Dr Vivek Murthy at Idea Exchange: ‘US-India health partnership is vital to protect the world from future pandemics’

Sandeep Singh: Since you are looking at areas concerning the health of society at large, what are some of the issues confronting society, both in the US and around the world?

We are dealing with many health threats so it is always hard to list and name them exhaustively. First are the challenges we face with mental health, which are taking a toll not just on our overall health and well-being but also have economic implications. I’m also concerned about the explosion in chronic diseases that we are seeing. Non-communicable chronic diseases like cardio-vascular disease, obesity and diabetes impact disability, healthcare costs and economic output. For instance, depression and anxiety cost the global economy over one trillion dollars per year. That’s the second category I’m concerned about. The third has to do with infectious disease threats. We just lived through the Covid pandemic and that reinforced how prepared we have to be to address future infectious diseases and pandemics. This is one of the reasons why the collaboration between India and the US is so vital. We’re collaborating on many health fronts but one of them is around vaccines and being able to work together to develop vaccines, to distribute them in a cost-effective way. It’s not only important for the US and India but it will help protect the world from future pandemics.

On Excessive social media use: The kind of problematic use of social media that often interferes with life function, you see patterns that are very similar to what we see with substance use disorders and addiction

Rupsa Chakraborty: Recently, in the US, the Mental Health Act has been made more accessible to the public. Do you have any recommendations for the Indian government, especially on the level of prevention?

In India, steps have been taken to increase access to mental health care. In the US, we are dealing with a lot of similar challenges when it comes to improving access to care, focusing more on prevention and what the root causes are, and also talking more openly about mental health, which is a cultural shift that we have to make. In all of these three areas, I do think there’s a lot we can learn from one another. But looking at the world more broadly, a few key lessons seem to emerge. One is that unless we proactively work to eradicate the stigma around mental health, people won’t take advantage of them because they won’t admit that they are struggling. The second thing is improving access to care has to involve technology, to use virtual services to bring care to where people are. The ‘Tele MANAS’ service, which in India is bringing some of that virtual care to people, has been important for us to learn about. We are also on our own journey in the US to expand access to telemedicine.

Dr.Vivek Murthy in conversation with Sandeep Singh, Editor (Mumbai), at The Indian Express office in Mumbai. (Express photo by Ganesh Shirsekar)

Traditionally, in health, we have focused on treatment rather than prevention, but we cannot keep up with the demand in terms of mental health services if we don’t simultaneously address the root causes. Issues like loneliness and isolation are increasing risk for depression, anxiety and suicide among the youth. And even though young people are much more advanced when it comes to talking openly about mental health, there are still many who struggle with the shame associated with mental illness and do not ask for help. My hope is that the conversations that we are having now and the ongoing partnership between our governments around health will give us a platform for that shared learning.

Rupsa Chakraborty: You had said in an interview that social media algorithms are affecting the mental health of younger people and suggested giving a warning similar to the one with tobacco consumption of cigarettes. Is there a need to implement legal measures?

In 2023, I issued a ‘Surgeon General’s Advisory’ on social media. I laid out a series of steps that we should take to address the harms related to social media. One of the things we have lacked has been accountability in terms of the impact that they are having on the health of our children. In many other industries, in the US for example, when you produce products that children consume or utilise, there are often safety standards that you have to meet. Think about medicines that we provide for children, they have to meet rigorous safety standards. We have not done that effectively when it comes to social media. That accountability needs to involve data transparency from the companies. I have called on our government in the US to put in place data transparency requirements. I have also called for warning labels on social media, specifically Surgeon General’s Warning Labels, as one step, not the only step, that we can take to help warn kids and parents about the risks. Another is safety standards.

In our relationship with tech: Part of what we need in terms of building a healthier relationship with technology is to have some technology-free zones in our life, where we can engage with the world without the distraction of our devices

When I was growing up as a child in Miami, Florida, I remember we had a high rate of car accident-related deaths in the country. Now, we didn’t say, ‘Get rid of all cars’. We said, ‘We have to make cars safer’. And we talked about establishing standards that got us seatbelts in cars, airbags, crash testing, and that helped reduce car accident-related deaths. We need safety standards for social media. We need to protect them from the kind of bullying and harassment, including from strangers, that we, too, often see on social media.

Zeeshan Shaikh: Internet penetration is high and very cheap in India. The problem that we eventually would end up facing while talking about regulating social media is also the issue of censorship. What is the right balance to strike in addressing this?

In the US, we have a strong belief in the importance of free speech. In order to prevent companies from subjecting children to features that would lead to excessive use, we don’t need to compromise someone’s ability to express themselves. When it comes to the algorithms on social media, what concerns me is that these algorithms have, too often, fed harmful content to children. I have had the painful experience of sitting with parents who have lost their children to suicide, after their child was served up content by the algorithm that encouraged them to harm themselves, and in some cases walked them through how to actually do it. That should never happen to a child. These measures can exist alongside someone’s ability to express themselves. What we should be focused on is the common sense measures that we frankly should have put in place years ago. And the failure to do so, I worry, has led to significant harm to many children worldwide.

Sandeep Singh: Like tobacco addiction and drug addiction, which were causes of concern, do you think social media addiction is now one of the biggest concerns?

Not just children, but many adults are also finding it very hard to regulate their use of social media and it’s not because willpower has somehow disintegrated in the current generation or the older generations. It’s because the technology itself is designed using some of the most cutting edge neuroscience and brain science, powered by some of the most talented product engineers, and resourced by some of the richest companies. These platforms are designed to maximise how much time we spend on them. So if you’re telling an adolescent, whose brain is still developing at a phase when they are more susceptible, when impulse control hasn’t fully developed, to use the force of their willpower to limit use, that is an unfair fight and that is what kids are facing today.

Dr.Vivek Murthy,US Surgeon Generai. in conversation with Sandeep Singh, Editor (Mumbai), at The Indian Express office in Mumbai. (Express photo by Ganesh Shirsekar)

When you look at the kind of problematic use of social media that often interferes with life function, you see patterns that are very similar to what we see with substance use disorders and addiction. You see similar pathways in the brain that are activated and similar structural changes in the brain on imaging tests.

Rupsa Chakraborty: Do you think the impact of social media can be worse in rural areas as compared to urban areas, since the latter has more education and urban parents might be more efficient gatekeepers?

I think it is important for us to understand the differences in harm based on not just rural and urban areas, but also based on socioeconomic status. In health, in general, disparities abound. Groups that are at the lower end of the socioeconomic spectrum tend to have worse outcomes, with less access to resources and information. But this is another reason why, in the US, we’ve come to understand that we need to put in place policies that protect everyone. If you make the platform safer, that will benefit everyone, whether they are in urban or rural areas, regardless of money and privilege.

Alok Deshpande: The priorities that are mentioned on the US Surgeon General’s website — a majority of them are related to mental health. Is it because of the post-COVID environment that forced the US government to think more carefully?

In our office, we have to focus on a wide range of health issues. Even though mental health has been a major focus for us, we also continue our work on tobacco, on vaccine preventable illness among others. But the reason we’ve had a much bigger focus on mental health than in the past is partly because of Covid. We, in the US, had been struggling with mental health even before the pandemic. If you look more globally, you see the concerning trends and rising rates of anxiety and depression among kids. Those trends were building before the pandemic arrived. That has made it clear that it is long past time for us to address this with a combination of dialogue programmes and policies. There’s a real urgency to this. Mental health is not just one other side issue to consider when we have time. Mental health is foundational.

On addressing mental health issues: Mental health is not just a side issue to consider when we have time. It is foundational… If we want to address mental illness, we need three things: acceptability, accessibility and affordability

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Pallavi Smart: Post the pandemic, a lot of students feel like their future is uncertain. What should educational institutions look at when it comes to mental health for students.

As a father, I think a lot about schools and what they can do for our children. Schools need to understand the mental health of their students and they need to help support it. If they do so, it’s good for their studies, their educational outcomes and it’s good for their overall health and well-being. How to do so has been challenging for many schools. It needs to involve having conversations with students about mental health to help reduce the stigma and shame associated with it.

Zeeshan Shaikh: Do you agree that prevalent world conditions — what’s happening in Gaza, Lebanon and Ukraine — have played a part in driving people downhill when it comes to their mental health?

The disturbing and difficult events that are happening in the world do weigh on them, whether it’s wars and conflicts, or the effects of climate change that they are seeing in terms of forced migrations and extreme weather events. All of these do weigh on them. But they weigh on them in particular because they’re also coming at them 24×7. When I was growing up, if I wanted to stop or slow down the flow of information into my life, I turned off the TV. These days you can’t turn it off so easily. Part of what we need in terms of building a healthier relationship with technology is to have some technology-free zones in our life. We can understand what’s happening in the world, engage with others on technology, but also have spaces where we can also interact with people in person without distraction, where we can engage with the world without the distraction of our devices.

Dr.Vivek Murthy,US Surgeon Generai. in conversation with Sandeep Singh, Editor (Mumbai), at The Indian Express office in Mumbai. (Express photo by Ganesh Shirsekar)

Mohamed Thaver: You seem to be taking on big tech companies. When you took over, you took on the National Rifle Association as well. There are big entities with big pockets. With all these pressures, how do you ensure that you manage your own mental health as well?

There have been times where

I’ve struggled, too, to figure out how to maintain my own sense of well-being when dealing with a lot of the same challenges that everyone else is also dealing with. One thing that has also compounded it is loneliness — the isolation, which I have felt in my own life as a child and at times as an adult. But what I’ve learned the hard way by experiencing those lows is that I need to prioritise social connection. I need to prioritise activities that ground me and turn off the noise, even if it’s for a brief period of time. In my life that happens to be meditation. My parents grew up in India. They focused on the importance of relationships and community, on the importance of finding a purpose in your life that involves contributing to society. My grandfather was very poor. If we did dinner at night, they would dilute the bowls of dough with water to make sure each of the six children had enough to eat, and often there wasn’t enough. They didn’t have money for shoes. Times were hard. But despite that, and despite the fact that my grandmother died when my father was 10, my grandfather spent several weeks every year travelling to different villages in the area, raising money to build a youth hostel so students could study. And I figure if my grandfather, in the midst of bracing poverty, can find it in himself to try to take some steps to improve the lives of children, then I should be able to do the same. These values from my ancestors continue to guide me.

Rupsa Chakraborty: In the US, the Mental Health Parity Act has recently been changed to make it more accessible especially for medical insurance. What can India do?

If we want to address mental illness, we need three things: acceptability, accessibility and affordability. If we don’t have any of those three, then people can’t get help. We passed our Mental Health Parity Law to require insurance companies to reimburse for mental health conditions at par with how they reimburse for physical health conditions. In many countries, mental health workforce is smaller than it needs to be. It takes years to train a psychiatrist. We have to think more broadly about who constitutes the workforce. Yes, it’s psychiatrists, but it’s also psychologists and counsellors and social workers and peer support.

Sandeep Singh: What solutions can various cultures and societies, like India or Japan, offer?

It’s so important to have global collaboration and partnerships around mental health. Moai, the Okinawan tradition from Japan, of young people coming together and making an explicit commitment to one another, is a tradition based on my own experience. That’s a gift from Japan. The tradition of meditation obviously has deep roots here in India. One of the many reasons I’m very grateful to be in India is because the health partnership between India and the US is not only vital now, but it would be especially vital for the future, whether we are thinking about mental health, or future pandemic threats, or how we take on non-communicable diseases like cancer and heart disease. The recent Cancer Moonshot agreement is a bold step that our countries are taking together around cervical cancer.

Alok Deshpande: Who would be the best person to support all your initiatives in the next four years?
Our office is a non-partisan office. We are here to serve the American public under whichever administration. I think what’s really important is that whoever wins the election, we have to keep health at the forefront, because this is one of the core building blocks of the future.