Transcript: Vivek Murthy: The Nation's Doctor

The Oath with Chuck Rosenberg

Vivek Murthy: The Nation’s Doctor

Chuck Rosenberg: Welcome to The Oath. I'm Chuck Rosenberg, and I am honored to be your host for another compelling conversation with a fascinating guest from the world of public service. This week, we talked to our first doctor. My guest is Vivek Murthy, the former Surgeon General of the United States. Vivek is a deeply thoughtful and reflective medical professional who served as the Surgeon General and simultaneously as a vice admiral in the Public Health Service Commissioned Corps. In that role, and after an exhaustive listening tour throughout the country at the beginning of his tenure as the nation's doctor, Vivek realized that loneliness is a pervasive medical issue in our country, and that it is both a cause of and a consequence of chronic illness. In his powerful and illuminating new book Together, Vivek explores the role of loneliness in society and its relationship to chronic illness and prescribes ways that we can identify it, think about it, and counter it. Vivek Murthy, welcome to The Oath.

Vivek Murthy: Thanks so much. Thanks for having me on.

Rosenberg: Well, it's a real pleasure to be with you. I appreciate your making some time for us.

Murthy: Of course.

Rosenberg: You were born in England, but your parents immigrated to England from India. Tell us a little bit about them and their journey.

Murthy: They both grew up in, I would say a modest background in India. My mother was from a middle-class background. She grew up in Bangalore, a large city in the south. My father grew up quite poor actually in a small farming village in South India. His grandfather was a farmer, his father was a farmer, and he was expected to be a farmer as well--his life took a different path. But in the village in those days, poverty levels were high, and people had very little in the way of material possessions. My father, for example, I think he was 15 or 16 years old before he owned his first pair of footwear. And it was, you know, times were tough, but what they were rich in, are relationships--they supported each other, they help each other. You know, all of that made it extremely unlikely that two people with those backgrounds would actually leave. My father eventually found his way through school, which was very unusual, actually went to college, which was the first in his village along with his brother to go to college.

Rosenberg: How did that happen?

Murthy: Well, I think he attributes it to his father who was very intent on his children being successful and being educated even though he himself and not completed elementary school. In fact, he went so far as to tell his three sons what they would become. So, he told my father's elder brother that he would be an engineer. He told my father, you need to become a doctor. And he told my father's younger brother that he had to become an agricultural expert, a horticulturist. He had ambitions for his daughters too, he had three daughters as well. But in that way, he set a direction for them. And my father, he always listened to what his father had to say. And it was, sort of like the rule of law--when father said it--then had to be executed. That was how he approached.

Rosenberg: Well, in fact, it his older brother end up as an engineer and his younger brother as a horticulturalist?

Murthy: They did actually, yes.

Rosenberg: How about your mom? How about her family?

Murthy: My mother's family is originally from Andhra Pradesh and neighboring state. They moved to Bangalore a few generations ago. Her father was an electrical engineer, and actually grew up in challenge times himself, his mother passed away when he was young. He had very difficult childhood with a stepmother who didn't really accept him or his brother, but he somehow made it through and became actually, eventually, the superintendent of the electricity board in the city. His wife, my grandmother, he actually studied through college, which was unusual during those times. But my mother was, while she loved her parents dearly, was largely raised by her grandmother who was a matriarch, you know, of the family and really set direction for everyone. So, it was because of my great grandmother, my mother's grandmother, that she worked hard, studied hard, and eventually, did her master's degree in English Literature, which again, was an unusual level of education for a woman to achieve at that time.

Rosenberg: And did your parents meet in India?

Murthy: They did meet in India, and they had an arranged marriage. So, they really didn't have much in the way of a conversation at all before they actually got married. Their parents spoke, agreed that this would be a good match. And a wedding was arranged, and they showed up.

Rosenberg: And the rest is history.

Murthy: Yes, it wasn't an easy history, if you will. Arranged marriages are ones where you got to learn who the person is after you actually get married, which can be challenging. When I was young, my parent’s friends, you know, the other Indian aunties and uncles, if you will, in our community, would often say, “in America, love comes first, then comes marriage. In India, marriage comes first and then comes love.” You learn to love someone, they would say, after you get married, so it was very different experience for them.

Rosenberg: What brought your mother and father to England? Why did they move?

Murthy: Despite growing up in very poor circumstances, my father had big dreams. He knew from a fairly young age he wanted to explore and he wanted to go where there were opportunities. And at that time, he was born around the time of Indian independence, that even though India had just separated from Great Britain, it was in Great Britain that the opportunities were for education, for higher jobs, and for greater achievement. And so, that was the first place he went. If he could do it all over again, he says he would have come directly to the United States. He actually left for England shortly after he got married, but without my mother, he went on his own first and there was a reason for that: he wanted to make sure that he established himself there and could bring my mother over when it was a little bit more comfortable for her. But he also had another goal in mind, which is that he wanted to pay off all of his father's debts before he brought my mother over. His father, you know, as a farmer who had struggled over time in India, had accumulated some debt like many farmers do, and it was debt that was incurred at high interest rates as well, and loan sharking is a huge challenge for Indian farmers. But my father knew that on his own his father, even though he would never ask for help and repaying the loan that he would struggle, so he saved every penny he could. Once he went to England, ate canned food and whatever he needed to do to save the maximum, paid off those loans, and then brought my mother to England.

Rosenberg: And established his medical practice in England?

Murthy: Yeah, so he worked in in different capacities as a doctor in England. He worked in the hospital, you know, on the inpatient side, he had outpatient clinics and he moved around a fair amount in England after my mother came. So, they spent time in London, in various parts of England, he was in Scotland for some period of time, in Wales, in Dublin, and Ireland. They spent time in many parts of the UK. Eventually, they left though because as much as they enjoyed their time in England, they also struggled because in the 1970s, there was still a fair amount of racism in England. And it was challenging if you were a person of their ethnic and cultural background to get the opportunities and have your ideas heard in the way that my father wanted, in that he had dreamed of. So, he wanted to come to the United States. The first opportunity he had to leave was to bring the family to Newfoundland, which is where our next pit stop was.

Rosenberg: So, between the UK and the United States, you lived in Canada for a time.

Murthy: We did, we were there for two years.

Rosenberg: And you tell a wonderful story about the small town in which they lived and worked, and how you were the only family of color, the only immigrant family, yet the town wholly adopted your parents and you and your sister.

Murthy: It was a profound experience for my parents, a very humanizing and I would say a reassuring experience after some of the challenges they faced in England. They came to this small town in Newfoundland. Newfoundland itself at that time was a largely rural part of Canada. And this was a rural part of Newfoundland. My father was designated as a medical officer for that particular part of Newfoundland, which meant that he was responsible for the health of the people in that area from birth to death and everything in between. But it was a fairly insular community at the time. And I'm not sure most people that had ever seen somebody who looked like my parents, but to their great comfort, people accepted them, and not only accepted them, but they embraced them. They would help them out with babysitting when my sister and I were young, they would bring over food and it was their way of showing that they cared about us, just as my parents did everything they could to take care of and provide for the people they were charged with in Newfoundland.

Rosenberg: You wrote in your book how looking back on that time, and their lives, you were very young, of course, that it had served as your guiding light. What did you mean by that, Vivek?

Murthy: I think in life, all of us spend a lot of time, years, often, looking for what we need and trying to understand what it is that we truly need. And for my parents, even though they left India looking for opportunity, one theme that came up numerous times over the course of their journey was that they also needed community. And this search for community was part of what took them from England, to Newfoundland, eventually, from Newfoundland to Miami. And it says so much of what shaped my childhood and what I saw them doing in terms of cultivating relationships in their medical practice and in the community, of serving the community, and that being a foundation on which they built relationships. A lot of that was oriented around building community and that urge and that need became even stronger I think after we were born. And so, my earliest experience of understanding the power and importance of relationships came through my parents and watching their journey.

Rosenberg: And so, on to Miami, which is really where you grow up, where you spend your childhood, where you go to middle school and high school, and where your parents put down significant roots in the community as medical practitioners. But you also described, while living in Miami, attending middle school there, and high school there, feeling lonely and being bullied. Could you talk about that a little bit, please?

Murthy: Sure. So, when we moved to Miami, it was very different from Newfoundland. It was not only warmer, but it was much more diverse. There were people of all ethnicities and backgrounds. But despite that, there were very few people who were of our cultural background. We didn't encounter that many Indian people, and certainly not in the school that I was going to, and elementary, or even in middle or high school.

Rosenberg: You went to public school?

Murthy: I did. I went to public schools in Miami, Florida. You know, little kids being little kids, often, they tend sometimes to poke fun at what they don't understand. So, while I'm of East Indian descent, there were kids who thought maybe I always have Native American descent, and you know, found it humorous, just to make fun of me in that regard. You know, I didn't quite know how to handle that, you know, when I was in second grade, and third grade and fourth grade, it made me embarrassed. I didn't feel ashamed of who I was, but I felt pain and I felt bad that I couldn't be who I was. My parents had brought me up to feel a lot of pride, about our cultural identity, not in an exclusive way, not to feel like we were better than other people, but to feel like we had something that we should be proud about that we could bring to this country just like other immigrants did. I felt, at school, that I couldn't necessarily be that person because I was made fun of for it. So, you know, they were some of that, you know, and it continued a bit in middle school, and as it child who was shy and lacked in self-confidence, I also wasn't quite sure how to stand up for myself. It was much easier for me to stand up for other people and to be kind to others than it was to somehow defend myself or stand up to a bully. So, in the face of that, I found myself getting further and further anxious about social interactions in school and anxious about just being alone, and worried about when the next bully might be around the corner.

Rosenberg: And you wrote that you actually thought you were bad at making friends or that you were intrinsically unlikable, that this self-doubt crept in.

Murthy: Yes, and that's one of the insidious things about being lonely: is that it can go from being a state of being, to somehow being a condemnation of who you are, as over time, you start to absorb that state of loneliness and think of it, not as just an accident of circumstance, but as somehow a product of who you are, and more specifically, a product of a deficiency that you have. And for me, that was the case as well. I started to think that maybe I just wasn't good at making new friends, maybe I wasn't likable. I never told my parents about my struggles with loneliness in school because I didn't, I didn't want them to feel bad. Honestly, I didn’t want them to feel like they had failed somehow or that--I knew that they would be so pained if they knew that I was being bullied or if that I was feeling alone, but, but you know, every morning when I went to school, it was a, I could feel that stress, you know, welling up in my stomach. Every day as I go through school, it was just, I just couldn't wait for the bell to ring telling me that hey, this was it was time to go home to a safe place where I knew I was loved.

Rosenberg: It got a little bit easier as you moved to high school and found a group of friends, but I imagine that self-doubt lingered for quite some time.

Murthy: It did, it did. You know, when I was in middle school, toward the end of middle school, I think I started to gain a little bit more confidence. Interestingly, it came because of my academic successes, which, you know, being a nerd is no great source of confidence for most people. But for me, what I was blessed with was to find community of teachers and students who valued my skill set and valued whatever strengths I had in the academic front and helped me realize hey, I'm maybe I do have something of value here. And building on that confidence, I was able to engage with more people and I built some wonderful friendships over time.

Rosenberg: And speaking of academic success, you graduated as the valedictorian from Palmetto Senior High School in Miami in 1994, and on the Harvard. Your family must have been thrilled.

Murthy: They were I'm, I'm surprised that you know that, Chuck. I rarely tell that to most people about graduating from high school in that way, but they were very excited. You know, again, keep in mind, my father came from a background where no one finished school, you know, when they came into this country, they came in part hoping that there would be greater opportunities for my sister and me, to see that we had been supported by teachers and by schools, and by a community to be able to have some degree of academic success and, and be able to go on to a good college. That was, that was to them, just one more manifestation of how the promise of America had become a reality for our family.

Rosenberg: Was Harvard easier in the sense that it was okay to be smart?

Murthy: I would say that by the time I graduated high school, I had no, no challenge or embarrassment about being smart or caring a lot about academics. The label of a nerd, if you will, is one that I wore with pride. And I didn't feel that it was denigrating in any way because I was around so many people by the time I went to high school who also valued those pursuit, but my time at Harvard was quite lonely. In fact, probably more lonely than my time I had spent in middle school or, or even high school. I ended up focusing a great deal on my studies to the exclusion of doing much at all socially. And I was away from my family, a family that I was extremely close to, and quite dependent on, and that I missed dearly every day. And it took me a good year during college to get to a point where I felt comfortable being there, where I met people who I felt like connect with, who I look forward to seeing when I came back to campus. There was another thread to this, which is that growing up, I had always had a spiritual practice that included meditation and prayer that had kept me grounded. And when I went to college, somehow, that practice just didn't feel like it worked for me anymore. And I felt like I had to give a lot of it up. And so, I felt like I was both losing my connection to, to God and my spiritual life, while at the same time, I was not able to see my family and was thrust into a new world where I wasn't quite sure if I would succeed. I didn't know if I was smart enough to make it in a sea of also very smart people.

Rosenberg: But you did.

Murthy: I was grateful, yes, to have made it through and to have, you know, had some great experiences academically. I think I wasn't always thrilled with how I did, but I think I did okay overall.

Rosenberg: If I can push back a little bit, Vivek, you did more than okay, you went on to Yale Medical School.

Murthy: I did, I did. Yeah, and I was very grateful for that. What was interesting is that at the time I was actually quite crushed because I had set my sights on going to Harvard Medical School. I had worked there as a research assistant in a lab, I had taken a year off after school to actually work full time in the lab was working on developing a vaccine for a very common bacteria called Staphaureus. And I thought, yes, this is where I want to be. My father, I remember during this time, said, “you know, you should try going to a new institution, you'll learn new things, you'll meet new people.” But I brushed that advice aside, I said, this is where I need to go. I know this place, and this is the best place I could be. I still remember the day I came home, and there was an envelope in the mailbox. And with great trepidation and anxiety, I hope in that I had heard that if you get a thin envelope not to worry about it, because Harvard Medical School would often send a single letter saying you've been accepted and your package would come later, but that was not to be the case. I opened up this letter and it was a letter of rejection, saying that I would not be going to Harvard Medical School and I was so crushed. And I remember calling my parents in tears and saying, “I feel like I failed. I feel like I, I didn't make it.” And I look back on it at the absurdity of it. And in some senses--absurdity in the sense that like it was so narrow to think that the only way one could make it would be to go to a single institution--I ended up thankfully getting into Yale medical school afterward. Ironically, both when I went applied to college and medical school, the school I had had the strongest positive gut feeling about was actually Yale both times because I had this instinct that a Yale people really took care of each other, that they looked out for each other and that it was a real community. When I thought about it again, when I got the letter from Yale saying that I had a seat there, you know, I embraced it, because I thought, you know, maybe there's something here to that instinct that now I've felt two times around. And I was really blessed to actually go to Yale and experience what ended up being a really powerful sense of community. And I had, I think, the greatest sense of belonging and connection to people that I had experienced at any point in my schooling.

Rosenberg: What was it about Yale that provided that sense of community?

Murthy: You know, I thought about this often over the years. And I think it was a couple of things. I think--all with a caveat that of course, I was evolving myself--but I found this story of community to be remarkably consistent, as I talked to people who had been at Yale and also been in other universities, they felt that there was just a sense of community there. It came from a couple of things. I think, one: in the medical school, the philosophy of education was very much based on stepping back from generating competition among classmates, to promoting collaboration and teamwork and friendships. And that was reflected in the structure of the curriculum. For example, the classes were pass/fail. The exams are actually, if you can believe it, all anonymous. And the idea of was--just that they gave you opportunities to learn and learning happened best together. And so, people were given a lot of encouragement to study together and to work together to help each other. That was really powerful. And it created an environment where we could really bond with and spend time with each other. But there was also a focus on, on thinking about how we wanted, as students, to create the educational experience. So, when I was in medical school as a first year, I made a trip to San Francisco to see a good friend who was a medical student at the University of California, San Francisco, UCSF. And there was this incredible course that he was taking at the time called the “Healer’s Art,” taught by a woman named Dr. Rachel Naomi Remen, who had created a course that would re-engage students in the deeper values that brought them to medicine. She had recognized as a doctor herself, that one of the things that gets shredded, if you will, very early in medical training, are those values that brought people to the profession--they get immersed in competition, memorizing facts executing on specific, the big outcomes, publishing research papers. And they forget the humanity of medicine and their own humanity in the process. And she wanted to do what she could to prevent that from happening. I came back after that visit, when during which I shadowed my friend and sat in on one of the core sessions and said to myself, I want to begin a Healer’s Art at Yale because I don't want this to happen to me. And I think it's a core part of what's valuable in medicine, remembering that we're here to relieve suffering and take care of others. And so, I received all of this support from faculty members who said, “We’ll help you, we will stand by you in building this course.” I think what they had recognized inside themselves was that in all the focus on mechanisms of disease and cellular processes that dominated so much of our medical school curricula, I think they too had felt the absence of that deeper humanity that brought them to the profession.

Rosenberg: When does a doctor first take the Hippocratic Oath? When did you take it, and where, and what do you recall about that?

Murthy: I first took the Hippocratic Oath at graduation, but there was another oath that we had taken at the beginning of medical school during something called the “White Coat Ceremony.” It's a ceremony where they give you your first white coat, it's usually a short white coat, as opposed to the long white coat that doctors who are done with their training wear. But during that time, I remember being invested, you know, with that code as part of a larger oath that we were taking to now learn medicine, not just during these next four years, but to become lifelong learners, so that we could serve our patients in the best way possible. But the Hippocratic Oath at graduation was particularly special for two reasons. One, because we knew that this was an oath that had been taken by generations of physicians over many, many years.

Rosenberg: Including your father?

Murthy: You know, interestingly, I've never asked my father the question I assumed he had in India, but I should ask him. But yeah, it was special because it had been taken by generations of physicians and it felt like it was part of what connected us to all of those doctors who came before. But the other thing that was special about it is that we customized the Hippocratic Oath because there are elements of the Hippocratic Oath that did not encompass the complexity of life today. There was an added focus on being conscious of our own well-being and nurturing ourselves so that we could contribute to the well-being of others. There was an element, I believe, of inclusion as well, that was in the oath, saying that we would treat all people equally--there are elements that that I remember that made me proud to feel that I was a member of this class and that we were taking this oath together. And even to this day, when I go to other medical school graduations, whether I'm attending as a friend, or speaking at a commencement, one of my favorite parts is to stand up with the new graduates and to recite that Hippocratic Oath again, to renew that oath, if you will. It's something they asked not just the graduates to do, but they will ask all of the doctors who are in the audience to stand and to reaffirm the oath that they took all those years ago, I actually like that, that in medicine, we have the opportunity to take that oath, time and time again, because I think all of us, as human beings, need to be reminded of the commitments we make. And when I began my tenure in government, I remember taking an oath as well, to support, protect, and defend the Constitution of the United States. I look back on it and, and I think that that was such a sacred moment for me. And I can't help but wonder if it would be helpful for those of us who serve in government to take that oath, repeatedly, again over time, to remind ourselves, as we all need to be reminded, of just who it is we serve.

Rosenberg: I think I've taken that oath nine or ten times, and I know that I've administered it to hundreds and hundreds of people, and every time I took it, or every time I administered it, not to sound too corny, it sent shivers down my spine. And it's not just a bunch of words. It stands for something fundamentally important about who we are and what we do, I believe.

Murthy: I couldn't agree more. You know, I think at our heart, as cynical as people are sometimes believe we are in the 21st century, I still think that we want to be a part of something bigger than us, and that we want to be a part of contributing to making the world better. And that means being motivated by a core set of values and by a vision for how to make America stronger, and our world better. And so much of that is a spirit I see in medicine. It's what I saw in the civil servants I worked with when I was in government. But I think that's why oaths are so powerful, is because they re-anchor us in a core set of values that I think is important for all of us to have. And I don't think it's corny at all, that it sends shivers down your spine. I think it's when we lose our sense of awe at these profound oaths and allegiances that we take--it's in those moments that I worry about us, because then we become perhaps too cynical, or we become too blind to the power of that promise and to the values that underlie it.

Rosenberg: For instance, whether or not your father ever took the Hippocratic Oath, he presumably took an oath as a new citizen of the United States.

Murthy: Very powerful moment. I remember him taking that oath when he became a citizen. And that's perhaps too young to fully appreciate just how profound that moment was. I remember years later, having the great privilege, after I served as Surgeon General, to speak at a citizenship ceremony, and a naturalization ceremony, and I felt so many chills going through my body, and such a sense of magic, if you will, in that moment, because I looked at this sea of people who were taking on this new identity as US citizens who are pledging their allegiance to not just a country and a flag, but a set of values that has helped lift up millions and millions of lives. I couldn't help think of my father and my mother and other naturalized citizens who have come to this country wanting, not just to make a better life for themselves, but wanting to make a contribution to a country, to their new home. And I felt proud. And I continue to feel proud every time I hear that citizenship vow renewed.

Rosenberg: I had the privilege of attending at least two naturalization ceremonies when I was the United States Attorney. And while a federal judge presided, I was asked to read the names of each new citizen. And it was so important to me, Vivek, because these men and women came from all over the world, and some of their names were difficult to pronounce. I got there two hours early, so I could speak to each one individually. So, I made sure I got their names right on that big day.

Murthy: Gosh, you know, Chuck, that is so wonderful that you did that. Not just because it helped made that special day a little more special for them, but there is so much power in a name. When we hear our name said, it means something to us. It's a way of saying “I see you,” and when you pronounce someone's name properly, especially somebody who might be used to having it mispronounced a lot, let me tell you as somebody who has a name that's a little tough to pronounce, it means a lot. It means “Hey, you took the effort.: But it also means that I took the effort because I want to see you. And that makes people feel good.

Rosenberg: Well, some of the names were easy. Some of them were difficult and cumbersome, at least in my native tongue. And so, I would write it out phonetically. And I would rehearse it with them. And so, when the time came in front of the audience, but also in front of their friends and family, I knew that I would feel awful if I got it wrong. I think I got it mostly right. I hope I did. You mentioned your service as the Surgeon General of the United States. And I wanted to move to that with you, Vivek. You're still a relatively young man and a relatively young doctor, when in November of 2013, President Obama nominated you to be the 19th Surgeon General of the United States. How did that happen?

Murthy: It was an unexpected moment, for sure. I was 36 years old at the time, I was practicing medicine as an internist in Boston at Brigham and Women's Hospital. And during the other part of my time, I was building a technology company to help improve the quality of clinical trials and was also helping build with my now wife, Alice, a nonprofit advocacy organization to get doctors involved in helping to improve our healthcare system and work with policymakers. And so, life was full of meaningful work. And I was grateful for it. I was actually not looking to work in government, and not sought out a job in the administration, but what happened is that in the course of my advocacy work, I think I had come to work with policymakers at the federal level in particular, but also at the state level. And I think some of the knew of my work, but on that day, July 10, my birthday as it turns out, 2013, when the phone rang, and there was a 202 number on my caller ID, I had no idea that this was a call that I'd be receiving—that it would be a White House representative asking me if I want to be considered for the role of Surgeon General

Rosenberg: Right. 202 is the Washington DC area code.

Murthy: And so, I was surprised. But two interesting things happen in that moment. One, is even though I had not been seeking out a job in government, even though I had actually been approached before about serving the administration and for other roles, in the department Health and Human Services, and had politely declined. There was something in that moment that felt, yes, this is actually the right position for me. And the reason was,--and it wasn't at a hubris that I felt like, oh, I'm the only one who could do this, no one else could--you know, when you get appointed to positions like this, as I suspect you might also feel, Chuck, you know that there are other qualified people out there, that other people could do the job well, too, and that you're fortunate to have the opportunity to be asked to do it. But that doesn't mean that you are somehow better or more qualified than anybody else in the country.

Rosenberg: Just more fortunate, perhaps.

Murthy: Exactly, like, you know, this is the kind of job that would be fulfilling to do, but also that I feel I could do well. It was an unusual job in government because unlike most appointed positions, the Surgeon General is supposed to be independent and not execute the agenda of the president, but to have the highest fidelity to science in the public interest. Which means that even if you disagree with your President, you're supposed to move forward with what science would recommend. And I think about that often, you know, I think about it during disease outbreaks and epidemics. I think about it, you know, as we are struggling to battle issues like e-cigarettes and marijuana and other issues, which are complicated in terms of their science, but which require interpretation and fidelity to facts. Because sometimes the politics and the science don't grow in the same direction. And what I liked about this role was that you were supposed to put yourself firmly in the boat of science. So, I liked that and I liked the fact that you could craft your own vision and agenda as well in this role. It might surprise some people to know that if you go to the go to statute, and look at what the actual responsibilities of what the Surgeon General are in law, there's actually only one thing that's really specified, which is that the Surgeon General will oversee the United States Public Health Service Commissioned Corps, which is one of the seven uniformed services in the United States government.

Rosenberg: I'm so glad you mentioned that because people, of course, are familiar with the Air Force, Army, Navy, Marines Coast Guard, but this is the Public Health Service Commissioned Corps, a uniformed service of the United States. And so, as Surgeon General, you are also a Vice Admiral.

Murthy: That's right. As Vice Admiral, which is a three-star Admiral, the Surgeon General oversees this service of 6,600 uniformed officers and they include doctors and nurses and physical therapists, pharmacists, public health engineers--it's a whole range of specialists who do two things: one, is during their day job, they serve to support the public health infrastructure in our country working at the CDC, in partnership with local departments of health at the FDA, at the NIH, and numerous agencies, but they also, during moments of crisis, respond and help to ensure that we are both providing money medical care and helping to rebuild the health infrastructure that's needed. They often do that domestically, so, during 9/11, for example, we sent so many officers to New York to help with the response. After major hurricanes like Katrina, we sent Public Health Officers to help provide care during times of terrible need. But also during the Ebola outbreak in West Africa we sent several hundred officers to provide medical care and to set up what was called the Monrovia Medical Unit in Liberia. And that was so important because prior to that, even though Ebola was spreading in West Africa, volunteers were not coming from around the world because governments weren't sure that if they got sick that they would get care. But I remember when I went to close down our operations at the end of a long mission, and bring our officers home, that I met with President Sirleaf in Liberia, and she told me she said “it was when your officers came and set up the medical unit, that is when the floodgates opened around the world and volunteers came,” because they knew that if they got sick that they'd be taken care of. So, in this way, the Public Health Service Officers, extraordinary men and women, have served our country for many, many years. And they continue to do so often in the shadows. People don't know about them, but they are still valued force.

Rosenberg: What a powerful signal that is to the rest of the world when the United States through the Public Health Service shows up to do its work. People see that, they feel that, they obviously need that. Did you know about this role of the Surgeon General, really before you were asked to take it on? Were you familiar with it?

Murthy: Only a little bit, I did not have as deep an appreciation for what the Commissioned Corps could do. I had known about its history. I knew about its involvement in the responding to the Spanish Flu years ago, to the fever epidemics, and so many other health challenges that we had faced, but what I had not, what I think, fully appreciated was just the caliber of the men and women who served in the commission Corps. And I also had not appreciated just how much more they could do if we widened their scope and provided them with a little bit more training. We have a lot of great institutions that we built like the CDC and the FDA and NIH.

Rosenberg: Explain what those are.

Murthy: So, the CDC is the Center for Disease Control and Prevention. It's one of the most important assets we have in preparing for and responding to disease outbreaks. Not just outbreaks like Zika, and the Coronavirus, but also the chronic illnesses that we are struggling with as a country, whether it's diabetes or high blood pressure or cancer. The NIH is the primary research engine that helps drive our understanding of illness and the development of new cures and therapeutics.

Rosenberg: National Institutes of Health.

Murthy: The National Institutes of Health, and then the FDA is the Food and Drug Administration. They're the ones charged with keeping our foods and our medications safe and ensuring that when a company, a pharmaceutical company makes drugs, that they are both safe and effective for people. These agencies are staffed by public Service Officers and others. But while they have done a tremendous amount of good in our country, if you go further down to the state and local level, what you find today in America is that local departments of health are really struggling. They're underfunded, they don't have the resources to respond during outbreaks that way we need them to, even to help provide the basic public health education and services that people need to address chronic illnesses. Many of these institutions have the knowledge of how to do so, but they don't have the resources to execute. And that is because over time, public health has been gradually dropped in the priority list and funding has come down with it. As I think about that, in the context of our Public Health Service Commissioned Corps officers, I think it would be extremely valuable for us as a nation to have a larger cadre of officers who could deploy and work with local departments of health all over the country to help provide the training and that person power that they need to execute on the ground to help prevent chronic illnesses, to respond to disease outbreaks when they came upon the scene, and to also work with policymakers to help them understand the value and importance of prioritizing our investments in public health. When I think about which we need to keep our country safe, we need a strong military, for sure, but there are threats, non-military threats, that we’re also subject to, and those include health threats. And there are few threats as powerful as the threat of chronic disease, you know, which has cost us so much in terms of lives and dollars right now, but which I do not think we are as well equipped to fight as we could be, and the Commissioned Corps officers and expanded corps with a focus on helping restore the public health infrastructure of the country, I think could help change that.

Rosenberg: For instance, the Commissioned Corps, as currently constituted, is relatively small. When you talk about the fact that many state health systems are underfunded, under resourced, even at the federal level--it's relatively small.

Murthy: It is relatively small, and the way it's structured now--and this is a level of detail which I certainly hadn't been aware of earlier on--the way it's structured now is that officers have day jobs and we want to deploy them, we have to take them away from their day jobs, which means that it creates some additional challenge for the agency that they're working in. What we really need, and what we have for some time, is we had a Reserve Corps of officers who could be deployed during times of emergency, but they were working, you know, in day jobs outside of the federal government, or sometimes they were retired. We have had challenges in maintaining and developing and training that Reserve Corps. But I think that an expansion, both of the Commissioned Corps officers as well as a Reserve Corps, could be of immense value to the country. We think sometimes about in these kinds of investments and say, “wouldn't that cost money?” And yes, it costs money to build a core just like it costs money to train an army and to build a navy. But we do that because we recognize that the value far outstrips the investment. And in this case, if we can help prevent more people from developing diabetes, if we were to help people who are struggling with chronic illness, to care for their illnesses, we can strengthen our public health infrastructure, the value that delivers to us in terms of life saved, and healthcare costs reduced, is extraordinary. And that's where the Commission Corps, I believe, could deliver tremendous value.

Rosenberg: It's not just financially sound, is also humane and thoughtful.

Murthy: Absolutely.

Rosenberg: So, after a little bit of a controversy over remarks that you made regarding gun violence in the United States, you are confirmed as the 19th Surgeon General in December of 2014. I would appreciate it if you would share some of your thoughts on that.

Murthy: Yes. Well, this was one of the, I would say, unexpected controversies of my nomination. When I was nominated, was during a time of partisanship which continues to today and we could never assume that any confirmation would be simple. But despite that, when I went through my confirmation hearing, it went pretty well from--by the administration's account, and it seemed like we would get support from Republicans and Democrats, which meant that hopefully the confirmation would happen quickly. What happened in the weeks that followed, though, was that there were comments that I had made, which had come up during the hearing as well about gun violence, which became not only an increasing focus, but which pulled in special interest groups into this battle. And the comments had to do with several tweets that I had posted after the terrible shooting in Newtown, Connecticut, at Sandy Hook Elementary School where we had lost so many children.

Rosenberg: Just a horrific tragedy in Newtown. And one that I followed closely. I was working in law enforcement at the time, it was heartbreaking.

Murthy: It really was and it touched the nation in a way that I think prior episodes of gun violence, at least recent ones, just hadn't, because it was so many children, you know, in elementary school--children who had lost her lives that was just truly horrific. And in the wake of that and thinking about the other episodes of gun violence that we had witnessed as a country, I had posted a message that said, “gun violence is a public health issue.” And I said that because whenever you have a large number of people who are dying for preventable reasons, that constitutes a public health issue, whether it's because of motor vehicle accidents or gun violence. I didn't at all think that was some radical statement, or I thought it was a truism, a statement of fact. The other thing that I had tweeted, though, is that I was also, like many people, frustrated that Congress wasn't doing more to help address these issues of gun violence. There's no one single law that you can pass that's going to somehow drop gun violence incidents to zero. It's a complex problem that has to do with, in part, how we think about sensible laws around gun ownership, with also how we think about our mental health care system, and without frankly, we think about the breakdown of community and the rise of loneliness and isolation. So, there's no simple solution, but it felt like the federal government was doing so little to actually act on this, in part because it was paralyzed by politics. And so, I had also tweeted that I was tired of politicians bowing to special interest groups, particularly the National Rifle Association, and not taking decisive action to help reduce gun violence deaths. These two tweets raised the ire of several politicians. But they also angered some interest groups, which thought that perhaps I would use the Office of the Surgeon General to try to do something radical, like take away everyone's guns, which was not at all on my agenda, and not at all a solution that I thought made sense.

Rosenberg: And not at all within your authority.

Murthy: And absolutely not at all within my authority. My views were not unique to me, prior Surgeons General had had very similar views, if not nearly all of their recent ones. You might see, you might ask, “Well, why didn't, you know, this become an issue for prior SGs.” And I think part of the reason was just what you said it's at the office does not have policymaking authority, or regulatory authority. So, I don't write laws, and I don't advocate for laws getting passed. And so, from that standpoint, interest groups that wanted to, to protect gun ownership in the--then protect the status quo, really--they really never focused on this office of the Surgeon General. But they were other reasons, I believe, sort of political reasons and members of Congress who wanted to position themselves for national office. It was all of that kind of came together to lead to them seeing this nomination as an opportunity to make some noise and create some added controversy that would help buttress and strengthen their bona fides, you know, as defenders of the Second Amendment, even though that was not at all, I think, fairly a part of the issue here, even though I wasn't an anti-Second Amendment person or something. There was value that they found in making this nomination now to be about that. And so, what seemed like it would be a relatively easy confirmation after my hearing, within a matter of weeks, turned into a very difficult nomination. And in fact, on the day of my committee vote, you know well, Chuck, but I'll just for the benefit of listeners who may not know, when you are nominated to serve in in a position in the federal government that will require Senate confirmation, you first have a hearing with your Senate committee. They vote on you. And if they vote you forward, then your vote goes to the entire Senate. So, on the day of my committee vote is when the National Rifle Association issued their letter, saying that they would strongly oppose my nomination, but would also score the vote, meaning that if other senators voted against them, and for me, that they would take that into account when giving them a letter grade, as they often did for all the senators, and that had an immediate effect. So, for people who wonder, do interest groups affect our politics really in a substantive way? The answer is absolutely yes. And the day that letter came out, the nomination went from being pretty secure with support of all democrats and a handful of Republicans, to suddenly having no republicans in support and having up to actually 12 Democrats suddenly moved from the “yes” column to the maybe to “no” column. And these are Democrats who are up for re-election during that year, or came from states that were purple states, if you will, you know, mix of liberal and conservative voters, and they were worried how this would play among their voters.

Rosenberg: Despite the opposition of the National Rifle Association, you are ultimately confirmed. It took over a year, but in December of 2014, Vivek, become the 19th, Surgeon General of the United States.

Murthy: I did and it was against all odds, really, I'm not sure very few people outside of a small circle of people in the administration, and a handful of us on the outside thought that the nomination would actually be confirmed, but I'm thankful that it was, and grateful to have had the opportunity to serve.

Rosenberg: How do you figure out, given the various threats to public health in the United States, what it is that you will focus on, what you need to focus on--there's chronic illness, there's obesity, there's smoking, there's gun violence, there's mental health issues. You ended up focusing, and I think it's both brilliant and fascinating, on loneliness—is that a fair summation?

Murthy: Yeah, it was one of the biggest challenges in the beginning of any job, I think is to figure out where to focus. And for me, it was no different. When I had my Senate confirmation hearing, I had to talk about my priorities. And one of the issues I wanted to focus on was obesity. There are others as well make the vaccine preventable illness and mental health. There were multiple issues I had listed. But I also knew that you can’t fully understand what the country needs by reading reports and relying on your own personal experience. Sometimes you just have to go out and have conversations with people and listen for a while. And so, even though I had a set of priorities that I had talked about, when I began my time in office, I started with a listening tour. I just spent time traveling to big cities and small towns all across America. And we asked people a very simple question, which is: “how can we help?” And I tried as much as I could to just shut up and listen to what people had to say.

Rosenberg: Which, by the way, takes both great confidence and great humility. This has been a theme in The Oath podcast, we talked to leaders who are very, very smart and very capable, but who shut up and listen. And that is a remarkably important trait in a leader.

Murthy: That's kind of you to say, Chuck, I attribute some of that to my medical training, where we, as doctors, are taught to listen, we're often taught that no matter how smart you are, if you just let a patient talk, and give them enough time, they will often lead you to the diagnosis. That was part of what was at work as well. But the other thing that was going on at the time is that I was under some pressure from people internally to get out there and just start acting and doing, whereas I had this instinct to just pause and to listen and to absorb. And it was for a few reasons. These are well intended recommendations I was getting from folks, including my advisors in the department and others. But they were saying, you know, now that you're confirmed, you know, we should just get you out there right away and all the morning shows and do interviews with all the big papers in the country to tell people what your agenda is, and what issue you're going to tackle, what campaign you're going to launch. Second, they said, you're going to be judged by what you do in your first hundred days. And so, we got to make sure that you have a concrete deliverable that you've executed on and some change people can point to and say, “Hey, because you were certain about this happened in the first hundred days.” Now, when you stop and think about it, these are fairly artificial constructs. And so, I had to ask myself the question, “Does that feel right, or not?” And I remember going home after the first day when I had met with a lot of the advisors and senior folks in that department who had given these recommendations and I sat at home and I was talking to my wife, Alice, and I said, “This just doesn't feel right. It doesn't feel like who I am. It doesn't feel consistent with our values. So, let's go with our plan.” So, I actually rewrote the communications plan that night, and I sent it back to the team. I think they were at little surprised, number one that I rewrote the communications plan--and I had actually been doing a fair amount of work on the communication side in my work and advocacy and such, I've actually had a bit of a feel for communications--but I think they were also surprised that I would push back on the department, especially given that I hadn't served in government. But you know, my view, Chuck on it was always that, you know, not only did I not intend to serving government, but I did not have an intention of building a lifelong career from that point forward in government.

Rosenberg: You didn’t need to serve in government,

Murthy: Right. And I also didn't need to necessarily make everyone happy so that I could get the next job in government. So, I could afford to, perhaps, angry irritate some people, if that meant, you know, pushing forward to do what I thought was right.

Rosenberg: But what you're proposing, Vivek, is not that radical, rather than going out and pronouncing, you decided to listen and learn first.

Murthy: Yeah. So, in the grand scheme of things, it's not at all radical. And I think most people who listen to it say, well, that just seems like it makes sense why, what's big deal? But in those moments, you have to understand that this stakes always seem really high, right. And so, for the department, which had invested an entire year plus, in getting me confirmed, felt the pressure to show the country that it was worth it to get me confirmed. They felt that, hey, we got to show that there is something of value here that's coming out of this confirmation process, that the political capital that was spent was worth it at the end of the day. But with that said, we went the path of doing the listening tour. I'm so grateful for it, because it is what taught me so much about what the country needs and where the country is. And what I heard were these stories of people's struggles that included stories about addiction, and about violence, about chronic illness, about depression, and anxiety. I heard from moms and dads who were really concerned about their children. They saw them spending more and more time on their devices and felt that they were more isolated, and they wondered if that was going to harm them. I heard from elderly people in the country who were struggling with chronic illness, and were often disabled and unable to get out of their house and meet loved ones and friends, and they also were wondering what could be done to help them. I met with a lot of people in local government, who felt that they were on their front lines, from mayors, to Public Health Department employees. And they felt that the struggles they were up against were so big, and the help they had to fight them were so small, they didn't have the luxury of pontificating on issues--they were on the frontlines, they had to deal with them. And they often felt like they were letting people down. And they wondered if there was additional help that could be brought to their side. These are the stories that I heard. What I didn't expect to hear, though, were the stories of loneliness that wove their way through so many of these other larger stories.

Rosenberg: In your new book, Together, which I read, which I loved, you wrote that as a result of that listening to your loneliness ran like a dark thread through many of the more obvious issues that people brought to my attention, like addiction, violence, anxiety and depression, that there was this common theme of loneliness. And you also wrote about it as both a cause of health problems and as a consequence, what did you mean by that?

Murthy: What I found is that two things were happening with loneliness. One is that often, when people became ill, it had the effect of isolating them, more often than not. So when they, for example, were struggling with severe arthritis, it was just harder to get out of the house, was harder for them to see people. When they became ill, sometimes it would take an emotional toll on them, they would have less energy to go out and initiate social interaction. But also, I heard from many people who felt that when they became ill, that people also started reaching out less, ironically, the reasons are complicated for why that happens, but it has happened to a lot of people, that they actually lose their social support, often at times when they need it the most. So, that was often how loneliness was a consequence of illness. But what was interesting and perhaps even more fascinating to me was how it was contributing to illness in the first place. And there, what I was finding , was that so much of the loneliness that people were struggling with was really a manifestation of a deeper emotional pain that they had in their lives. And people wouldn't come up to me and say, you know, “my name is Chris, I am struggling with emotional pain,” or “I'm Betsy and I'm got a lot of emotional pain in their lives.” They wouldn't say it. But it became very obvious in the stories that they were pained. And I could tell because in so many of the patients, I have cared for the thousands of patients over the years and hearing their stories over and over again. It's clear when people are speaking from a place of pain, and that's what I kept hearing again and again. And the thing about pain, Chuck, is that when we feel pain as human beings, we will seek to relieve it. And the question is, what do we reach for? Do we reach for the phone to call a friend? Do we reach for alcohol to help numb our pain? Do we reach for drugs to do the same? Do we reach for food? Do we reach for work? It’s very interesting, there are some avenues of addressing our pain which may harm us but which are socially acceptable. So being a workaholic, so to speak, is seen as an okay thing to do, you know, you're still being productive, you're contributing, you're earning money, etc. But it could be extremely harmful if the reason that you're working is because you were trying to escape unaddressed pain in your life.

Rosenberg: It's masking loneliness.

Murthy: It’s masking loneliness, right. And so, what I found so often in these cases was that the pain of loneliness was driving people to behaviors that were ultimately destructive to them. And as it turned out, as I came to learn later, as I studied the science of loneliness, that the very experience itself of loneliness when it's played out over time, of chronic loneliness, has an impact on our biology. It puts us in a chronic stress state, which increases inflammation in our bodies, and elevates our risk of cardiovascular disease and other illnesses.

Rosenberg: You write about in your book, in Together, about how doctors treat physical pain and they're quite good at that versus how they treat emotional pain, which and I take it from your thesis, there's still a long way to go.

Murthy: So, I think there are two reasons for that. One, is that we're not really trained in medicine to think about emotional pain, much less to figure out how to address it. But I think the second thing is that when we think about emotional pain, as a result of not being trained, we also feel powerless as practitioners. When confronted with it, we're not sure what to do. That was the case for me, certainly, when I was practicing medicine, especially in those early years in Boston. I would encounter emotional pain, it's not that I didn't see it. I didn't quite know what to do, and that created discomfort for me.

Rosenberg: In fact, you tell the story of a patient you had as a young doctor named James who won the lottery, which effectively, should, we would think, make them quite happy and it had much the opposite effect.

Murthy: That's right. Yeah, I read wrote about this because it's a story that has stuck with me over the years. An alleged man, James, who literally actually did win the lottery. He had money that was going to be coming to him, you know, on a regular basis and he had no financial needs to worry about. So, he did what most people think one would do when you win the lottery, he quit his job, he bought a big house, he moved into a fancy community, but he became profoundly lonely. He left the clients that he loved serving, he left the coworkers that he enjoyed getting up every morning to see, he left his neighborhood where he had friends and people that he recognized, and he moved to a place where people didn't see each other, they had big walls between their houses. And he became angry, and became depressed. And he developed diabetes and high blood pressure shortly after that, which is what brought him in to see me. But the truth is sitting in that office that day, seeing him, recognizing just how lonely he had become, I felt lost as to how to really help him. I didn't know how to talk to him about his loneliness. I tried to be as empathic as I could and just listen, but I didn't really know what to do about it. And that has stuck with me because I think that when we think about burn-out in medicine, a subject which has been written about a lot and which is a profound issue in the profession, and I think is helping drive, sadly, rates of suicide, which are very high in the medical profession, we often point to the electronic health record and paperwork as being the primary reasons that people are burning out. And those are challenging, don't get me wrong, doctors spend much more time in front of screens and with paperwork than they do with patients at times. And it's very frustrating to them. And it's not good for patients either. But I think one of the greatest contributors to burnout is a lack of self-efficacy. When you feel, as a doctor, that there are problems that your patients have, that you just don't know how to solve, or you just can't solve because the system is broken, that eats away at you, it makes you feel that you're not effective, that you don't have as much worth as you thought you did. It's in direct contradiction to the values that brought you to the profession in the first place, which is to relieve suffering. And so that I think about often because I felt that profound lack of self-advocacy at that point, and I felt terrible that I couldn't help him. But I don't think it has to be that way. I think if we were able to reimagine medical training, such that we see the charge of a doctor as helping to support the physical, mental, and emotional well-being of their patients, then I think that changes what we study in medical school, it changes what we train doctors to do in residency training. And it changes, frankly, what we test doctors on in their continuing medical education.

Rosenberg: And if you saw James today, knowing what you know, now, knowing what you learned as Surgeon General, what would you do differently?

Murthy: I wish I knew where James was, I wish I could find him. But if I did, number one, I would tell him that he is not alone in his loneliness, that as profoundly isolating as being lonely can feel, there are so many people who are struggling with loneliness, not because they are broken, but because of circumstances. The second thing I would tell James is that because he is struggling with loneliness also does not mean that it's irreversible. There is a path forward, and I would work with him to find that path. Some of the things that I've learned over time is that service is a very powerful way to lead us out of loneliness--it's a backdoor. an unexpected, in fact, solution to loneliness. And that's in part because when we become lonely, one of the things that happens to us, which is, frankly, counterproductive, is that our focus shifts from other people, increasingly to ourselves. And that's because we feel that we're under threat when we're lonely. So, thousands of years ago, for example, when we were hunters and gatherers, our safety depended on being with other people.

Rosenberg: Part of a community.

Murthy: That's right. And that's because we looked out for each other, we helped keep watch at night, you know, make sure nobody was eaten by a predator, we shared and pooled our food supply so that everyone had a little bit each day and nobody starved. We helped to take care of each other's children, and help with family obligations, we did things that help each other, and when we were separated from the group, survival was much harder. Because of that, over time, that state of separation became, effectively, a threat state, and it became, as a result, a stress state. When wherever we're in a position of where we're under threat, our body's stress level goes up, because it's preparing to respond to either fight, to run away and flee--but it's preparing us for what may come. Now in the short term, that's really helpful, because you want to have all your resources marshaled, you know, in the face of threat. The problem is when you're chronically lonely, then you're in a chronic threat state. And that stress level remains elevated for a long period of time. When you're also in a threat state, though, your focus shifts almost entirely to yourself, because you have to, you want to know if anything's coming at you. You're not thinking about, you know, the person that you met, you know, on Facebook, you know, two weeks ago, you're not thinking about anything else you're thinking about yourself and how to survive. In that survival state, though, it can be actually quite challenging to engage with other people. Imagine if you meet somebody who's really focused on themselves, and who has a greater likelihood of seeing threat where none exists because their threat level is up. Those aren't the most fun people to be around all the time. And sometimes that can turn people off. What is so powerful about service is that it allows us to break that pattern, it shifts the focus immediately to somebody else, the person you're serving, but also, and very powerfully, reminds us that we have value to offer the world, which is something that we can so easily forget when we're in we're in the throes of loneliness.

Rosenberg: In your book, for instance, Vivek, you write about “Men's Shed Associations,” S-H-E-D, I thought that was wonderfully illuminating. And I guess the problem is that loneliness fosters even more loneliness, and that you need a way to break that cycle. Is that fair?

Murthy: That's fair. Absolutely.

Rosenberg: What are the shed associations?

Murthy: The men’s sheds are fascinating. They are efforts, effectively, to bring men together to build community, but not with the express intent of making friendships. What the Men Sheds do, is they bring men together to do things together, like woodwork and metalwork. And in the process of working side by side, or as they would say “shoulder to shoulder,” they build relationships, they have conversations, and they ultimately create community. The men’s sheds were actually started by a woman named Maxine Chaseling in Australia. And Maxine had seen loneliness impact her father. Maxine saw this and she recognized, over time, to a really longer and fascinating story, that what was happening to her father was not unique, there were many men struggling with loneliness, but she realized that they were not going to join discussion circles. So, she ended up creating the Men's Shed with a friend of hers as a place where men can go and work together. And their motto at that time--and even though this is a generalization, they found it to be true--they said “women talk face to face, and men talk shoulder to shoulder.” And what they created in these sheds was opportunities for men to work shoulder to shoulder. And they found that in the process relationships developed. Thanks to her work, not only did Australia replicate those sheds, in fact, they have now nearly 1000 Men Sheds. But the sheds ideas spread all over the world.

Rosenberg: Do men and women experience loneliness in the same way? I mean, you talked about how women have face to face relationships, and men, shoulder to shoulder but do they experience loneliness in the same way?

Murthy: I think men and women both experience loneliness. In fact, if you look at rates of loneliness, they're similar, you know, find some studies a little bit different here and there. But by and large, they have similar high rates of loneliness. In terms of how they manifest in their lives, I think this can often look different, and it's very much personality dependent, so I hesitate to make sweeping generalizations, but, but what, what I hear often from, from men and from women and from researchers who study this topic, is that men, you know, are often raised with a concept of masculinity that tells them that they need to be stoic, they need to be independent, so not dependent on other people. And they also need to not be affected by emotions, and to do so would be a sign of weakness. And so, as a result, young boys, when they become adolescents, start taking this on and turning away from friendships and, or suddenly, they talk about friendships differently and, and are more embarrassed to discuss feelings or to be vulnerable in some way, which--and vulnerability is such an important part of building relationships--to be vulnerable is to be real, to be real is to have the most important ingredient for developing relationship. And so, if we have a culture that tells men that being vulnerable is to be weak, and from the get go, we're making it harder for them to build the meaningful relationships that they need. And the one relationship that society tells men maybe they can be vulnerable in, is in their romantic relationship with their spouse, which is why one of the reasons we find that when men either lose their spouse, or when they retire from their job, or when they experience illness, these three end up being potential triggers for loneliness in men. Women, I think have historically and generalizing, of course, tend to be better at maintaining relationships than men. They tend to be more likely than men to be open and vulnerable. They tend to be better about staying in touch with people, which is again, one of the reasons why so many men struggle after their spouse dies, their spouse as a woman, because often times it is the woman who is helping nurture and sustain so many of the social relationships that that couple has. But the challenge, I think, for women is that we have constructed the world and the workplace in particular in a very masculine model. We’ve told women, for example, and men, that if you want to be a good leader, that, that means you've got to know all the answers, they can't show any emotion, that you have to lead with strength, you have to be loud, you've got to speak up and speak up often, you've got to take up a lot of space in the room. For a lot of women whose natural tendencies aren't like that, I worry that we are forcing them to try to be like men in the workplace. Another sort of general rule I found is any time where we are forced to be someone that we are not, we end up becoming lonelier as a result of it. Because we end up feeling, over time, that we've got to wear a mask and be somebody else. We feel like we have a smaller and smaller circle of people with whom we feel we can truly be who we are. And that can be profoundly isolating. So, I think while the forces that are driving loneliness in men and women, perhaps are slightly different, there are also common factors as well. We know, for example, that one of the challenges with social media is that it tends to promote a culture of comparison, and whether you're a man or a woman, you can often be left, through your social media experiences, to feel that you are not rich enough, not good looking enough, not good enough, not successful enough, funny enough, or likable enough, because the challenge with social media is we're often comparing our average days with other people's best days. And we often come up short in that process.

Rosenberg: And when you talk about online networks or social networks, obviously, there's also a comparison implicitly to traditional social networks, the things that have sustained people and cultures for thousands and thousands of years. You write in your book about your uncle, Rajesh, and I thought it was an extraordinarily compelling story. I was hoping you would tell it.

Murthy: My uncle Rajesh, he was not somebody I thought would have as profound an impact on my life as he did. He was the person that you would miss in a room. People would show up and people would say was he really here? Because he just blended in. He rarely spoke up and he was almost invisible. But he came to the United States from India when I was young, when I was in high school. He came, not at the age my parents did in the early part of their professional lives, but he came actually in them in the middle of life. I believe he was in his 50s at the time. And I was surprised, you know, that he would choose to uproot himself and come all the way to the United States. But he came because he wanted to build a better life and see if there was a better opportunity here for himself and his family. Rajesh was an engineer, and he built bridges in India. And he was very passionate about that work and wanted to engage in bridge building and some sort of like Civil Engineering here in the United States as well. When he came here, though, it was hard for him because he spoke English, but he spoke with a very thick accent, which made him hard to understand. So, communicating with others was sometimes challenging. He was also very shy, and so he didn't proactively go out and engage with other people. But my father, who was very supportive of family, did his best to help him, he helped him find a job through his friends, and he ended up working at an engineering firm and was enjoying that work. He ended up also moving out of our house where he stayed for a number of months and lived with two roommates a few miles away from us. That was a new experience for him. He had never really lived with roommates before. But you know, he was making it work. But then what happened is one day he lost his job. And this was a huge blow for him because the job was not just a source of money, but it was a source of pride. It was evidence that he could make it in the United States. And when he lost that, he was not only quite sad, but he was embarrassed. So, he didn't tell people in India that he had lost his job. He kept it to himself,

Rosenberg: And his core social network remained in India, even though he was living with your family.

Murthy: That's right.

Rosenberg: And then with roommates.

Murthy: That's exactly right. So even though he had some limited interaction with other people, he wasn't actually building relationships with other people. And this is really important because when people think about loneliness, they often think, well, if you're around people all the time you can't be lonely. There's a difference between loneliness and isolation. Loneliness is a subjective feeling that the connections you need are far greater than the connections you have. Isolation is a more objective measure of the number of people around you. And we know that people can be surrounded by people online and in person and still feel profoundly lonely if the quality of the connections with those people is not strong.

Rosenberg: So, isolation is a risk factor for loneliness, but it's not the same thing as loneliness.

Murthy: That’s exactly right. And in fact, there are some circumstances where isolation can be quite healthy, you know, and we would term that solitude. So, when people intentionally use solitude as a time to reflect and to renew, that can be really healthy. In fact, not having any solitude can be really problematic because then we don't have any time to process and to let our thoughts wander, which is so important for our own creativity. And it's one of the concerns I have in the modern world is that all of the whitespace in our lives, even those moments--to just think that we had maybe when we were driving somewhere or when we were walking to the bus stop or sitting at the bus stop waiting for a bus--all that whitespace has disappeared because we now pull out our devices when we when we have a minute or two to spare. And we check our email, we check our social media, or we check the news. But to come back to Rajesh, what was happening to him after the loss of his job, was that the absence of his social connections and community in Miami were becoming all the more apparent. And he was getting more and more isolated, because he also, again, wasn't confiding anyone in India. He was trying to look for other jobs, and we were trying to help him as well--my father and my mother--but time after time, even when he got interviews, a job wouldn't manifest. We didn't know how much pain he was in, I recognize in retrospect. As a child, I would try to talk to him here and there. But I never imagined that like, you know, I was just a little kid at the time, I didn't think a little kid, I mean, I was in grade school at the time, and I didn't think that the conversations he had with me had any meaning like that. I figured adults who he could talk to about adult stuff was--that's what he needed in his life. But one day when I was sitting at my dining table on a Sunday, with my sister, we were doing our homework together, the phone rang, and my parents were away. It was a Sunday, they were religious services at the time at the temple. And I picked up the phone, and it was his roommate, Sophia. And she said, “He's not coming out of his room.” And my initial thought was, he's not coming out because he can't hear you knocking and he's really hard of hearing. So, I said, “Why don't you call 9-1-1. And let's see if we can get the emergency responders here. They may need to break down his door.” So, she said, “okay,” she hung up. And it was 10 minutes before she called but I'll tell you, it felt like 10 hours because I was sitting with my sister, what could be going on? We couldn't drive, so I couldn't go there. And this was pre-cellphone era as well, so I couldn't call my parents on their cell phone and tell them something was going on. So, she called back Finally, 10 minutes later, and she said “they came and they broke down the door, and they found him hanging from the ceiling fan, he's dead.” And she paused. And those words just hung in the air for what seemed like an eternity. I had never experienced something like this before. I had lost my grandfather who I was very close to, to heart disease, and he had a heart attack, and that was extremely painful, but I had never experienced suicide. I had never, I just never been in the situation before, where I was the first person in the family to know. I called the temple where my parents were, the landline, I asked somebody to find my mother and father, I told them what had happened, and it was just a terrible shock for, for everyone. We asked ourselves so often in them days and months and frankly, years thst followed. What did we miss? Was there some sign that we should have been more aware of, should we have reached out more to make sure he was okay, should we have brought him back to live with us in some way? There's so many ifs that we still wonder about to this day. But that stood as a painful reminder to me, one that I thought of often as I wrote this book: that migration, whether it happens because you come from one country or another, or because you move even within your own country, can have a profound impact on our lives if we're not able to find new community, and lean on the relationships that we had before. And that sense of shame and embarrassment that further isolated Rajesh at a time where he really needed to reach out, shame that he felt after he lost his job and felt like he wasn't a success anymore, that fed into, I think, the pain that he was experiencing. And it made me realize that we probably in our lives, will walk around and encounter people all the time who are struggling—who are in real emotional pain--maybe they just lost their job, maybe their child is sick, and they don't have enough insurance to cover them, and they're feeling like a failure as a parent. Maybe they themselves, you know, are struggling with illness, you know, and are feeling like there's no one they can reach out to. We probably encounter people like this all the time, but we don't know it because people are reluctant to share that pain, they don't want to seem weak in a world that tells them vulnerability is a liability. But the truth is that we're encountering that pain all the time. And I wonder, as I did with Rajesh, how our small interactions with them might be far more powerful than we think. I think about those days when I would come back from school, and he was at home when he lived with us when he and I would walk around outside and look at the construction that was happening on our house at the time, and he would explain different things to me about how the concrete should be poured. And he would tell me that in--you pour concrete, it gets stronger, but the real strength comes from the water that you pour on it day after day in the water that gets absorbed. And I wonder maybe those conversations were more meaningful than I thought. If I was perhaps one of the only people that he had interaction with, maybe even as a child, I was able to make a difference, even temporarily, in this man's life. And I think the truth is that all of us have far more power than we realize when it comes to helping others feel better, and to addressing loneliness. We don't need a medical degree or a nursing degree in order to help heal people who are in emotional pain. What we need is the willingness to listen, the willingness to pause, and ask people how they're doing and actually listen for the response. We need the willingness to sometimes be vulnerable ourselves, so that we can encourage them to do the same. And I realized that in a world where everyone feels like they're on their own, that loneliness is a problem that's not going to go away. But we have the ability and the power ourselves to help change that, person by person, interaction by interaction. When I came out of office, and even when I was in office, the thing that has continually nagged me is this question of what should I focus on? How can I contribute to the world in a way that will most deeply and effectively address the big problems we're facing? You know, I worked a lot on the opioid epidemic when I was in office, I worked a lot on issues around e cigarettes. I worked a lot on physical activity and trying to increase our rates of physical activity in the country. And all those were important. I don't regret focusing on those at all. I found myself asking, is there a deeper root cause of so many of the challenges we face that I could help contribute to even if in a small way? And that's where I kept coming back to this issue of our emotional well-being, and in particular, loneliness and social connection. Because I realized that it was at the heart of so much of what ails us. It was driving, not the sole contributor to, but an important contributor to the opioid epidemic, to addiction more broadly, that it was affecting and driving violence in our communities, that it was contributing to our rates of chronic disease, and possibly increasing early mortality. But it also can be realized that it was having effects far outside health too, that it was impacting how we showed up in the workplace, having profound impacts on our productivity, on our engagement in the workplace on retention, and unsatisfaction, that was impacting how our kids performed in school, as well and that so many of our children were actually struggling with loneliness at a time where they're so connected by technology. And as somebody who has worked in government and seen just the profound costs of political polarization, I came to see also that this disconnection between us, this fraying of connections between people and communities all across America, is making it harder for us to talk to each other, to have the kind of dialogue that we need in order to address the big threats we face, whether that's climate change, or the opioid epidemic, or chronic disease. And so, as I came out of this, I came to, to realize that not only is loneliness a problem that is deeply connected to so many of the others, but that social connection is actually a resource that we have largely under-appreciated, and that we have not really cultivated as intentionally as I think we could. If you think of social connection as a tool that can help us improve our health and our productivity and our children's education, and even help to mend our dialogue and fix the polarization that we're experiencing in politics, that it seems like an invaluable asset that we should be cultivating. But I think that we see it as a “nice to have,” in society, as opposed to a “necessary to have.” I think we see it as something that is pleasant, but not a strategic value, but I think it's central to what we need to do to build a stronger and a healthier country.

Rosenberg: In your book, you write: “what is humanity really, but a family of families, we all share this planet. And all our children together shall inherit this earth.” And then, I think in a very powerful way, you write a letter, not just to your children, but to all children about that planet they're going to inherit one day. I was hoping you would read a section of that letter for us.

Murthy: Thanks, Chuck. So, here's the section of the letter, and I did write this letter with my children in mind, my son, Tejas, and my daughter, Shanti, also, with all children in mind, this is my hope for the world that they will inherit for their lives. “Right now, the world you are inheriting is locked in a struggle between love and fear. Fear manifests as anger, insecurity, and loneliness. Fear eats away at our society, leaving all of us less whole, so we teach you that every healthy relationship inspires love, not fear. Love shows up as kindness, generosity, and compassion. It is healing. It makes us more whole. The greatest gift to ever receive will come through these relationships. The most meaningful connections may last for a few moments, or for a lifetime, but each will be a reminder that we were meant to be a part of one another's lives, to lift one another up, to reach heights together, greater than any of us could reach on our own. Our hope is that you will always have friends in your lives who love and remind you of your innate beauty, strength, and compassion. Equally as important, we hope you will do the same for others. It pains us that we won't always be there for you when you feel lonely and sad, but we offer this simple prescription to remind you, you are loved. When those moments of loneliness and suffering arise, take both your hands and place them on your heart and close your eyes. Think about the friends and family who have been there for you throughout your life, in moments of joy, and also in the depths of disappointment, the people who have listened to you when you were sad, the people who believed in you, even when you lost faith in yourself, the people who have held you up, lifted you, and seeing you for who you really are. Feel their warmth and their kindness washing over you, filling you with happiness. Now, open your eyes.”

Rosenberg: I'm sure, Vivek, that you felt privileged to serve as the Surgeon General the United States. Let me just say how privileged we were to have you serve, a man of your depth and integrity of your warmth and kindness and your intellect and your decency. Thank you for writing a wonderful book about what you found as Surgeon General, it's entitled Together, and I very much enjoyed reading it. Even more, I enjoyed the opportunity to sit down and talk with you. Thank you.

Murthy: Thank you so much, Chuck. It was a privilege to write this book. It was a privilege to serve, certainly in government. It gave me a chance to fall in love with America all over again, as I came to understand and meet people in communities all across our great country who reminded me that, despite the polarization that we read about in the news, that there are fundamental core values around decency, around kindness, around compassion that most of us still deeply believe in, because it's part of our shared humanity. And that experience has given me hope, that as we seek to build a more connected world, that we are not asking people to be something that they're not, but instead, we're asking people to return to who we ultimately are deep inside, which is beings that are deeply compassionate and connected to each other. And that if we give ourselves that permission to reach out, if we recognize that we are, in fact, truly interdependent, and that we are stronger when we are together, then I believe that we can build is the kind of society all of us dream of--one where we do come together and take on big problems, one where we are healthier and stronger, where our kids thrive, or when they fall down, we know there'll be people to lift them up. Or we go to workplaces and thrive because we are coming to work, to build and to create, not just with co-workers, but with friends. It's the kind of society we're capable of creating. You know, in the writing of this book, I found many things that I believe can help us build the greater connection. I found that it is through service that we can build stronger connection to other people and to ourselves. And I found that by focusing on the quality of our time, and putting our devices and distractions away and making sure that even the few minutes we have with people we love, make sure that's good quality time, that can have a dramatic impact on how we feel. Being disciplined about making sure that we spend at least five minutes a day with other people, especially with people we know and love, can over time have a sustained impact on how connected we feel. I found that using time in solitude well, so that we have opportunities to reflect and to be are incredibly powerful as we seek to strengthen a connection, our connection to ourselves and remind ourselves that we have value to give, that we are worthy simply because we have the ability to give and receive love, not because of how much wealth we have, how powerful we are, or how famous we may be. These are lessons that I found, not only helpful for humanity, but that I needed to learn and be reminded of myself. Some people write books because they've spent 30 years doing research on a topic, and they want to share their accumulated knowledge with the world. I wrote this book because I knew I still had something to learn. And it was in the process of writing this, that I came to learn and appreciate so much about the power of connection. And I left the writing of this book, just as I left my time in office, more optimistic about our country and humanity than when I began both efforts because I truly believe that we are better together, that it is our nature to be connected to each other, and that if we bring our energy, our focus, and most importantly, our heart, to rebuilding our relationships, that we can create, the kind of world that we want, and that our children deserve.

Rosenberg: Vivek, we all have something to learn. Thank you for being an extraordinary physician and teacher, and thank you for spending some time with us.

Murthy: Thank you so much, Chuck, and thank you so much for your service to our country. And I'm so grateful that when you were a DEA, that we had a chance to work on the opioid effort together.

Rosenberg: Thanks to Vivek Murthy for being a guest on my podcast. Vivek was the Surgeon General of the United States, the nation's doctor, where his work focused on the role of loneliness as both a cause of and a consequence of chronic illness. He is the author of an important new book, Together, that explores loneliness, and prescribes ways that we can identify it, think about it, and counter it. If you liked this episode, please let us know by leaving us a five-star rating on whatever app you use to listen and ask your friends to subscribe. We are available on Apple podcasts, Spotify, Tune In, and every major listening app as well as msnbc.com/theoath. If you're listening on a smartphone, tap or swipe over the cover art of the podcast. You'll find our episodes Notes including some details you might have missed. If you have any thoughtful criticism, feedback, or questions about this episode or others, please email us at theoathpodcast@gmail.com that's all one word: theoathpodcast@gmail.com And though I cannot personally respond to every email, please know that I read each one of them, and that I appreciate it. The Oath is a production of NBC News and MSNBC. This podcast was produced by FannieCo. With Fannie Cohen, Nic Bannon, and Rob Hebert. They are a wonderful team and I am fortunate to work with them. Olivia Cruiser provided excellent production support, as always, our associate producer is Allison Bailey. And Steve Lickteig is our executive producer. This is The Oath with Chuck Rosenberg. Thank you so very much for listening