare providers are finding it hard to provide services at a distance.

That’s a technology problem. It’s also a much broader problem with how we have embraced and integrated telehealth into our larger approach to healthcare. When it comes to getting medications, getting buprenorphine [or] getting other medications that are important for the folks with substance use disorders, it is also harder. What we’re seeing is more stressors that will tip people toward relapse. At the same time, we’re seeing a functional reduction in the services that people are getting. I think unfortunately, we’re going to see the consequences of that show up in the coming weeks and months.

I think this is waking us up to the fact that we’ve got to do a better job of ensuring that people can get high-quality care, but that they can also get it in flexible settings. When I think about the future, I think about a society that needs fewer and fewer clinics and hospitals because we’re doing two things better. We’re bringing care to where people are in their homes and in their neighborhoods. Also, because we’re doing better at prevention and changing those underlying drivers of health, whether they be someone’s access to food, their ability to actually get out an exercise, [or] their ability to form strong social connections.

What this epidemic has done is just pulled back the curtain on the good, bad, and the ugly of what’s happening in our healthcare system. It’s shown us that we’ve got heroic staff, we’ve got extraordinary nurses and doctors and frontline workers. We’ve got many hospital systems that are working well and that have risen to the challenge. But it’s also showing us just how incredibly uneven things continue to be, how access is still difficult, how quality is still so variable, and how we have just frankly failed in medicine to use technology to its fullest extent. To be able to deliver not just the that care that people need, but to actually handle the data that we receive and generate the insights that we need, so we can target care in the most appropriate way.

This is a call for us to do that better, to do it faster, [and] more aggressively. So that not only are we prepared for the next pandemic, recognizing that even COVID-19 is going to go on for some time, but also so even in between pandemics, we can [provide] better care to people and do the job I think they expect of their medical and public health systems.

Pooja: Yeah, certainly in my work over the last few months in the response phase of this, I have never seen as many Band-Aid solutions—manual data collection, Excel tracking—as I have before. Some of it is great because we’re finally asking for it and asking for this information to be looked at in a way that allows us to make better decisions.

I do wonder sometimes, how easy will it be to slip back into what we used to have and the ways in which we used to work versus take the real lessons from this and invest to build something greater from a systems level that will allow us to be more resilient and more prepared.

Vivek: I think your warning is so appropriate because what happens in general, not just around healthcare but in every realm of life, is after a crisis people slip back to the way it was before the crisis. I think what has to happen with COVID-19 is that we have to make it different this time. We can’t afford to go back into our old lives, where we allowed people and relationships to slip to the side, in terms of priority. You’ve got to keep people back at the center. When it comes to healthcare, we can’t afford to go back to the way it was working, or not working, pre-pandemic because we now know that the cost was tremendous in terms of dollars and also most importantly in terms of lives.

I just want to give you one example. We know we need technology and it can help us do better, but we can also get fascinated with technology for its own sake and with novel ideas and applications. And go down the path of creating something that is intellectually fascinating, but perhaps practically less useful. Departments of health could sure use some help from technology companies that have the ability to set up systems to handle data, to organize it, to set up firewalls, [and] to respect privacy. But they can also allow the larger data analysis that we know is so desperately needed and lacking in the larger public health system.

Local departments of health had their budgets shredded in 2008, during the Great Recession. And while everything else built up, many of their budgets stayed about the same. So, they have lost so much capacity, and a big part of that has been in the realm of technology. They have not been able to often modernize. If you have a case that presents of COVID-19 in your community and somebody has to contact trace, it’s your local department of health. They rely on systems and funding and people. Right now, in all of those three areas, they’re struggling. So, even though it’s not always the most exciting thing to think about building databases that work for local departments of health, it turns out that we have a major technology gap that we have to fill at a very basic level. This is our chance to lean into that, to do it well, so that we can serve our communities now and also in the future.

Pooja: Yeah, I love that point. How do we take so many of the weaknesses that COVID has exposed that are not “sexy” to talk about—supply chain, IT systems—and actually make them the big areas where we can double down our focus?

As we think about a reimagined future for public health, what role do you think private entities can play in interacting with the government to prepare and potentially prevent another pandemic?

Vivek: One thing that this pandemic and other outbreaks have made clear is that the partnership between the government and the private sector is essential. And it’s essential on several levels.

One is when it comes to communicating information about what people need to do to protect themselves and their families. That information needs to be echoed by companies, by universities and schools, [and] by local leaders. The stronger the partnerships are with government to communicate and share information openly, including around messaging, the more effective the dissemination of information could be.

The other place where I think these partnerships are going to be really essential is on the supply portion of the response effort. We know if we look at testing and personal protective equipment as just one example in this pandemic, that in order to do that well, what the government really needs is to partner with manufacturers. It needs to partner with distribution entities that can actually help get the materials to where they need help, better assess needs, and set up ways to gather feedback from the field to know whether we’re actually getting the materials and tools to the right places. The truth is that you don’t build partnerships overnight. And if you wait until the pandemic is there to build those relationships, it’s usually not nearly as effective as if you start building ahead of time. This is a place where we have to imagine the next pandemic and think, “What partnerships can we build to produce the materials and distribute the materials we know are inevitably going to become necessary?”

The final part I’ll say is about supporting people. COVID-19, I think more than almost any other natural disaster that we have faced in our lifetimes, has created such a profound economic need and inflicted such deep economic pain on such a large number of people across the world. And in these moments, all of us have to step up to support people in need. The government can’t cut enough checks to resolve and alleviate all the pain that people are feeling right now. That economic support is important, don’t get me wrong, but what also has to happen is government needs to be working closely with companies to figure out what to do to support workers beyond cutting checks. It might mean that we need to be providing more mental health services to people who are struggling during this time of crisis. It might mean that we’ve got to take the input and the power of companies to understand what is happening among their employee base, to find signals as to where hunger may be becoming more of an issue in a population, or where other mental health issues like depression and anxiety might be becoming a concern.

So, as we move forward, I would be thinking about how we reimagine our partnerships with nonprofit organizations, with schools, and with companies going forward, so that we can be a singular part of a response effort. Monitoring how people are doing, helping to get people the healthcare they need and the economic support that they require, and working together as one unit, so we can also be speaking with the same voice and sharing reliable information driven by science to make sure that it gets to everyone. That kind of synchrony is what we need in pandemic response. When it happens, people’s lives are saved. When we don’t do that, then we measure the costs in terms of human suffering and lives lost.

Pooja: Well, Vivek, thank you so much for joining us today. It’s been a pleasure to hear your lessons learned and reflect a bit on what you’ve seen in this journey but also in our broader quest to address some of the biggest issues of healthcare in our time. So, I appreciate your taking the time out.

Vivek: No problem. It’s so good to be with you, Pooja. Thank you and to all your colleagues for everything you’re doing to try to help us build a better healthcare system and address the COVID-19 pandemic. Really appreciate it.

For more related insights, visit the Center for Societal Benefit through Healthcare’s webpage.

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