    [Senate Hearing 117-172]
    [From the U.S. Government Publishing Office]

                                                           S. Hrg. 117-172

                          NOMINATIONS OF VIVEK MURTHY
                               AND RACHEL LEVINE

    =======================================================================

                                    HEARING

                                     OF THE

                        COMMITTEE ON HEALTH, EDUCATION,
                              LABOR, AND PENSIONS

                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 FIRST SESSION

                                       ON

    EXAMINING THE NOMINATIONS OF VIVEK HALLEGERE MURTHY, OF FLORIDA, TO BE
    MEDICAL DIRECTOR IN THE REGULAR CORPS OF THE PUBLIC HEALTH SERVICE, AND
     TO BE SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE, AND RACHEL LELAND
             LEVINE, OF PENNSYLVANIA, TO BE AN ASSISTANT SECRETARY

                                   __________

                               FEBRUARY 25, 2021

                                   __________

     Printed for the use of the Committee on Health, Education, Labor, and
                                    Pensions

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                   __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    46-752 PDF                 WASHINGTON : 2022

    -----------------------------------------------------------------------------------

              COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                        PATTY MURRAY, Washington, Chair
    BERNIE SANDERS (I), Vermont          RICHARD BURR, North Carolina,
    ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
    TAMMY BALDWIN, Wisconsin             RAND PAUL, M.D., Kentucky
    CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
    TIM KAINE, Virginia                  BILL CASSIDY, M.D., Louisiana
    MAGGIE HASSAN, New Hampshire         LISA MURKOWSKI, Alaska
    TINA SMITH, Minnesota                MIKE BRAUN, Indiana
    JACKY ROSEN, Nevada                  ROGER MARSHALL, M.D., Kansas
    BEN RAY LUJAN, New Mexico            TIM SCOTT, South Carolina
    JOHN HICKENLOOPER, Colorado          MITT ROMNEY, Utah
                                         TOMMY TUBERVILLE, Alabama
                                         JERRY MORAN, Kansas

                         Evan T. Schatz, Staff Director
                   David P. Cleary, Republican Staff Director
                      John Righter, Deputy Staff Director

                                C O N T E N T S

                                  ----------

                                   STATEMENTS

                          THURSDAY, FEBRUARY 25, 2021

                                                                       Page

                               Committee Members

    Murray, Hon. Patty, Chair, Committee on Health, Education, Labor,
      and Pensions, Opening statement................................     1
    Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State
      of North Carolina, Opening statement...........................     3

                                   Witnesses

    Murthy, Hon. Vivek, Hallegere, Miami, FL.........................     8
        Prepared statement...........................................    10
    Levine, Rachel, Leland, Middletown, PA...........................    11
        Prepared statement...........................................    13

                              ADDITIONAL MATERIAL

    Statements, articles, publications, letters, etc.
        Letters of support for the nomination of Vivek Murthy to
          serve as Medical Director in the Regular Corps of the
          Public Health Service and Surgeon General of the Public
          Health Service.............................................    48
        Letters of support for the nomination of Rachel Levine to
          serve as Assistant Secretary of Health and Human Services..   149
    Senator Richard Burr:
        Data for the Record..........................................   229

                          NOMINATIONS OF VIVEK MURTHY.
                               AND RACHEL LEVINE

                          Thursday, February 25, 2021

                                           U.S. Senate,
           Committee on Health, Education, Labor, and Pensions,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 10 a.m., in room
    216, Hart Senate Office Building, Hon. Patty Murray, Chair of
    the Committee, presiding.
        Present: Senators Murray [presiding], Casey, Baldwin,
    Murphy, Kaine, Hassan, Smith, Rosen, Lujan, Burr, Paul,
    Collins, Cassidy, Murkowski, Braun, Marshall, Romney, and
    Tuberville.

                      OPENING STATEMENT OF SENATOR MURRAY

        The Chair. The Senate Health, Education, Labor, and
    Pensions Committee will please come to order. Today, we are
    holding a hearing on the nomination of Dr. Vivek Murthy to
    serve as Surgeon General and the nomination of Dr. Rachel
    Levine to serve as Assistant Secretary for Health. Senator Burr
    and I will each have an opening statement and I will introduce
    Dr. Murthy and recognize Senator Casey to introduce Dr. Levine.
        After Dr. Murthy and Dr. Levine give their testimony,
    Senators will have five minutes each for a round of questions,
    and I am happy to stay for a second round if any Senator has
    any remaining questions. Before we begin, I want to work
    through the COVID-19 safety protocols in place. We will follow
    the advice of the Attending Physician and the Sergeant-at-Arms
    in conducting this hearing. We are all very grateful to
    everyone who has worked so hard to get this set up and help
    everyone stay safe and healthy. Committee Members are seated at
    least six feet apart, and some Senators, including myself, are
    participating by video conference. And while we are unable to
    have the hearing open to the public or media for in-person
    attendance, live video is available on our Committee website at
    www.help.senate.gov.
        We received Dr. Murthy's formal nomination on January 20th
    and his Committee paperwork and his Office of Government Ethics
    paperwork, including his public financial disclosures and
    ethics agreement on February 3rd. And we received Dr. Levine's
    formal nomination on----
        Senator Burr. Hey, Patty, can you hold for one second? They
    are working on getting you unmuted, and your video went away
    for just a second. So if you will, let us make sure that we
    have got you back before you continue.
        The Chair. Can you hear me yet?
        Senator Burr. We can hear you.
        The Chair. Okay, great. And I am not sure where you lost
    me----
        Senator Burr. If you back up about two sentences, I think
    you will have us.
        The Chair. Okay. Well, let me just say we received Dr.
    Levine's formal nomination on February 13th and Committee
    paperwork on February 10th and her Office of Government Ethics
    paperwork on February 17th. Dr. Murthy, Dr. Levine, thank you
    both for joining us today. While I have not been able to meet
    either of you in person since your nomination, I was pleased to
    speak with each of you about the challenges our Nation is
    facing and I look forward to continuing those conversations
    today and working with you both in the future, remotely for now
    when it works and in person when this pandemic is over.
        Of course, in order to end this pandemic and rebuild our
    Nation stronger and fairer, the Biden administration needs an
    all hands on deck as soon as possible, which is why it is so
    important that this Committee move quickly to consider and
    confirm qualified nominees like Dr. Murthy and Dr. Levine. We
    have lost over a half a million people to this pandemic to say
    nothing of the countless other ways it is upended the lives of
    families across our country. We desperately need trusted public
    health experts who can debunk misinformation and rumors,
    promote public health guidance on mask wearing, social
    distancing and more, and encourage vaccinations and inform
    people about vaccine safety and efficacy.
        We desperately need leaders who understand what our
    communities are going through and who will go above and beyond
    to help our states, cities, and tribes get the support they
    need. In other words, we need people like Dr. Murthy and Dr.
    Levine. Dr. Murthy is a crisis tested leader who is uniquely
    qualified to help the American people navigate the health
    challenges ahead of us. I will say more about his impressive
    record shortly, but one of the reasons I know Dr. Murthy is the
    right pick to serve as Surgeon General is because he has
    already done the job and done it well. During his last tenure
    as America's doctor, he established himself as a trusted voice
    on public health issues, saw our Nation through public health
    emergencies like the Zika epidemic in 2016, he led the charge
    against the Opioid Crisis, and he shined a light on how stress,
    isolation, and other mental health issues threaten America's
    well-being, an issue that is all the more urgent given the
    trauma of this pandemic.
        In short, he proved why he is exactly the kind of leader we
    need as Surgeon General today. I was proud to vote to confirm
    him as Surgeon General back in 2014. I am proud to support his
    nomination to return to that role now, and hopefully my
    colleagues will join me in working to get him in place quickly.
    I am also proud to support the nomination of Dr. Levine, who is
    a highly qualified and a historic choice to serve as Assistant
    Secretary for Health. I have always said our Government should
    represent the people it serves and the nomination of Dr.
    Levine, who would make history as the highest ranking openly
    transgender official in the U.S. Government, brings us a step
    closer in making sure that happens.
        Dr. Levine is a public health expert who has a firsthand
    understanding of the challenges our states are facing and the
    support they need. As the highest ranking health official in
    Pennsylvania, Dr. Levine led the state's COVID-19 response and
    advocated for resources and support Pennsylvanians needed. She
    focused on transparency and clear, science-based communication
    throughout the response and gave daily briefings on the status
    of the epidemic. But even before this crisis, Dr. Levine
    established herself as a trusted voice to the people of
    Pennsylvania on matters of public health through her work to
    establish opioid prescribing guidelines and education for
    medical students, make life saving treatment for opioid
    overdoses widely available, combat eating disorders, increase
    health equity, and help the LGBTQ community get healthcare. She
    served the state as Physician General, a position the
    Republican-led state Senate confirmed her to unanimously, and
    then Assistant Secretary of Health, a position she was
    confirmed to by an overwhelming 49 to 1 margin. Given her clear
    qualifications and the urgency of this crisis, I hope she will
    have similar bipartisan support here because a pandemic isn't
    the time to focus on politics.
        We need to focus on getting people reliable information
    from expert voices that they trust, getting states, tribes, and
    communities the resources and support that they need, getting
    testing and tracing and vaccinations up, and bringing new cases
    down. We need to focus on providing mental health care as the
    Nation grapples with the trauma of this pandemic and on
    eliminating inequities that existed long before this crisis,
    have grown worse during it, and have made the pandemic so much
    more deadly for communities of color. We all know this pandemic
    is not going to be stopped by partisan politics. It is going to
    be stopped by swift action and by public health experts like
    Dr. Murthy and Dr. Levine. So I hope we can come together to
    confirm them in quick bipartisan fashion and work with them the
    way families across the country so desperately need us to.
        Finally, I seek unanimous consent to put in the record 29
    letters in support of Dr. Murthy's nomination, 51 letters in
    support of Dr. Levine's nomination, and--from hundreds of
    hospitals, public health groups, patient advocates, medical
    schools and universities, LGBTQ advocacy groups, and
    clinicians, faith based and medical organizations, reproductive
    rights and family planning groups, civil rights groups, and so
    much more. So ordered.
        [The information referred to can be found on page 47 and
    148]
        The Chair. With that, I will recognize Ranking Member Burr
    for his opening remarks.

                       OPENING STATEMENT OF SENATOR BURR

        Senator Burr. Well, thank you, Madam Chair, for the
    opportunity to provide remarks as the Committee reviews the
    qualifications for two critical public health positions at HHS,
    the Assistant Secretary for Health and the Surgeon General. Dr.
    Levine, welcome. And Dr. Murthy, welcome as well. I also want
    to reinforce the Chairs's words that we all seek bipartisan
    votes on nominees, but that doesn't mean that answers to
    questions don't have to be sufficient. Today is your
    opportunity for that. Each of you have accepted the nomination
    at an important time, when our country is facing one of the
    most challenging times in our history as we combat COVID-19. I
    have no doubt that should you be confirmed to these important
    leadership roles, the majority of your time will be focused on
    responding to the novel coronavirus and its impact.
        As Assistant Secretary of Health, Dr. Levine, you would be
    in charge of a range of health issues including human research
    protections and research integrity. As Surgeon General, Dr.
    Murthy, you would be responsible for providing Americans with
    the best scientific information and overseeing the Public
    Health Service Commission Corps, both of which continue to be
    critical to our pandemic response. The question before us today
    is are both of you prepared and qualified to take on the roles
    and responsibilities required? In addition to the challenges
    that face us today with the pandemic, this hearing will help
    answer those questions, but I am very concerned about a
    nomination that is not before us today. In fact, it hasn't yet
    been made by the Administration. The Assistant Secretary of
    Emergency Preparedness and Response, or ASPR for short, is a
    top adviser to the Secretary of HHS during public health
    emergencies. Congress created the ASPR to serve in a dedicated
    role that coordinates among all the operating divisions and
    agencies within HHS, including the Assistant Secretary of
    Health and the Surgeon General. We have been--we have before us
    nominees for both Assistant Secretary for Health and Surgeon
    General but not the coordinator, the ASPR.
        While the words of this administration claim urgency in
    their response to COVID-19, their actions or lack thereof speak
    otherwise. The law calls for strong leadership during pandemic
    health emergencies. But the nominations before us, while
    important, do not fill the role of the Department charged with
    leading an emergency response. The Administration claimed to be
    ready on day one and the fact that a nominee for the ASPR
    hasn't yet been made and no meaningful effort in consultation
    with Congress about filling the position, quite frankly, raises
    serious questions. The ASPR is directed to communicate
    information from across the Department to the Secretary, bring
    in a daily vigilance and constant urgency to the health care
    needs of the American people so that the Secretary can make
    informed decisions both in the midst of a public health crisis
    and in times of preparation for the next threat we will face.
    We have been grappling with the novel coronavirus public health
    emergency for over a year.
        The new administration has had ample time to choose an
    individual for this critical role. So it is difficult to
    understand why the ASPR nominee is not at least sitting here
    with the two of you, if not before your hearing. Since it is
    our responsibilities as Members of Congress to vet two nominees
    before us, I will try to understand the roles each of you will
    play at HHS during the COVID-19 pandemic and the qualifications
    and experiences you have to do so. Now, Dr. Levine, the
    position of Assistant Secretary of Health evolved during the
    pandemic under the previous administration, playing an integral
    role in the COVID-19 response. Dr. Giroir, and we have all
    struggled with exactly how to pronounce his name, but Dr.
    Giroir worked with NIH and BARDA as they partnered with
    innovators to develop and scale up testing technologies, help
    to address shortages of testing supplies, and worked with
    States to meet its testing needs. Dr. Levine, you have been on
    the front line of the COVID-19 response in your home State of
    Pennsylvania, which faced great challenges with testing
    capacity early in the pandemic and vaccine rollout to this day.
    The state public health lab was only able to perform six tests
    per day in March of last year, six, severely limiting the
    public health response that relied on identifying where the
    state virus was spreading. Along with testing challenges from
    last spring, your state failed to adequately protect nursing
    home residents from the virus and is making unacceptable
    mistakes in the vaccine distribution process.
        Pennsylvania ranks as one of the most dangerous states for
    long term care residents battling COVID-19. 52 percent of
    Pennsylvania's COVID-19 deaths came from nursing homes, and 3
    in 10 of the deadliest facilities in the country were in
    Pennsylvania. Your state came in 46 in the country in its
    effort to put safeguards in place that manage the spread of
    infections in these settings, with only 16 percent of the
    state's nursing homes receiving infection control inspections
    that could have saved residents from the spread of COVID-19.
    While you stated that you relied on Federal guidance for the
    nursing home care during the pandemic, the tragic high
    mortality rate in your state's nursing homes shows that more
    was needed but wasn't provided. In my State of North Carolina,
    our health secretary also relied on Federal guidance for
    nursing homes and long term care settings. In North Carolina,
    nursing home mortality rate, while still high, account for 36
    percent of the deaths in our state.
        This discrepancy clearly shows that hiding behind Federal
    guidance is no excuse for taking action to protect our most
    vulnerable. I look forward to understanding exactly why your
    decisions when relying on the same Federal guidelines as my
    state resulted in a different outcome for Pennsylvania seniors.
    In regards to vaccine rollout, reports from your state recently
    indicated that tens of thousands of Pennsylvania residents
    mistakenly received the dedicated second dose of Moderna
    vaccine, meaning the second dose that was reserved for those
    who had the first dose and the second dose went to newly
    vaccinated people. While you may not have been in office during
    the last few weeks of the challenges facing your state, you
    were serving as the state's Health Secretary during the
    development and submission of its COVID-19 vaccine plan last
    October.
        I might note that yesterday in the HELP Committee, Senator
    Marshall put into the record, I believe, 50 state plans that
    had been submitted and I think it is important that we
    understand that you cannot separate your role from the
    performance of your agency a matter of weeks after your
    departure. So I hope you will take those questions on
    seriously. At each step, testing, treatment and now
    vaccination, your state's response has fallen short. As the
    state's Health Secretary, this track record reflects on your
    ability to meet the challenges that would come across your desk
    immediately should you be confirmed. I am sure we will find
    similar problems in all 50 states and similar blame could be
    leveled on Congress. But you are the nominee, and I hope you
    will address those questions as best you can. Dr. Murthy,
    earlier this week you and I had an opportunity to discuss a
    range of issues, and I am thankful for that time as I did with
    Dr. Levine, that the Surgeon General will face in this
    administration, starting with the response to COVID. You have
    already served once as the Nation's doctor, and my friend from
    Kentucky often tells us in the conference not much education
    comes out of the second kick of a mule. So I hope to learn more
    about why you want to do this again. Should you be confirmed,
    the American people will be placing their trust in you to
    communicate without political preference or pressure the best
    ways to keep their families safe during the crisis.
        I worry about your ability to separate political influence
    from your ability to communicate health care decisions. In
    fact, you spoke at the Democratic National Convention, a wholly
    political event, just a few months ago. As a Co-Chair of the
    Transition Team's Coronavirus Task Force, you said that the
    President's goal of 100 million vaccinations by 100 days was
    doable, lowering expectations for an accomplishment well within
    our reach today. Before President Biden took office, our
    country was already vaccinating 900,000 people a day and had
    administered over 20 million doses--20 million shots. I am in
    politics, so I know lots of people try to lower expectations in
    order to look like they are accomplishing something when they
    are simply showing up, but the Surgeon General has to be
    trusted for the facts. 100 million people in 100 days isn't a
    stretch goal. And you shouldn't be afraid to stand up to the
    political staff who want you to lower the expectations so the
    Administration can easily reach them. The American people
    deserve a Surgeon General who will separate fact from fiction
    and level with us on the science.
        Madam Chair, in conclusion, Dr. Levine and Dr. Murthy, the
    actions and positions that they have taken prior to your
    nomination and the process lead me to have some concerns. I
    hope that you will use today's hearing to address those
    concerns to earn my support. The position of Assistant
    Secretary of Health and Surgeon General are important and must
    be filled. But it is frustrating that the Administration chose
    to prioritize the nomination of candidates for these positions,
    as important as they are, instead of the nomination of the
    leader for Federal Government's response to pandemics that is
    required by law. Strong leadership will continue to be
    absolutely necessary throughout this phase of pandemic
    response. And I will use my time today to get an answer to the
    questions or the question, who is in charge?
        Chair Murray, Dr. Levine's challenges in Pennsylvania to
    bring early adequate testing and to keep nursing home residents
    safe and Dr. Murthy's inability to separate politics from good
    public health policy are especially concerning when the role of
    ASPR still stands vacant. I look forward to hearing their
    testimony today, their plans to navigate a response at HHS
    without a Senate confirmed ASPR to provide the direction these
    two offices need during a challenging time. I thank both of our
    nominees for being here today. I yield back to the chair.
        The Chair. Thank you very much Senator, Ranking Member
    Burr. We will now introduce today's witnesses. Dr. Vivek Murthy
    has a distinguished career that has solidified his reputation
    as a trusted public health expert. He has worked to improve the
    health of people across the country and across the world. And
    in doing so has shown beyond a doubt he is the right person to
    see us through this pandemic as Surgeon General.
        Before he was a doctor, before I was a public health
    expert, Dr. Murthy was a kid growing up in Miami, Florida, the
    son of two immigrants from India. He attended Harvard
    University for his undergraduate degree, Yale for both his M.D.
    and M.B.A. and completed his residency in internal medicine at
    Brigham and Women's Hospital and Harvard Medical School. His
    passion for public health was evident even as a freshman in
    college. That was when he co-founded Vision's Worldwide, an
    organization focused on HIV, AIDS education in the U.S. and
    India. And since then, he has only further demonstrated his
    ability to lead and his drive to help people stay healthy. He
    also co-founded the Swasthya project, which empowered women
    with training to become health care providers in rural India,
    Trial Networks, a company that works to improve medical
    research and collaboration and data sharing, and Doctors for
    America, a group of over 18,000 doctors and medical students
    that advocate for quality, affordable healthcare. In 2011,
    President Obama tapped Dr. Murthy to serve on the Advisory
    Group on Prevention, Health Promotion, and Integrative and
    Public Health. And in 2013, he nominated Dr. Murthy to be
    Surgeon General.
        As America's doctor, he saw the Nation through the Zika
    epidemic in 2016, released landmark reports on the Opioid
    Crisis and the dangers of e-cigarettes to youth, and lead
    important discussions about mental health, something the trauma
    of this pandemic has made even more urgent. He also championed
    preventive health, including a memorable video he did with Elmo
    to help promote vaccines. Seems to me it is about time for us
    to do both. During this pandemic, he has been an important
    voice, urging people to follow public health guidance and keep
    themselves and others safe and has been a key adviser to
    President Biden.
        He was a critical member of Biden's campaign's COVID-19
    team and served as co-chair of the Transitions Coronavirus Task
    Force. Dr. Murthy is also the proud father of two children and
    the husband of Dr. Alice Chen, who is a physician as well and
    who is watching with us today. Dr. Chen, welcome to you. Dr.
    Murthy, we are so glad to have you with us today. Thank you for
    being here. And now I will turn it over to Senator Casey to
    introduce Dr. Levine.
        Senator Casey. Thank you, Chair Murray, for your
    introduction of Dr. Murthy. And I am pleased to introduce Dr.
    Rachel Levine, the former Secretary of Health for Pennsylvania,
    also a former Professor of Pediatrics and Psychiatry at Penn
    State University, and the immediate past President of the
    Association of State--[technical problems]--Health Officials,
    and the nominee to serve, of course, as Assistant Secretary of
    Health at the Department of Health and Human Services.
        I have known Dr. Levine for years, thanks to a previous
    service as both Secretary of Health as well as the Physician
    General at Pennsylvania, a position that is comparable to that
    of our other distinguished nominee today, Dr. Murthy. In this
    terrible time of crisis for our country, when we have
    tragically lost over a half a million people to this terrible
    disease, the need for expert, experienced, and fact-based as
    well as compassionate leadership could not be more critical.
    This is the type of leadership that Dr. Levine has demonstrated
    in Pennsylvania throughout the pandemic. Dr. Levine has strong
    roots in academics, clinical care, and protecting the most
    vulnerable among us. She has a distinguished career practicing
    pediatric and adolescent medicine in both New York and
    Pennsylvania, serving as Director of Pediatric Ambulatory
    Services and Adolescent Medicine at Penn State Hershey Medical
    Center, and she was the Founding Director of the Division of
    Adolescent Medicine and Eating Disorders.
        She is the author of numerous papers on opioids,
    adolescence, eating disorders, and LGBTQIA medicine. When
    COVID-19 came to our state, Dr. Levine's leadership was marked
    by clear, science based communication at her daily briefings.
    Her early action, her collaborative style, and her calm were
    recognized by the medical community as well as leaders on both
    sides of the aisle. The COVID-19 pandemic response was not Dr.
    Levine's first experience with crisis management. She earned
    the praise of Pennsylvanians and the public health community
    for her comprehensive and strategic approach to addressing the
    opioid addiction crisis in our state. She changed addiction,
    medical education, and prescribing practices, and she made
    naloxone, the lifesaving rescue medicine needed at the time of
    an overdose, she made it widely available to law enforcement,
    schools, and residents alike.
        She worked tirelessly to address health disparities,
    including Black maternal mortality and obstacles to access to
    care faced by the LGBTQ community. Dr. Levine has dedicated her
    career to children and young adults, addressing physical,
    mental, and social care needs. As Pennsylvania's Secretary of
    Health, she brought that approach to all residents, including
    our seniors and long term care residents. As further evidence
    of her effectiveness and style of leadership, I would note that
    Dr. Levine was confirmed three times, three times to her prior
    positions in State Government by Pennsylvania's Republican
    majority state Senate.
        I am grateful for her willingness to continue her
    distinguished career in public service, and I look forward to
    working with her in the role that I know she will be confirmed
    as Assistant Secretary of Health at the Department of Health
    and Human Services. Thank you, Chair Murray.
        The Chair. Well, thank you, Senator Casey. Dr. Murthy, Dr.
    Levine we are looking forward to hearing from both of you now.
    And Dr. Murthy, you will begin with your testimony.

       STATEMENT OF HON. VIVEK HALLEGERE MURTHY, M.D., MIAMI, FL

        Dr. Murthy. Thank you so much, Chair Murray. Chair Murray,
    Ranking Member Burr, distinguished Members of the Committee, I
    am deeply honored and incredibly grateful for the opportunity
    to appear before you today. I would like to first introduce my
    wife and my best friend, Dr. Alice Chen, who is sitting behind
    me. It is her love and support that has brightened each day of
    my life since we first met more than a decade ago.
        While they weren't able to be here in person, I am thinking
    today about the rest of my family who is watching from afar, my
    children, Teyjas, who is four, and Shanthi, who is three, my
    grandmother Sarojini and my sister Rashmi and brother in law
    Amit. And especially my parents Hallegere and Myetraie Murthy.
    They came to this country from India decades ago. They had few
    contacts or resources, but they had high hopes that America
    would be a place where their children would find education and
    opportunity. They set up a small medical practice in Miami, and
    as a child, I watched them make house calls in the middle of
    the night and wake up early to visit patients in the hospital
    before heading into their office. They attended birthdays,
    weddings, and funerals for their patients, always there in the
    moments that mattered because they saw their patients as family
    and that is what you do for family. I have tried to live by the
    lessons that they embody, that we have an obligation to help
    each other whenever we can to alleviate suffering wherever we
    find it, and to give back to this country that made our lives,
    my life and the lives of my children possible.
        This is a moment of tremendous suffering for our Nation.
    More than half a million people have lost their lives to COVID-
    19, including beloved members of my own family. Many more are
    facing long term health consequences and stressful financial
    struggles. If confirmed as Surgeon General, my highest priority
    will be to help end this pandemic. In the work I have done over
    the past year with Government leaders and schools and
    businesses and health care providers, I have seen the
    importance of providing clear, science based guidance to
    Americans on how to protect themselves and others. And I know
    how urgent it is that we communicate clearly about the safety
    and effectiveness of vaccines and get them to people as quickly
    as possible, particularly those in underserved rural
    communities and communities of color. But as we address COVID-
    19, we cannot neglect the other public health crises that have
    been exacerbated by this pandemic, particularly the opioid
    epidemic, mental illness, and racial and geographic health
    inequities.
        I have witnessed how these challenges are destroying lives
    and devastating families all across America. During my prior
    service as Surgeon General, I listened to and learned from
    people in rural communities in Oklahoma and in Alaska, and in
    big cities, including Indianapolis, New Orleans, and Charlotte.
    Their stories are what led me to issue the first Surgeon
    General's report on alcohol, drugs and health and to launch a
    national education campaign on opioids and safe prescribing.
    But we have so much more to do, and if confirmed, I will work
    tirelessly to address these crises. I will do so guided always
    by the very best science. And I will work with Secretary-
    Designate Becerra, Dr. Levine, and with colleagues across the
    Federal Government and at state and local levels. Equally as
    important, though, I will also work closely with community
    partners, from faith leaders and businesses to doctors, nurses,
    and educators.
        I would also welcome once again the chance to work hand in
    hand with congressional leaders on both sides of the aisle, as
    I was privileged to do in the past as we together addressed the
    opioid epidemic, the Zika virus, and other public health
    challenges. And I would be honored, deeply honored to once
    again lead the United States Public Health Service Commission
    Corps, which for more than a century has helped our Nation
    respond to public health threats, including COVID-19. Senators,
    I know that the challenges before us are daunting. But if
    confirmed, I will never forget that at its essence, the role of
    the Surgeon General is that of a doctor, one charged with
    serving every single American. I learned as a doctor to
    approach each patient with both head and heart, with science
    and compassion, recognizing that both have the power to heal.
        I learned to respect the uniqueness of each patient,
    recognizing that solutions must be tailored to each individual.
    And I learned to listen deeply to the patient in front of me,
    to look beyond any labels, and to see that person in their
    fullest humanity, knowing that they were someone's mother,
    father, grandparent, child, sibling, and friend.
        The most important job of a doctor is to help patients
    heal, and if confirmed, that will be my mission as Surgeon
    General, to do whatever I can, for as long as I can to help our
    communities and our Nation heal. Thank you so much for your
    consideration of my nomination, and I look forward to your
    questions.
        [The prepared statement of Dr. Murthy follows:]
                     prepared statement of vivek h. murthy
        Chair Murray, Ranking Member Burr, and Distinguished Members of the
    Committee, I am deeply honored and incredibly grateful for the
    opportunity to appear before you today. I would like to introduce my
    wife and best friend, Dr. Alice Chen, whose love and support has
    brightened my life in countless ways.

        While they weren't able to be here in person, I'm thinking today
    about the rest of my family who are watching from afar--my children
    Teyjas and Shanthi, who are our greatest joy; my grandmother Sarojini;
    my sister Rashmi and brother in law Amit; and especially my parents
    Hallegere and Myetraie Murthy, who came to this country as immigrants
    decades ago and set up a small medical practice in their community in
    Miami. As a child, I watched them make house calls in the middle of the
    night and wake up early to visit patients in the hospital before
    heading to their office. They attended birthdays, weddings, and
    funerals for their patients, always there in the moments that mattered
    because they saw their patients as family, and that's what you do for
    family.

        I have tried to live by the lessons they embodied: that we have an
    obligation to help each other whenever we can, to alleviate suffering
    wherever we find it, and to give back to this country that made their
    lives and my life and the lives of my children possible.

        This is a moment of tremendous suffering for our Nation. More than
    half a million people have lost their lives to COVID-19, including
    beloved members of my own family. Many more are facing long-term health
    consequences. And millions of Americans are experiencing secondary
    impacts on their health--from missed preventive care, to stressful
    financial struggles, to anxiety and depression.

        If confirmed as Surgeon General, my highest priority will be to
    help end this pandemic, work I've been doing over the past year with
    state and local officials, schools and universities, businesses, health
    care providers, and others. I have seen first-hand the importance of
    providing clear, science-based guidance to Americans on how to protect
    themselves and others. And I know how urgent it is that we communicate
    clearly about the safety and effectiveness of vaccines and get them to
    people as quickly as possible, particularly those in underserved rural
    communities and communities of color.

        But as we address COVID-19, we cannot neglect the other public
    health crises we face, crises that have been exacerbated by this
    pandemic: particularly the opioid epidemic, mental illness, and glaring
    racial and geographic health inequities.

        During my prior service as Surgeon General, I saw firsthand how
    these challenges are destroying lives and devastating families in every
    corner of this country. I listened to and learned from people in rural
    communities in Oklahoma and Alaska and in big cities, including
    Indianapolis, Indiana, New Orleans, Louisiana, and Charlotte, North
    Carolina. And their stories are what led me to issue the first Surgeon
    General's Report on Alcohol, Drugs, and Health and to launch a national
    education campaign on opioids and safe prescribing.

        But we have so much more to do, and if confirmed, I will work
    tirelessly to address these crises. I will do so guided always by the
    very best science. And I will work with Secretary-Designate Becerra,
    Dr. Levine, and with colleagues across the Federal Government and at
    state and local levels. Equally as important, I will work in
    coordination with partners outside government: community organizations,
    businesses, faith leaders, doctors and nurses, and educators.

        I would also welcome the chance to once again work hand in hand
    with congressional leaders on both sides of the aisle as I was
    privileged to do in the past in addressing the opioid epidemic, the
    Zika virus, and other public health challenges.

        I am particularly eager to work with our Nation's great public
    health assets: the United States Public Health Service Commissioned
    Corps, which has already helped our Nation respond to Ebola, Zika,
    H1N1, and COVID-19 and which has the potential to be an even more
    robust and resilient force to protect our Nation's health during and
    between pandemics.

        I know the challenges before us are daunting. But if confirmed, I
    will never forget that at its essence, the role of the Surgeon General
    is that of a doctor--one charged with serving every single American. I
    learned as a doctor to approach each patient with both head and heart--
    science and compassion--recognizing that both have the power to heal. I
    learned to respect the uniqueness of each patient, recognizing that
    solutions must be tailored to each individual. And I learned to listen
    deeply to the patient in front of me, to look beyond any labels, and to
    see that person in their fullest humanity, knowing they were someone's
    mother, father, grandparent, child, sibling, or friend.

        The most important job of a doctor is to help patients heal. And if
    confirmed, that will be my mission as Surgeon General--to do whatever I
    can to help heal our communities and our Nation.

        Thank you for your consideration of my nomination, and I'm happy to
    take your questions.
                                     ______

        The Chair. Thank you very much, Dr. Murthy. And we will now
    turn to Dr. Levine for your testimony.

        STATEMENT OF RACHEL LELAND LEVINE, M.D., MIDDLETOWN, PA

        Dr. Levine. Madam Chair Murray, Ranking Member Burr,
    distinguished Members of the Committee, thank you for the
    opportunity to appear before you today.
        The Chair. Could we make sure the mic is on? Thank you.
        Dr. Levine. I am honored to be President Biden's nominee to
    serve as the Assistant Secretary for Health at the Department
    of Health and Human Services. If I am fortunate enough to be
    confirmed, I look forward to working with Secretary-Designee
    Becerra, Dr. Murthy, and with each of you in service to our
    country. At its core, my career has been about helping people
    live healthy lives. As the Assistant Secretary for Health, I
    would be committed each day to helping the people of our Nation
    and improving our public health. I am both humbled by the
    opportunity and ready for the job. As you know well, we each
    come to public service in our own unique way.
        In my case, I was a physician for many years, specializing
    in pediatrics and adolescent medicine and managing educational
    and departmental responsibilities at a major academic hospital
    system. Throughout my medical career, I have been particularly
    invested in health issues that are at the intersection of
    physical and behavioral health, and I brought that expertise to
    public health in addressing substance use disorders. After
    receiving my education at Harvard College and the Tulane
    University School of Medicine, I trained at the Mount Sinai
    Medical Center in New York City. I practiced pediatrics and
    adolescent medicine at Mt. Sinai and Lenox Hill Hospitals. Then
    I moved to Pennsylvania and worked at the Penn State College of
    Medicine and the Penn State Hershey Medical Center. At Penn
    State, I initiated a division of adolescent medicine for the
    care of complex teens with medical and psychological problems,
    and in addition, I started the Penn State Hershey Eating
    Disorders Program, which offers multidisciplinary treatment for
    children, adolescents, and adults with eating disorders.
        When I left Penn State Hershey in 2015, I was Professor of
    Pediatrics and Psychiatry, Vice Chair of Pediatrics for
    Clinical Affairs, and the Chief of the Division of Adolescent
    Medicine and Eating Disorders. In 2015, I was named by Governor
    Tom Wolf to be the Physician General for the Commonwealth of
    Pennsylvania and confirmed unanimously to the post by the state
    Senate. I was confirmed twice more on a bipartisan basis to be
    Secretary of Health. In both roles, I concentrated on
    addressing the opioid misuse and overdose crisis in our state,
    working in partnership with the Federal Department of Health
    and Human Services on these efforts.
        We focused on opioid stewardship, meaning the safe,
    appropriate, and responsible prescribing of opioids. We taught
    those practices to the medical students. In addition, we
    developed continuing medical education programs, we established
    prescribing guidelines, as well as a robust prescription drug
    monitoring program as part of our efforts. One of my most
    significant accomplishments as physician general was signing
    the first ever statewide standing order for the distribution of
    the lifesaving medicine naloxone. This enabled emergency
    medical personnel to carry naloxone to reverse overdoses as
    well as the public to readily access the medication, saving
    thousands of lives as a result. As Secretary of Health through
    the Pennsylvania Rural Health Model, we work to save rural
    hospitals by transitioning them from fee for service to global
    budget payments. This model aligns incentives for providers to
    deliver value based care and for rural hospitals to transform
    their care to better meet community health needs.
        In addition, we establish a maternal mortality review
    committee to better understand and respond to the causes of
    maternal deaths. And we worked to improve childhood
    immunization rates as well as other priorities. Of course, our
    focus changed dramatically last year, and COVID-19 became my
    most urgent and primary focus. We concentrated on three key
    priorities to combat COVID-19 containment, with expansion of
    testing and contact tracing, mitigation with masks and social
    distancing, and medical countermeasures such as the
    distribution of medications such as monoclonal antibodies and,
    of course, authorized vaccines. As part of these efforts, we
    created a health equity task force, which included many
    community stakeholders, such as the Pittsburgh based Black
    Coalition Against COVID-19 and the Latino Connection.
        We also launched a faith based testing strategy where
    people could get tested at their places of worship. There is
    still so much more to do. If confirmed, I will continue
    focusing on these issues at HHS to work to get the pandemic
    under control. I look forward to driving efforts and oversight
    within the office of the Assistant Secretary for Health that
    will bolster the health of our Nation. I look forward to your
    consideration and I humbly ask for your support. And I look
    forward to your questions.
        [The prepared statement of Dr. Levine follows:]
                     prepared statement of rachel l. levine
        Chair Murray, Ranking Member Burr, distinguished Members of the
    Committee. Thank you for the opportunity to appear before you today.

        My name is Dr. Rachel Levine, and I am honored to be President
    Biden's nominee to serve as the Assistant Secretary for Health at the
    Department of Health and Human Services.

        If I am fortunate enough to be confirmed, I look forward to working
    with Secretary-Designate Becerra, Dr. Murthy. And with each of you, in
    service to our country.

        At its core, my career has been about helping people live healthy
    lives. As the Assistant Secretary for Health, I would be committed
    every day to helping the people of our Nation and improving our public
    health. I am both humbled by the opportunity, and ready for the job.

        As you know well, we each come to public service in our own unique
    way. In my case, I was a physician for many years specializing in
    pediatric and adolescent medicine and managing educational and
    departmental responsibilities in a major academic hospital system.

        Throughout my medical career I have been particularly invested in
    health issues that are at the intersection of physical and behavioral
    health, and I brought that expertise to public health in addressing
    substance use disorders.

        After receiving my education at Harvard College and the Tulane
    University School of Medicine, I trained at the Mt. Sinai Medical
    Center in New York City.

        I practiced pediatrics and adolescent medicine at Mt. Sinai and
    Lenox Hill Hospital before moving to Pennsylvania and working at the
    Penn State College of Medicine and the Penn State Hershey Medical
    Center.

        At Penn State, I initiated a Division of Adolescent Medicine for
    the care of complex teens with medical and psychological problems. In
    addition, I started the Penn State Hershey Eating Disorders Program,
    which offers multidisciplinary treatment for children, adolescents, and
    adults with eating disorders such as anorexia nervosa and bulimia
    nervosa.

        When I left Penn State Hershey in 2015, I was Professor of
    Pediatrics and Psychiatry, Vice Chair of Pediatrics for Clinical
    Affairs, and Chief of the Division of Adolescent Medicine and Eating
    Disorders.

        In 2015, I was named by Governor Tom Wolf to be Physician General
    for Pennsylvania and confirmed unanimously to the post by the State
    Senate. I was confirmed twice more--on a bipartisan basis--to be
    Secretary of Health.

        In both roles, I concentrated on addressing the opioid misuse and
    overdose crisis in the state and worked in partnership with the
    Department of Health and Human Services on these efforts. We focused on
    opioid stewardship--meaning the safe, appropriate, and responsible
    prescribing of opioids--and teaching these practices to medical
    students. Additionally, we developed continuing medical education
    programs training providers on the safe and judicious use of opioid
    medication and established prescribing guidelines and a prescription
    drug monitoring program as part of our efforts.

        One of my most significant accomplishments as Physician General was
    signing the first-ever statewide standing order for the distribution of
    the lifesaving medicine naloxone. It enabled emergency medical
    personnel to carry naloxone on the job to reverse overdoses and the
    public to readily access the medication, saving thousands of lives as a
    result.

        As Secretary of Health through the Pennsylvania Rural Health Model,
    we worked to save rural hospitals by transitioning them from fee-for-
    service to global budget payments. This model aligned incentives for
    providers to deliver value-based care and for rural hospitals to
    transform their care to better meet community health needs.

        In addition, we also established a Maternal Mortality Review
    Committee to better understand and respond to the causes of maternal
    deaths, and improve childhood immunization rates, among other
    priorities.

        Of course, our focus changed dramatically last year, and COVID-19
    became my urgent and primary focus.

        We concentrated on three key priorities to combat COVID 19:
    Containment with expansion of testing and contact tracing. Mitigation
    with masks and social distancing. And medical countermeasures such as
    distribution of medications such as monoclonal antibodies and, of
    course, authorized vaccines.

        As part of these efforts, we created a Health Equity Taskforce,
    which included many community stakeholders such as the Pittsburgh-based
    Black Coalition Against COVID-19 and the Latino Connection. We also
    launched a faith-based testing strategy where people could get tested
    at their places of worship.

        There is still so much more to do.

        If confirmed, I will continue focusing on these issues at HHS to
    get the pandemic under control and look forward to driving efforts and
    oversight within the Office of the Assistant Secretary for Health that
    will bolster the health of our Nation.

        I thank you for your consideration and humbly ask for your support.

        I look forward to your questions.
                                     ______

        The Chair. Thank you very much to both of you. We will now
    begin a round of five minute questions. And I do ask my
    colleagues to please keep track of your clock and stay within
    those five minutes. I am happy to stay if any of you have
    additional questions for a second round. The United States is
    in the midst of the worst pandemic we have ever seen in over a
    century. And the previous administration's response to this
    pandemic was marked by the rejection of science, dissemination
    of misinformation, and the erosion of trust in our scientific
    agencies. And as we mark over a half a million people dead in
    this country, it goes without saying the toll has been profound
    under President Biden's leadership. We now have a science-led,
    coordinated national response.
        In the past months, we have already seen significant
    increases in testing and tracing and vaccination, and we have
    seen downward trends in the number of new cases,
    hospitalizations, and deaths. But there is a lot of work ahead
    to keep families safe, get everybody vaccinated, and fight
    misinformation with reliable public health guarantees. And we
    need to address troubling reports about people choosing not to
    get vaccinated by having trusted public health experts and
    trusted partners communicating with the American public about
    these issues.
        Dr. Murthy, one of the important roles of Surgeon General
    is being a clear and prominent voice on the importance of
    science. If confirmed to this role, how will you promote
    confidence in our scientific agencies and in COVID-19 vaccines?
        Dr. Murthy. Well, thank you, Chair Murray, for that
    question. I think it is absolutely--for sure, that the
    essential job of the Surgeon General has to be to communicate
    in a way that is driven by science. And one of the great
    challenges during this past pandemic, or that is ongoing, is
    that we have been responding to the virus while we have also
    had to learn about the virus.
        As our knowledge has changed, it hasn't always been easy to
    communicate clearly with the public about those changes. But my
    goal, if I was confirmed to serve, Senator, would be number
    one, to first and foremost work with the CDC, with the NIH, and
    other scientific entities and Government to make sure we are
    clear on what the science says, to go out to where people are
    and communicate that information clearly, including
    communicating why we change our recommendations if we do make
    changes. But I think, perhaps most importantly, Senator, I
    think public education actually starts not with speaking, but
    with listening.
        I think that, I can say this for myself and perhaps, not in
    all the roles that I have played, but I have learned far more
    by listening to the people that I have sought to serve than I
    have by listening to textbooks--by reading textbooks.
    Understanding their concerns, their needs, understanding how
    they interpret information can help us do better as public
    servants and public educators. And that would be the approach I
    would seek to take if I had the privilege of serving.
        The Chair. Okay. Thank you. Dr. Levine, in your role as
    Pennsylvania's Secretary of Health, you worked closely with
    experts throughout the state on your COVID-19 response. How
    will that experience inform your efforts to work with state,
    local, and tribal public health and community leaders if you
    are confirmed as Assistant Secretary for Health?
        Dr. Levine. Well, Senator, thank you so much for that
    question. I certainly, if confirmed to this position, look
    forward to working with the Administration, the CDC, Health and
    Human Services on President Biden's strategic response to the
    COVID-19 pandemic. I feel that I have a unique perspective on
    the COVID-19 pandemic, working as a state health official in
    Pennsylvania, in addition to my work as the president of ASTO,
    the Association of State and Territory Health Officials. I know
    firsthand the importance of the collaboration and coordination
    between Federal public health officials, state public health
    officials, and local public health officials. And if confirmed,
    I look forward to working with the Biden administration and
    others on coordinating our response.
        The Chair. Thank you. The COVID-19 pandemic has really been
    a painful reminder that deep health inequities remain
    entrenched in our society, driven by structural racism,
    discrimination, and bias. From the beginning, this pandemic has
    taken a disproportionate deadly toll on people of color, which
    is entirely unacceptable. In addition to centering equity in
    our COVID-19 response, we have to commit ourselves to the hard
    work of building a more equitable health care system for all
    people, including families of color, people from low income
    backgrounds, underserved areas, LGBTQ people, people with
    disabilities and others that need to be able to get high
    quality, affordable care.
        I am out of time, but Dr. Murthy and Dr. Levine, I know
    that is a priority we share, we have talked about, and I want
    you to know I look forward to working together to make sure
    health equity is incorporated in the COVID-19 response and all
    of HHS's public health work. So thank you again for being here.
    I will have more questions in the second round, but I will turn
    it over to Senator Burr for his questions.
        Senator Burr. Thank you, Madam Chair. Dr. Levine, as I
    mentioned in my opening statement, your state continues to
    struggle with COVID-19 response. How can you assure that the
    same challenges that Pennsylvania experienced in testing,
    nursing home care, and now vaccinations will not occur when
    given the opportunity to serve in the public health policy
    area?
        Dr. Levine. Well, Senator, thank you for that question and
    the opportunity to respond. In Pennsylvania, we did work to
    have a scientific, evidence based response to COVID-19. There
    were significant challenges because this is a novel
    coronavirus, and especially in the spring, we had challenges
    with testing, we had challenges with contact tracing, etc. We
    had a lack of personal protective equipment, as most other
    states did, that were impacted in the spring.
        I think that the Nation's response has improved
    significantly and under President Biden's leadership and his
    strategic plan and task force, if confirmed, I look forward to
    my role in the Nation's response. I look forward, as I
    mentioned, to collaborating with a local, state, as well as
    Federal officials and working on that coordination and
    communication.
        Senator Burr. Over the past few years, the National
    Institute of Health has been investigating cases involving NIH
    supported researchers who have failed to disclose support from
    foreign Governments and other entities, who have diverted
    intellectual property through grant applications and other NIH
    funded projects, or who have sought to influence or undermine
    the peer review process. The Office of Assistant Secretary for
    Health oversees the Office of Research Integrity. If confirmed,
    how will you seek to address attempts by foreign Governments to
    influence U.S. funded research?
        Dr. Levine. Well, Senator, thank you for that question. If
    I am fortunate enough to be confirmed as the Assistant
    Secretary of Health and oversee, as you mentioned, the Office
    of Research Integrity, I certainly commit to working with you,
    to working with Congress, with other experts at Health and
    Human Services and NIH to make sure that research standards are
    of the highest quality and that there is no interference in
    research in the United States.
        Senator Burr. Dr. Murthy, vaccine hesitancy is not limited
    to COVID. The 2019 measles outbreak, there were 182 cases
    reported in 31 states, and it shows the vaccine hesitancy is a
    growing problem for other conditions as well. Given your
    previous participation in politics and controversial policy
    debates, will you be able to effectively communicate the safety
    and efficacy of vaccines to those Americans who may not agree
    with your policy or your political views?
        Dr. Murthy. Thank you, Senator, for that question. Senator,
    I approach issues like vaccines and all public health issues,
    first and foremost, as a doctor. I was taught in medical school
    that it doesn't matter what someone's background is, doesn't
    matter what their race and ethnicity is, doesn't matter
    certainly what their political affiliation is, each person is a
    human life that has unique value, and we have to treat them
    with dignity and respect. And that is how I approached my job
    when I had the privilege of serving last time, Senator. With
    regard to the measles outbreak, my approach then in talking
    about vaccines was to start by listening to what people's
    concerns were, not to demonize them or castigate them for their
    stance, but rather to understand what their concerns are.
        Second is to bring the best of science so that people can
    understand what the data actually tells us about these
    vaccines, what we know, but also to be honest about what we
    don't know. And last, sir, I believe it is important also to
    recognize that the Surgeon General is an important messenger,
    but not just directly in speaking to the American people, but
    in engaging with partners, in mobilizing trusted voices,
    including faith leaders and doctors and nurses in local
    communities.
        That convening role is also important as Surgeon General.
    It is what I used certainly when I was building a national
    opioid campaign to work on changing prescribing practices. That
    approach to partnerships is what I would incorporate if I was
    working on a vaccine hesitancy strategy today.
        Senator Burr. I am curious. Throughout the last year, the
    Surgeon General frequently communicated with the American
    people the best ways to keep families safe and healthy during a
    difficult time. How do you think the role of Surgeon General
    differs today from when you previously held that role?
        Dr. Murthy. Well, Senator, that is a great question. And I
    think it is especially important because I think the country is
    evolving and it is changing, and people's needs are evolving.
    And the Surgeon General's role has to evolve accordingly. You
    know, when I was there some things that are similar to when I
    served last time, some things that are different, I think, we
    have ongoing concerns around vaccine hesitancy, but I think
    that they are more complex and nuanced now than they were pre-
    pandemic. I think that the fragmentation in how people get
    their information is even greater now than it was seven years
    ago, with people not just getting their information from a
    couple of sources or a couple of social media platforms but
    getting it for a wide variety of sources.
        To me, that increases the importance of us engaging with
    local partners who can speak to and access people where they
    are, as opposed to solely trying to, as individuals in
    Government, get on a few platforms or news, sources and assume
    that we are going to reach everyone. So that partnership
    strategy, the convening role of this Surgeon General, I think
    is even more important now than it was when I served in the
    last time.
        Senator Burr. Thank you for that. Thank you, Chair Murray.
        The Chair. Thank you, Senator Burr.
        Senator Casey.
        Senator Casey. Madam Chair, I thank you very much. I have a
    question for Dr. Levine and one for Dr. Murthy. I will start
    with Dr. Levine. Two issues relating to children. One is the
    mental health and the other is child abuse. One in five
    children, before the pandemic, suffered from mental health
    issues, and rates of anxiety and depression have doubled since
    the pandemic. It is hard to comprehend the scale of that. In
    fact, mental health issues now account for 30 percent of
    emergency room visits for high school and middle school
    students, 30 percent of emergency room visits, over half of
    young adults' report symptoms of anxiety and depression. That
    is mental health.
        Then we go to the horror, the American scourge of child
    abuse, frankly, that neither party has done enough to combat.
    Child abuse is on the rise. We know that. And yet without the
    contact provided through in-person school, many more cases are
    going undetected. With all of these terrible stressors that are
    burdening our children, it is more important than ever that we
    focus on children's health and behavioral health needs. Dr.
    Levine, given the depth of your experience in addressing
    quality and access to mental health services, can we be assured
    that these issues will be a priority for you if you are
    confirmed to this position at HHS?
        Dr. Levine. Well, Senator, thank you very much for this
    question. And I would like to thank you so much, you and your
    staff, for all of your work on these very important issues. I
    am a pediatrician in my original field, and I still have a
    pediatrician's love for children and adolescents. And we will
    do everything possible to work for the betterment of children
    and adolescents in our country. Mental health, as I mentioned
    in my opening statements, has been really--that intersection
    between medical issues and mental health issues has been really
    one of the basis of my career, and I look forward to bringing
    that experience that I have in academic medicine and at the
    Penn State Department, the Pennsylvania Department of Health,
    to my role if I am confirmed as the Assistant Secretary of
    Health. And I would very much like to look forward to working
    with you and your office and your staff, since I know that you
    have done a lot of work in this area.
        Senator Casey. Dr. Levine, thank you. Dr. Murthy, I have a
    question for you. Based upon your work combating vaccine
    hesitancy and the culture of prevention you have often spoken
    up to reduce the burden of preventable illnesses related to
    diet or exercise or isolation or vaccine preventable disease.
    To your credit, you have worked with others on these goals,
    reaching out to employers, faith based leaders, even partnering
    as Chair Murray mentioned, with Elmo and Sesame Street to
    better reach families.
        When you co-chaired the coronavirus advisory team, you
    collaborated with Dr. Marcella Nunez-Smith, who is now leading
    the COVID-19 Equity Task Force, working to reduce disparities
    related to the pandemic and assure equitable allocation of
    resources, including the vaccine. We are now fortunate enough
    to see a light at the end of this terrible dark tunnel we have
    been in. The vaccines are helping us prevent disease and death.
    If we have all the information we need and trust so that more
    of us will make the decision to take the vaccine when it is our
    turn, if that happens in greater numbers, we will all be in
    better shape.
        As Surgeon General, how will you use your leadership and
    the full force of the public health service to address this
    issue of vaccine hesitancy so the people of our country can
    establish the trust they need to take the vaccine?
        Dr. Murthy. Well, Senator, I thank you for raising this
    important issue. You know, I think we have seen concerning
    rates of vaccine hesitancy when it comes to the COVID-19
    vaccine, and what I would seek to do if I had the privilege of
    serving is number one, seek to understand directly by listening
    to people, by showing up where they are, what is driving their
    concerns. And it is different. I think we can't assume that the
    same issues are concerns for everyone. We can't assume there is
    also one size fits all solution to vaccine hesitancy. We have
    got to understand what people's concerns are and then we have
    to bring the best of science to address those questions the
    best we can.
        But, Senator, I also think that we have got to do this in
    partnership with local communities. I learned from my past
    experience as Surgeon General that one has to approach the task
    of communication with humility, recognizing there is a lot we
    do not understand and that people on the ground, faith leaders
    and educators and doctors and nurses, often know far more about
    what their communities need and what their concerns are. So we
    have got to listen with them, work with them. And together, I
    do believe that we can help reduce rates of vaccine hesitancy.
        Senator Casey. Thank you. Thank you, Chair Murray.
        The Chair. Thank you very much.
        Senator Paul.
        Senator Paul. Genital mutilation has been nearly
    universally condemned. Genital mutilation has been condemned by
    the WHO, the United Nations Children's Fund, the United Nations
    Population Fund. According to the WHO, genital mutilation is
    recognized internationally as a violation of human rights.
    Genital mutilation is considered particularly egregious
    because, as the WHO notes, it is nearly always carried out on
    minors and is a violation of the rights of children. Most
    genital mutilation is not typically performed by force, but as
    WHO notes that by social convention, social norm, the social
    pressure to conform, to do what others do and have been doing
    as well as the need to be accepted socially and the fear of
    being rejected by the community.
        American culture is now normalizing the idea that minors
    can be given hormones to prevent their biological development
    of their secondary sexual characteristics. Dr. Levine, you have
    supported both allowing minors to be given hormone blockers to
    prevent them from going through puberty, as well as surgical
    destruction of a minor's genitalia. Like surgical mutilation,
    hormonal interruption of puberty can permanently alter and
    prevent secondary sexual characteristics.
        The American College of Pediatricians reports that 80 to 95
    percent of prepubescent children with gender dysphoria will
    experience resolution by late adolescence if not exposed to
    medical intervention and social affirmation. Dr. Levine, do you
    believe that minors are capable of making such a life changing
    decision as changing one's sex?
        Dr. Levine. Well, Senator, thank you for your interest in
    this question. Transgender medicine is a very complex and
    nuanced field with robust research and standards of care that
    have been developed. And if I am fortunate enough to be
    confirmed as the Assistant Secretary of Health, I look forward
    to working with you and your office and coming to your office
    and discussing the particulars of the standards of care for
    transgenderism.
        Senator Paul. The specific question was about minors. Let's
    be a little more specific since you evaded the question. Do you
    support the Government intervening to override the parent's
    consent to give a child puberty blockers, cross sex hormones
    and, or amputation surgery of breasts and genitalia? You have
    said that you are willing to accelerate the protocols for
    street kids. I am alarmed that poor kids with no parents who
    are homeless and distraught, you would just go through this and
    allow that to happen to a minor.
        I would hope that you would have compassion for Kira Bell,
    who is a 23 year old girl who was confused with her identity.
    At 14, she read on the Internet about something about
    transsexuals. She thought, well, maybe that's what I am. She
    ended up getting these puberty blockers, cross-sex hormones.
    She had her breasts amputated. But here is what ultimately she
    says now. And this is a very insightful decision from someone
    who made a mistake but was led to believe this was a good thing
    by the medical community. ``I made a brash decision as a
    teenager, as a lot of teenagers do, trying to find confidence
    and happiness, except now the rest of my life will be
    negatively affected,'' she said, adding that the medicalized
    gender transitioning was a very temporary, superficial fix for
    a very complex identity issue.
        What I am alarmed at is that you are not willing to say
    absolutely, minors shouldn't be making decisions to amputate
    their breast or to amputate their genitalia. For most of our
    history, we have believed that minors don't have full rights
    and the parents need to be involved. So I am alarmed that you
    won't say with certainty that minors should not have the
    ability to make the decision to take hormones that will affect
    them for the rest of their life. Will you make a more firm
    decision on whether or not minors should be involved in these
    decisions?
        Dr. Levine. Senator, transgender medicine is a very complex
    and nuanced field. And if confirmed to the position of
    Assistant Secretary of Health, I would certainly be pleased to
    come to your office and talk with you and your staff about the
    standards of care and the complexity of this field.
        Senator Paul. Let it go into the record that the witness
    refused to answer the question. The question is a very specific
    one. Should minors be making these momentous decisions? For
    most of the history of medicine, we wouldn't let you have a cut
    sewn up in the E.R., but you are willing to let a minor take
    things that prevent their puberty and you think they get that
    back? You give a woman testosterone enough that she grows a
    beard, you think she is going to go back looking like the woman
    you stopped with testosterone? You have permanently changed
    them. Infertility is another problem. None of these drugs have
    been approved for this. They are all being used off label.
        I find it ironic that the left that went nuts over a
    hydroxychloroquine being used possibly for COVID are not
    alarmed that these hormones are being used off label. There is
    no long term studies. We don't know what happens to them. We do
    know that there are dozens and dozens of people have been
    through this who regret this happened, and a permanent change
    happened to them, and, if you have ever been around children,
    14 year olds can't make this decision. In the gender dysphoria
    clinic in England, 10 percent of the kids are between the ages
    of 3 and 10.
        We should be outraged that someone is talking to a 3-year
    old about changing their sex. I can't vote for you if you can't
    make a decision on this.
        The Chair. Thank you so much, Senator Paul. Dr. Levine,
    thank you for answering the question.
        I will turn to Senator Baldwin.
        Senator Baldwin. Thank you, Chair Murray, and I want to
    welcome Dr. Murthy and Dr. Levine to the HELP Committee. It is
    good to see both of you again. I want to turn our attention,
    perhaps not turn our attention, sort of been speaking about
    this already, but to the issue of health disparities, which I
    know both of you have worked on, worked to address throughout
    your careers. Back when I served in the House of
    Representatives on the Energy and Commerce Committee, we had a
    series of hearings on health disparities.
        These hearings were shocking and perhaps part of the early
    stages of us as a Congress trying to tackle health disparities
    that exist. And I am recalling in multiple hearings where we
    would have a panel of expert witnesses talking about the health
    disparities that exist, talking about possible ways to diminish
    these disparities. And I would often ask this panel of
    Government experts or academic experts, what can you tell me
    about health disparities affecting the LGBTQ community? And the
    response I would often get is stammering and muttering, and we
    will have to get back to.
        The Institute of Medicine ultimately did a very profound
    study on gaps in knowledge and a set of recommendations to how
    to close these gaps in our knowledge about health disparities
    impacting the LGBTQ community. Dr. Levine, based on your
    experience as a state health official, what should the Federal
    Government do to support state and other efforts to better
    prioritize and address the health needs of people in the LGBTQ
    community?
        Dr. Levine. Well, Senator Baldwin, thank you so much for
    your question and thank you so much for your work on this
    issue. Health equity is a critical aspect of our approach to
    COVID-19 and really to all health issues. COVID-19 has
    certainly shown us the challenge in healthcare disparities that
    we see in our Nation, and that would include the LGBTQ
    community. In Pennsylvania, we have had an annual LGBTQ health
    assessment which has given us very important data about the
    community.
        In addition, we are the only state that is collecting
    sexual orientation and gender identity data in terms of COVID-
    19 testing. And I think this brings up the point of the
    importance of data. It is critically important that we include
    questions about sexual orientation and gender identity in our
    data collection. That would include many studies done by Health
    and Human Services and the CDC. And I think that as we get more
    data, then we understand more about these health disparities
    and then we can develop the appropriate policies in order to
    address them.
        Senator Baldwin. I really appreciate that. I want to pivot
    to the opioid and substance use disorder epidemic. It is
    certainly one of my top priorities and it is also a top
    priority for many Members of this Committee on both sides of
    the aisle. Unfortunately, the ongoing COVID-19 pandemic has
    exacerbated challenges in our response.
        I am deeply concerned about reports of--well, reports of
    data of increased overdoses and other harmful effects of this
    crisis. This is to both Dr. Levine and Dr. Murthy. As Surgeon
    General and Assistant Secretary for Health, what would you
    prioritize in our response to the opioid and substance use
    disorders epidemic, including to make up for lost time, lost
    ground over the past year?
        Dr. Levine. Well, Senator, thank you for this question. It
    is very, very important. The Opioid Crisis has been with us for
    a number of years, and it has worsened, as you mentioned,
    during the COVID-19 pandemic. In Pennsylvania, as Physician
    General and Secretary of Health, I concentrated on this. We
    worked on prevention, on rescue with naloxone, and an expansion
    of treatment, particularly medication assisted treatment. If
    confirmed, I look forward to working with Dr. Murthy and SAMHSA
    and other experts on making sure that we fully address the
    Opioid Crisis.
        Senator Baldwin. Dr. Murthy.
        Dr. Murthy. Thank you, Senator, for that question. The
    issue of opioids and the Opioid Crisis is certainly near and
    dear to my heart. It is an issue that I focused a significant
    amount of attention on when I was Surgeon General last time.
    And as a clinician, as a doctor, I cared for many patients in
    Massachusetts and in neighboring states, including New
    Hampshire and Maine and Rhode Island, who struggle with issues
    related to opioids. You know, I think in the 2016 report that I
    issued on an alcohol, drugs, and health, I had laid out a
    number of steps we can take as a country not only to address
    opioids, but the larger crisis of addiction. But I still feel
    that there is important work we have to do, given exactly what
    you said, that overdose deaths have not gone down, in fact they
    have gone up, especially over the last year.
        I think we still have more we can do to expand access to
    naloxone. We still can take steps to expand access to
    treatment, not only making medication assisted treatment more
    available by integrating it into primary care, but by making it
    easier also for clinicians to prescribe to their patients when
    they feel it is needed. But I also, Senator, feel that we can
    do more to invest in prevention.
        We detailed in the 2016 report a number of programs,
    including school based programs that provide an extraordinary
    return on investment in terms of reduce healthcare costs,
    economic losses, and criminal justice costs with relatively
    modest upfront investments. I think a lot of those programs are
    still not well known. They are certainly under invested. But
    these are places where I think a little investment can go a
    long way and can ultimately help save lives.
        Senator Baldwin. Okay. Thank you very much.
        The Chair. Thank you, Senator Baldwin.
        Senator Collins.
        Senator Collins. Thank you, Madam Chair. Dr. Levine, we had
    a very good discussion prior to this hearing covering a host of
    issues ranging from COVID in nursing homes to the need to get
    children back to school, to the opiate crisis that Senator
    Baldwin just touched on. I want to follow-up on two of those
    issues with you. And I want to read to you a statement that was
    made in an Op-ed that appeared recently in The Washington Post
    by some public health experts. They said, ``at some point we
    have to recognize the consequences of keeping millions out of
    school for a year and treat this like the national emergency
    that it is.''
        I could not agree more with that statement. About half of
    the K through 12 students are out of school even as we meet
    today. Studies are showing that low income children in
    particular are falling behind academically. We have seen an
    increase in suicides and mental health problems due to
    isolation. Social development is being set back. There are very
    real consequences of children not being in schools, not to
    mention the extraordinary stress it is placing on many parents.
    In this Op-ed, public health experts suggested that three feet
    of distancing from student to student while keeping adults six
    feet from everyone else would be sufficient to allow many
    classrooms to reopen.
        Similarly, the American Academy of Pediatrics, and I know
    you are a fellow of the academy, has said that, ``schools
    should weigh the benefits of strict adherence to the six feet
    spacing rule with the potential downside if remote learning is
    the only alternative.'' I would like to ask you very
    specifically what you will do to help us get our children back
    to school and whether you think that there are ways to safely
    accommodate, including looking at this recommendation for only
    three feet of spacing, which is a major obstacle now.
        Dr. Levine. Well, Senator, thank you very much for your
    question. And I very much enjoyed our conversation the other
    day about this and other issues. I think everyone agrees and
    certainly as a pediatrician is that we need to do everything we
    possibly can to have children safely go back into the classroom
    and that it is very, very important. A number of weeks ago, the
    CDC did put out guidance regarding schools. And of course, this
    is a local issue. In Pennsylvania, of course, we have local
    control. So as the Pennsylvania Department of Health, we had
    put out guidelines, but it ultimately was the decision of the
    superintendents and school boards about whether their learning
    would be remote, hybrid, or in person.
        But I have had the opportunity to read the articles that
    you mentioned and review the American Academy of Pediatrics
    statements and I found them very interesting. And if I am
    fortunate enough to be confirmed to this position, I would very
    much like to work with others at Health and Human Services, to
    work with Dr. Walensky at the CDC and look really closely at
    this issue.
        Senator Collins. Thank you. Because there are a diversity
    of views of how we can safely open schools and we are really
    seeing the downside of not having them open. We also talked
    about COVID in nursing homes. And you assured me that
    Pennsylvania did not do what New York did, that it accurately
    reported. However, I am told that in September 2020, Spotlight
    Pennsylvania reported issues with inadequate disclosure of
    cases and deaths in nursing homes. For example, some facilities
    were consistently listed as having no data in the weekly state
    reports. Yet at least one provider, which operates five
    facilities, said that they did respond with information. Do you
    still stand behind your statement to me that the data were
    accurately reported?
        Dr. Levine. Well, Senator, thank you for that question and
    the opportunity to clarify this issue. I do stand behind my
    statement. Pennsylvania was always completely transparent in
    terms of our data, in terms of COVID-19 deaths in nursing homes
    as we were in and other data that we reported. What you do have
    to understand is that there is a lag time from the time that a
    tragic death would occur to the time that it hits our
    electronic death reporting system and then we would report that
    death. And that lag time can be sometimes days, but sometimes
    weeks. And so a nursing home might have had a death, but it
    wouldn't have hit our system for several weeks later and then
    it be recorded in terms of our data. So that lag time explains
    the Spotlight PA report.
        Senator Collins. Thank you.
        The Chair. Thank you very much, Senator Collins.
        We will turn to Senator Kaine.
        Senator Kaine. Thank you, Madam Chair and Ranking Member.
    And to our nominees, congratulations on your nominations. You
    know, I think I will just start here. I think the U.S. response
    to COVID-19 will go down in history as the worst failure of
    domestic governance in the history of the United States. And I
    feel very emotional. As I say those words--there have been some
    failures in the U.S. on foreign policy issues that have been
    notable ones. But in the sense of domestic governance, I cannot
    think of a worse one. This is now the third most deadly event
    in the history of the United States, just a single event.
        Spanish Flu, 675,000 Americans died. Civil war, 620,000
    Americans died over the course of the war. We are now north of
    500,000 and climbing. More deaths than the entire WWII, for
    example. So many of these deaths were unnecessary if you
    measured the United States against the experience of other
    nations and set aside nations that are communist nations, that
    have a command and control over citizens that a democracy
    doesn't, but just use democratic nations, our peers in the OECD
    or in the G7 and look at their experiences.
        If you just wanted to average them together and say if we
    had done what they had done, hundreds of thousands of fewer
    deaths in the last couple of days, Dr. Fauci said that no
    nation handled this worse than us. And we are a Nation with the
    best health care institutions in the world, the best health
    care providers in the world, an industrial base that, when
    pressed under warp speed, did an amazing and miraculous job of
    producing a vaccine, vaccines, multiple vaccines that work. We
    have had health care providers on the front lines who have just
    been unbelievably heroic. We have got Virginia Guardsmen and
    women and guardsmen and women from other states who are out
    doing the testing and then out again doing food bank
    distribution. And they are out right now doing vaccinations. So
    many people to be proud of.
        But how did a Nation like this, how did a Nation like the
    United States find ourselves in a position where we have led
    the world in deaths at such an untold scale? It really just
    started--in my way of thinking, there were a whole lot of
    things that caused it. But it started with the big lie
    perpetrating that this was going to go away, that it wasn't
    anything we needed to worry about. We have learned that a
    president with a microphone has the loudest voice in the world
    and that voice can be used for good or evil. But the big lie
    that was perpetrated at the beginning of this, together with
    other errors, like the CDC mistakenly deciding not to use the
    test protocol and then developing a faulty protocol on their
    own that had to be scrapped.
        Did this put us in this horrible situation? I am very
    emotional about this. I know nine people that have died of
    COVID. Last time I checked, the Nation of Taiwan only had nine
    deaths. The entire nation right across a narrow strait of water
    from China where the virus originated. I think if we are not
    willing to sort of acknowledge that, look in the mirror, then
    we are not going to be prepared for the next one. And one of
    the things that I am excited about, both of you, your
    nominations, is you have a track record that can help us
    prepare for the next one. I have colleagues who are very
    focused on trying to do a 9/11 commission to analyze the events
    that happened here on January 6th. We need a commission that
    will analyze why the U.S. got the pandemic wrong. That is much
    more important. Senator Collins, you and Senator Menendez had a
    bipartisan bill to do that, which should be a pressing need for
    us to analyze what went wrong in the pandemic, because there
    will be another one.
        When there is another one, we have to show that we are
    wiser and able to deal with it, Dr. Levine, I want to ask you a
    particular question. I was a little worried at the beginning of
    the Biden rollout of sort of a COVID response team that I
    didn't see enough people who I thought had state level
    experience. As a former mayor and Governor, I love doctors. I
    love academics. I love, people at think tanks. I love the
    brainiacs, but I really love the implementors because what
    happens in a situation like this is everything we do has to
    survive the reality test of being able to be implemented at a
    state level or in a city.
        Talk about your state level experience and what that does
    in terms of adding to the team so that we can both fight our
    way out of COVID, but then ensure that the Nation never falls
    down so badly on a job as we have in the last year.
        Dr. Levine. Well, Senator, thank you very much for that
    question. Thank you for your passion about this subject and for
    public health. COVID-19 certainly has been the biggest public
    health crisis that the country has seen in 102 years. And it
    has taken an enormous toll on our country and with over 500,000
    deaths. Each death is a tragedy, as you have been pointing out.
        I think that this pandemic has shown the importance of
    public health like nothing else possibly could, and that would
    include local public health, state public health, and Federal
    public health, and most importantly, the collaboration and
    coordination between all different aspects of public health.
        You are correct, as the Secretary of Health in
    Pennsylvania, under the Governor's leadership, I lead
    Pennsylvania's response in containment and mitigation and then
    distribution of medical countermeasures, such as medications,
    remdesivir, monoclonal antibodies, and the vaccine. If
    confirmed to this position, I would very much like to take that
    experience in operationalizing the Federal initiatives and the
    Federal guidelines and strategy really at the state and local
    level. And I hope to make my contribution that way.
        Senator Kaine. I am over my time. Thank you for indulging
    this, Chair Murray and Ranking Member Burr.
        The Chair. Thank you.
        We will turn it over to Senator Cassidy.
        Senator Cassidy. Thank you. Doctors Levine and Murthy. I
    could ask either of you my questions, but I will start with
    you, Dr. Murthy. Dr. Murthy, health equity is something that we
    must all be concerned about. I spent 25 years caring for
    patients in a public hospital for the poor and uninsured and so
    that, as you might guess, particularly means something to me.
    That said, when I hear some people speak about it, it sounds as
    if it is something to stoke resentment, as if any health
    inequity must reflect injustice.
        Now, we are all, all three of us are physicians and so I
    just want to explore this because I think it is important. Are
    there biologic or scientific reasons that make somebody more
    susceptible to dying if they contracted the virus? And of
    course, there are. The older someone is when they get it, the
    more likely they die, up to if you are over 85, you really have
    a high death rate. But Dr. Murthy, could you suggest some of
    the other comorbidities, medical condition, that if they are
    present, can be associated with increased morbidity, mortality
    from COVID infection?
        Dr. Murthy. Well, Senator Cassidy, thank you for that
    question and it is good to see you today. I enjoyed our
    conversation a few weeks ago. You know, I think you are right
    that the origins of the disparities that we see in health are
    complicated, and with COVID in particular, why some communities
    are experiencing worse outcomes than others. Some of that we
    understand but we have--we are still learning about that. It is
    a complex product, I believe, of the environment, of biology,
    of preexisting structural inequities in our system, which make
    it harder for----
        Senator Cassidy. Specifically though, what are some--I have
    limited time, specifically what are some of the medical
    comorbidities associated with worse worst outcomes? Because we
    don't make the diagnosis. We are docs. If we don't make a
    diagnosis, we are doomed to fail in terms of the treatment. And
    so I guess I am just exploring if you have thought about this,
    which I am sure you have, but could you be a little bit more
    pointed to answer my question?
        Dr. Murthy. Sure, Senator. Well, fortunately the CDC has
    noted a number of conditions that do increase the risk of poor
    outcomes with COVID. Obesity is one of them. Cardiac disease is
    another. We know that some preexisting lung conditions as well
    can do the same. We know diabetes----
        Senator Cassidy. Can I ask you--thank you, and again,
    sorry, I just have limited time?
        Dr. Murthy. That is Okay.
        Senator Cassidy. Are these medical conditions generally
    distributed through the population or are they more likely to
    occur in some groups of Americans as opposed to other groups?
    However you define that, socioeconomic or, however.
        Dr. Murthy. Sure, yes, they are not evenly distributed,
    Senator. They are disproportionately distributed in the
    population.
        Senator Cassidy. If such a group that which has a
    disproportionate representation of such a comorbidity has worse
    outcomes, that is important to know, because if all we do is
    assume it is injustice and there may just be an increased
    prevalence of obesity, then our diagnosis is flawed, maybe
    partially, maybe partially true in one instance, but not true
    in the other. To the degree that it is not true would
    negatively affect our ability to effectively address. Is that a
    fair statement?
        Dr. Murthy. Senator, I think you are correct that we have
    to look clearly at the data and understand what it is telling
    us. And I think that this is where I think science has to lead
    us as we make the diagnosis, as you put it, and also as we
    formulate solutions for how to address the disparate outcomes
    that we see.
        Senator Cassidy. I agree with that. And so if we are going
    to talk about health inequities, it is important not to just
    stoke resentment, but to acknowledge that there is a biologic
    basis for why some do worse than others, for example some
    people are older, and then recognize that frankly, as however
    we can't address it, obviously we can't affect age, I wish we
    could, in order to have the appropriate treatment. So let me
    ask you--let me ask you both. I will ask this to Dr. Levine.
        If obesity is a major risk factor for heart disease,
    diabetes, hypertension, gallstone disease, many of what I just
    listed is associated with the worst outcome, is it fair to say
    the Federal Government should be doing more to address the
    epidemic of obesity?
        Dr. Levine. Well, Senator, thank you for that question and
    bringing up the issue of health equity and health disparities.
    In terms of your specific question, we certainly need to
    concentrate on the prevention and treatment of obesity and as a
    pediatrician, particularly childhood obesity. But I also think
    that when looking at COVID-19 healthcare disparities, that we
    have to look also at the social determinants of health, which
    are critically important in terms of influencing health
    outcomes from COVID and many other conditions.
        Senator Cassidy. I agree with that. We do need to look at
    social determinants of health. If we look at somebody and we
    control for social determinants, but nonetheless, they were
    obese, that hypertension and diabetes, do we think--are you
    telling me that the social determinants would overwhelm those
    medical risk factors, or do you think that the medical risk
    factors would be more important in determining somebody's
    outcome?
        Dr. Levine. I think all of those factors would be
    important.
        Senator Cassidy. Yes, but that is not what I am asking Dr.
    Levine. I am asking to rank them, please. And I don't mean to
    be rude, but I am out of time and I am about to get called
    down. How would you rank them?
        Dr. Levine. I don't think it is possible to rank them, sir.
    I think that they are all involved.
        Senator Cassidy. I yield back. Thank you, Dr. Levine. I
    yield back. Thank you.
        The Chair. Thank you, Senator Cassidy. Before I turn it
    over to Senator Murphy, I do want to say Dr. Levine, I want to
    say I appreciated your thoughtful and medically informed
    response to Senator Paul's questions earlier in the hearing. It
    is really critical to me that our nominees be treated with
    respect and that our questions focus on their qualifications
    and the work ahead of us rather than on ideological and harmful
    misrepresentations like those we heard from Senator Paul
    earlier. And I will focus on that as Chair of this Committee.
    So thank you again for your response. And with that, I will
    turn it over to Senator Murphy.
        Senator Murphy. Thank you very much, Madam Chair. Let me
    associate myself with your remarks. Thank you for the way in
    which you handled those questions. Really looking forward to
    working with you, Dr. Levine. Have two sets of questions for
    both of you. One for each, excuse me. Dr. Murthy, I wanted to
    talk once again about this issue of vaccine distribution. I
    know there was some conversation about vaccine hesitancy
    earlier.
        I convened a conversation in Connecticut last week to talk
    about vaccine equity, and I received a significant amount of
    pushback from the folks around the table when this conversation
    came up about hesitancy. Many of them felt like that was an
    effort to blame communities of color for a problem that has, I
    think, potentially been created through the design of how we
    have administered the vaccine. When you create a sort of first
    come, first serve vaccine system, you disadvantage those who
    work two or three jobs, who have trouble taking a day off work
    in order to make the one appointment that is available.
        I heard a lot about just the lack of information that when
    you don't listen to people about where they get information,
    that you end up with broad sectors of the population,
    especially those maybe who don't have English as the first
    language, not having basic information about when the vaccine
    is available. And so when we have this conversation about
    equitable distribution of vaccines, I want to make sure that we
    are building systems that meet people where they are, rather
    than just looking at these numbers.
        Where in Connecticut we have incredibly low rates of
    African-Americans and Latinos who are taking up the vaccine and
    say, oh, that's because, those populations don't want it or we
    have to convince them why it is important, a lot of it, I
    think, is that the design just makes it harder for communities
    of color, low income communities to be able to access it. How
    do you respond to that critique?
        Dr. Murthy. Well, Senator, it is good to see you and thank
    you for that question. Look, I think that you are highlighting
    a critical issue here, which is a vaccine hesitancy is complex
    and not solely experienced by members of racial minority
    groups. But there are many groups in society right now that at
    some level are concerned about vaccines. And we have to
    recognize that and understand that their reasons for hesitancy
    are different because that will inform our response. But the
    distribution, you are right, the disparities we often see with
    vaccine distribution are often related to preexisting
    structural challenges that we have, one of them being a lack of
    access to health care that many people unfortunately face.
        If we want to, not only with COVID, but with future
    potential pandemics, have a system that can respond well, we
    have got to ensure that we have community health centers that
    can actually distribute this vaccine. And this is why these are
    such a powerful part of our health care apparatus. We have got
    to be able to quickly stand up mobile units to bring the
    vaccine to where people are. And we also have to ensure that we
    are establishing community vaccination centers strategically in
    locations where typically it is hard for people to access these
    vaccines.
        Senator Murphy. Thank you. Appreciate that. I think so much
    of our conversation on the subject is around this question of
    hesitancy is an important one. But we have to be talking about
    systems as well. Dr. Levine, I and a group of my colleagues
    have been pushing really hard to have specific money set aside
    in the COVID package for summer programing. And summer
    programing for kids that is centered on their emotional well-
    being. As a parent of two school age kids in the public school
    system, neither of which have set a foot inside their school,
    have been doing full distance learning for the last year, I
    really worry about our kids' emotional health.
        I know we have talked about that already today. We have
    seen suicide rates increase, emergency visits skyrocket. And
    this summer I really think we have got to work on emotionally
    resetting kids, getting them reconnected to their peers. They
    are ready to learn. You know, this is your field of specialty.
    What is your sort of broad sense of what kids need right now?
    Where should our focus be on making sure that kids are
    emotionally healthy once schools sort of fully reopen and get
    back to normal in the fall?
        Dr. Levine. Well, Senator, thank you for this question. I
    particularly enjoyed our discussion about this a number of days
    ago. Certainly, the mental health needs of children in our
    country right now are at the forefront. Pediatric and
    adolescent mental health has been part of my career in academic
    medicine and at the Pennsylvania Department of Health, and I
    think COVID-19 has certainly exacerbated those mental health
    issues and mental health needs. I was really quite taken by
    your idea in terms of summer programing. And if I am fortunate
    enough to be confirmed to this position, I would very much look
    forward to meeting with you again and your staff and working on
    this issue and see what we can do to actualize it.
        Senator Murphy. Right. Well, thank you very much. Thanks to
    both of you for your willingness to continue your service to
    the country. Thank you, Madam Chair.
        The Chair. Thank you.
        I believe that Senator Marshall is next on the Republican
    side.
        Senator Marshall. Alright, thank you, gentlemen. Appreciate
    the time. Welcome, Dr. Murthy. Good to see you again, Dr.
    Levine. Good to meet you in person as well. Appreciate your
    time with the doc caucus four years ago and hope you will come
    back and visit us. My question, and I will let you both answer
    it. You know, we talk about the goal of the current
    administration is 100 million vaccines in 100 days today.
        Today we have already got 85 million vaccinations out the
    door. We should be able to be doing 2 or 3 million vaccinations
    a day. We have the infrastructure, as you all know, to do 3
    million flu vaccines per day. And I am trying to get how you
    both think because you are going to be offering advice and
    goals. And is it feasible? But I would think that we could do 3
    million vaccinations a day in March, get us up to 150 million
    people vaccinated by the end of March. I think 25, 50 percent
    of people have had the vaccine, or have had the virus already.
        My theory is we could have herd immunity by April or May.
    Is that possible? Is that feasible? What type of advice would
    you be offering to the president and the team that is working
    on this, and maybe like a 30 second answer? Dr. Murthy, what is
    your advice as potential Surgeon General?
        Dr. Murthy. Well, thank you, Senator. It is good to see you
    again as well. I love the spirit of what you are asking, which
    is how can we think bigger? How can we do better? How can we
    move faster? And what I would seek to do if I were serving as
    Surgeon General, sir, is work with the Administration to
    understand how we can expand capacity for distribution. One of
    the reasons we have the ability to distribute so much flu
    vaccine is we have engaged primary care providers in that
    network. And if we got more of our fellow physicians engaged in
    their offices and distribution----
        Senator Marshall. Why are we reinventing the wheel? Let's
    just hit the backbone of the vaccinations, our doctors'
    offices, community health departments, and pharmacies, right.
    Why do we need to reinvent the wheel? Let's get the vaccines in
    their hands.
        Dr. Murthy. Yes, so I think we can get more vaccines into
    pharmacies. I think we, especially with the Johnson and Johnson
    vaccine potentially coming on, that would be easier to store
    for clinicians and their offices and ultimately get into
    patients' arms.
        Senator Marshall. Dr. Levine, any thoughts? Your advice?
        Dr. Levine. Well, Senator, thank you for that question. I
    mean, certainly we need to do everything we can to ramp up the
    vaccination program as much as possible. And I think the
    president has an excellent strategy, an excellent vaccine
    program to be able to accomplish that. They are having vaccines
    go to pharmacies through the vaccine program as well as to
    federally qualified health centers, as well as vaccine clinics.
        But we do need to make sure that we get vaccines into arms.
    We also need to take into account the health equity issues that
    we were discussing before to make sure that we target
    vulnerable populations such as the African-American community,
    the Latino community, and rural communities so that they have
    access.
        Senator Marshall. Of course. With the new big news saying
    that the vaccines we are already using already are 75, 80
    percent effective with one shot, what type of advice would you
    be offering to getting, a greater number of people vaccinated
    right now as opposed to getting that second shot into the same
    person's arms? Dr. Murthy.
        Dr. Murthy. Well, Senator, I thought that was really
    interesting data. And I think that because of the way the
    trials were done with the two dose model, while I think that is
    the foundation we should use. We should absolutely be quickly
    seeking to study what that one dose model could look like or a
    delayed second dose model. And if the data holds up that people
    achieve sustained protection not just for the first few weeks,
    but sustained protection, then I think that is a model that we
    absolutely should examine. I think science really has to guide
    us here. We have got to collect the data, get the knowledge,
    and then implemented in our policy.
        Senator Marshall. Dr. Levine, any other?
        Dr. Levine. Well, I would agree. I think that we need to
    stick to the two dose model now for the Pfizer and the Moderna
    vaccines because that is how the studies are done, but then
    study other models to see if they could be effective.
        Senator Marshall. But you said we are going to follow the
    science and the science says one shot is 80 percent effective.
    If our goal is to get herd immunity, why wouldn't you try to
    get more shots into more people? I am still prioritizing people
    at age 65, people with health care problems, etc. But why
    wouldn't you follow that science?
        Dr. Levine. Right now, the FDA approval recommends two
    doses. I think we need to look at the science that you are
    discussing and have more studies in that regard. But I also
    share everyone's enthusiasm about the Johnson and Johnson----
        Senator Marshall. You think following the FDA guidelines is
    a good idea as well. Last question on kids in school. I want to
    know what your opinion is. You follow the science. American
    Academy pediatrician says kids can go back in school. What is
    your opinion? Should kids be back in school now?
        Dr. Levine. Well, we certainly want to get children back in
    school as quickly as possible, Senator. The CDC has spoken
    about that. But I am interested in the American Academy of
    Pediatrics literature that you are referring. And if confirmed,
    I look forward to collaborating with Dr. Lewinsky----
        Senator Marshall. But you don't have a recommendation? Is
    that--is that a goal? Is that your goal? You think the kids
    should be in school now or is there not enough science to say
    that kids should be in school yet?
        Dr. Levine. I think that we all want children to be in
    school in a safe way, sir.
        Senator Marshall. Dr. Murthy, I mean, what is your opinion?
    Is there enough science to say the kids should be in school
    now?
        Dr. Murthy. Well, Senator, I do think we have a growing
    amount of data that tells us how to get kids back in school
    safely, and tells us that if kids are masked, if there are
    distanced, if we have good ventilation in schools, that we can
    actually do a pretty good job of reducing transmission in
    school. And on top of that, if we can get teachers vaccinated,
    if we can get testing in schools, that can even further reduce
    the risk.
        Senator Marshall. I am out of time, but I certainly want to
    publicly thank all the teachers that are in school, that are
    out there. We are focusing on the ones that aren't. But I am so
    grateful for the teachers that are out there on the front line
    teaching and just what we can do to empower them to get our
    kids back in school. Thank you and I yield back.
        The Chair. Thank you very much.
        We will go to Senator Smith.
        Senator Smith. Thank you, Chair Murray and Ranking Member
    Burr. And thank you so much to Dr. Levin and Dr. Murthy for
    being with us today and your willingness to engage in public
    service, particularly in this way, which is just so important
    to our country right now. As Senator Kaine said so powerfully,
    we are in the midst of a tragic loss of life and a pandemic
    that has totally upended our economy and our health, and our
    sense of well-being. And I know that you both understand this.
    And so I am just grateful for your willingness to serve in this
    way. You know, I am always reminded of something that a
    Minnesota farmer said to me earlier last year. He said, when it
    comes to COVID-19, we are all in the same storm, but we are not
    all in the same boat.
        I think that this gets at the ways in which COVID has
    magnified the inequities that already existed in our society.
    So I am so grateful for your willingness to serve, Dr. Levine.
    And I also want to say how much I appreciate the dignity and
    the professionalism that you demonstrated in your response to
    Senator Paul as a physician and as a public servant. And I want
    to be really clear that this is a moment where we should be
    focusing on the grave challenges before us. And one of these
    challenges is that LGBTQ people have long faced discrimination
    and barriers to healthcare, and they are much more likely than
    non LGBTQ+ people to lack access to insurance and to affordable
    medical care.
        We need advocates at all levels to make sure that we
    address that inequity, and we fight against discrimination and
    ensure that everybody, all patients, have access to care,
    especially amid this crisis, which has revealed so many
    inequities. So I wanted to thank you. Dr. Murthy, when you and
    I spoke, we had a great conversation about the listening tour
    that you did when you were Surgeon General the first time, and
    you talked about how you went out and you expected to hear
    people's concerns, health concerns, and you instead discovered
    this theme of Americans feeling lonely and isolated.
        We talked a little bit about this broad based social
    isolation that is happening right now among older adults, among
    kids that are not able to be in school among so many people.
    And this is something that I know we both care a lot about
    because of the direct impacts that social isolation can have on
    people's health. This lack of social connection is not just
    about being lonely. It is about the direct impact on people's
    long term health outcomes.
        Dr. Murthy, could you talk a little bit more about this and
    maybe say a bit about how you expect to continue to work on the
    issue of social isolation, and what we can do in Congress to
    help? And how we can incorporate some of these ideas into our
    thinking about healthcare?
        Dr. Murthy. Senator, thank you so much for that question. I
    really enjoyed our conversation on that topic of isolation and
    loneliness as well. This was one of the unexpected things for
    me that came up during my service as Surgeon General. I
    expected when I began my listening tour to understand what was
    on the minds of Americans, everywhere that I would hear about
    issues like obesity and substance use and depression and
    anxiety. And I did hear about those concerns. But what I heard
    so often were stories of loneliness and isolation from not just
    elderly individuals who are living alone, but I heard them from
    college students on uncrowded campuses, from moms and dads,
    from teachers, from doctors and nurses, and even from some
    Members of Congress who told me behind closed doors that they,
    too, struggled with loneliness.
        These stories resonated with me because I had seen so much
    loneliness in my patients, patients who had often come in by
    themselves. And even in the moments of extraordinarily
    difficult, hard decisions about treatment, we would have to
    have that conversation alone with them because they had no one
    who could come in and be a part of that conversation. And I
    also experienced a lot of loneliness as a child. So that
    experience is very, very raw still and present in my mind. But
    what was concerning to me as Surgeon General where the health
    consequences also.
        The fact that the increasing body of data showing that
    loneliness is associated with an increased risk of premature
    death and heart disease, as well as other conditions like
    depression and anxiety. There is a lot we can do, starting with
    communities, faith organizations, other community organizations
    have a powerful role they can play in helping to stitch
    together the fabric of a more connected society. Clinicians,
    doctors and nurses can also play a powerful role in surfacing
    issues like loneliness, which are unfortunately stigmatized and
    which people struggle with but don't feel comfortable talking
    about. And finally, Government does have a helpful role it can
    play too.
        When Government chooses to name an issue as important, when
    it convenes people to come together and build a strategy to
    address an issue, it can have a powerful effect on moving the
    needle on the actions we take. We have seen that with opioids
    and with other issues. So this would be an issue I would love
    to work on with you and with other Members of Congress that
    affects people all across our country and has significant
    health impacts.
        Senator Smith. Thank you very much, Dr. Murthy.
        The Chair. Thank you.
        We will turn to Senator Murkowski.
        Senator Murkowski. Thank you, Madam Chair. Dr. Murthy, it
    was good to speak with you some weeks ago. I appreciated that.
    Dr. Levine, I look forward to our conversations as well. I--in
    my conversation, Dr. Murthy, we talked about the disparities
    that we see in our rural areas. Know that, again, that will
    continue to be a pressing, pressing issue for me. I just came
    from a gathering of Arctic parliamentarians by way of Zoom, and
    one of the things that we were focusing on in our discussions
    was what we are seeing in the Arctic nations, not only during
    COVID, but prior to COVID. And these are the issues of mental
    health, just general behavioral health issues. And our reality
    that during this pandemic, we are seeing rising levels of
    substance abuse.
        We are seeing rising levels of suicide, particularly among
    our youth. And I raise this again to ask your commitment, your
    focus to not only mental health in a pandemic, at a time of
    global pandemic, but really moving forward and how we can
    address these mental health needs in areas where we already
    have disparities with access to all kinds of medical services.
    So if you can speak very briefly to the mental health as it
    relates to substance abuse, suicide, and in some of the other,
    again, very troubling realities that we are facing right now.
        Dr. Murthy. Well, Senator, it is good to see you again as
    well, and thank you for that question. The issue of mental
    health broadly is obviously deeply concerning. It is an issue
    that I have dealt with as a clinician, that I have seen as a
    Surgeon General. But the impact in rural communities in
    particular has been heartbreaking. I had a window into the
    disparities that exist in rural communities through my father,
    actually early in life. He grew up in a small village half a
    world away in India. But interestingly, many of the stories he
    told me hold true in America that rural areas often have
    disparate access to healthcare as well as to education and
    economic opportunities.
        When I was Surgeon General, Senator, when I visited Alaska
    in particular, when I visited Oklahoma and other rural areas, I
    saw firsthand that those disparities were real and that the
    access to mental health care through telehealth, the access--
    the ability to have access to providers as well in person was
    often far reduced in an environment where we just didn't have
    sufficient access to resources.
        One of the things I would love to do if I have the
    privilege of serving is to work with you and to work with other
    Senators to see how we can close the gap that exists in rural
    communities when it comes to mental health care by providing
    not only better telehealth and telemedicine, but also by
    working to strengthen our workforce of mental health providers,
    which are often in scarce supply.
        I believe we can do that in part by investing in community
    health centers, which are the backbone of communities all
    across this country, but which can help provide mental health
    resources as well.
        Senator Murkowski. When, as you know, the significance that
    they play in providing for care in Alaska throughout our state.
    I want to ask you about homelessness as a public health issue.
    We see growing areas of homelessness in my state. And it is a
    pretty tough place to be homeless, particularly this time of
    year where it is cold, and it is going to be cold for some time
    forward. But we are seeing this in so many areas of the
    country. My view is that there has been little focus on our
    public health authorities to research, to implement evidence
    based comprehensive strategies to address what we are seeing
    with regards to homelessness.
        I think we are going to see more homelessness as a result
    of this pandemic. In your role, if you are confirmed as Surgeon
    General, what do we need to do to be raising the awareness to
    be not only becoming more aware, but actually working to
    address these, I believe, significant health issues as it
    relates to homelessness?
        Dr. Murthy. Well, Senator, I am glad you raised this. Of
    all the social determinants that we talk about with regard to
    health, housing and homelessness is one of the most powerful.
    It is something I saw firsthand as a doctor. I remember,
    Senator, one of the first patients I cared for who was
    homeless. I was a medical student at the time. And I remember
    talking to the patient as they were being discharged about the
    medications they needed to pick up from the pharmacy and the
    three follow-up appointments they needed to have.
        At some point, I realized how foolish I was because their
    primary concern was where they were going to sleep that night.
    Not and all those other issues as to when they were going to
    follow-up in three weeks with cardiology were secondary and
    less likely to happen, unfortunately. I believe there is a
    powerful connection between housing and health. I think there
    is a growing body of data that tells us that. I think part of
    what we have to do is make sure that data and that science is
    clear and evident to the public and to policymakers. But when I
    was Surgeon General last time Senator, I also worked with HUD,
    with Housing and Urban Development, on in that case, a program
    and an approach to reduce exposure to secondhand smoke.
        That was just one example of how housing and health go
    together. And I would welcome the opportunity to do that again,
    to engage with HUD and with policymakers to see how we can put
    roofs over our heads, how we can reduce homelessness,
    recognizing that can improve health outcomes as well as
    people's overall experience.
        Senator Murkowski. Well, I would love to work with you on
    that. I would recognize, though, that through HUD, that is one
    avenue, obviously, to address the issues of homelessness. But
    so many are these invisible homeless that are in our community,
    particularly our children, our families. And whether or not we
    have a--whether or not HUD is best able to respond to these
    issues of kids who are couch surfing, who are technically
    homeless, what the structure is to best address them. I am over
    my time and I appreciate that, but this is a conversation I
    would love to follow-up with.
        Dr. Murthy. Well, thank you.
        Senator Murkowski. Thank you.
        The Chair. Thank you, Senator Murkowski.
        Senator Rosen.
        Senator Rosen. Thank you, Madam Chair. I want to thank both
    the doctors here today for your willingness to serve, your
    thoughtful responses. You know, I know being a doctor takes
    both intelligence and empathy, and I believe that the two of
    you possess both those important characteristics. So I
    appreciate you being here today. I want to have a question for
    each one of you. Mental health concerns, K through 12, kids,
    mental health concerns for seniors. So to both of you,
    tragically, Nevada has seen an increase in youth suicides
    throughout the pandemic. In our county school district, 18
    students have taken their lives in just 9 months. Sadly, we are
    the highest in the Nation. The pandemic also has been
    particularly hard on seniors or most vulnerable to the virus.
        We have talked about the social isolation, the tremendous
    toll that it takes. In Nevada, we have roughly about 370,000
    seniors and 25 percent of those estimated to live alone. So to
    Dr. Levine, I will go first. I want to build upon Senator
    Murphy's question, a little bit on Senator Murkowski question.
    Given what is happening in Nevada, you have extensive
    experience addressing youth mental health needs, how would you
    address the disturbing trends in youth suicides, mental health
    problems? I know that you have programs and public--and
    services in Pennsylvania that help out with the students. And
    so what would you do for our youth experiencing suicidal
    thoughts?
        Dr. Levine. Well, Senator, thank you so much for that
    question. I enjoyed our conversation a number of days ago very
    much about this and other issues. Clearly, mental health issues
    among our youth, remains a significant public health problem.
    As you pointed out in my career in academic medicine at the
    Penn State College of Medicine, I saw many troubled children
    and teenagers, some of whom were suicidal and required
    intensive treatment to treat some of their underlying mental
    health issues and other issues that were leading to those
    concerns and their suicidal ideation. I participated in a
    suicide task force, suicide prevention task force as part of my
    role as the Secretary of Health in Pennsylvania.
        If I am fortunate enough to be confirmed to the role of
    Assistant Secretary of Health for the Nation, I look forward to
    collaborating with SAMHSA, collaborating with Dr. Murthy and
    other content experts, and then working with you on making sure
    that we can address this issue, which has just become
    exacerbated during the COVID-19 pandemic.
        Senator Rosen. Thank you. Next, I would like to address the
    senior issue. So, Dr. Murthy, many seniors have been really--
    continue to isolate in their homes. And as you suggest, senior
    health needs--we really have to think about the connection they
    have. They are missing people. They are missing that important
    touch. Now we have COVID. We are not even allowed to hug
    people. We don't get to be close. And that isolation is so
    devastating. It causes a lot of depression and other kinds of
    health issues that follow that. So can you talk about the
    importance of the social plans that we can do, investing in
    meal programs, some kind of home visits, check ins, or those
    things that serve seniors, particularly in our rural areas
    where it might even be hard to get people out there?
        Dr. Murthy. Well, Senator, thank you for that question, and
    I think you have touched on an issue that is painful, frankly,
    for many families, which is the experience that seniors have of
    being lonely and isolated, especially during this pandemic,
    which I think is worse than that isolation for many of them. I
    think, Senator, I don't think it is often well appreciated in
    the general public just how profound an impact that isolation,
    loneliness has on health. And I think that is one place where
    as Surgeon General I would hope to bring some attention is just
    to the fact that social connection and loneliness is important,
    not just so we can feel better, but so we can do better in
    terms of our health.
        But I think, second, there is a powerful role that
    community organizations can play. So often I find, and I found
    this was true when I was traveling the country as Surgeon
    General as well, that many organizations, because they don't
    have primary expertise in health, they think that they can't do
    anything to improve health outcomes. But organizations that can
    connect young people with the elderly for visits, that can
    provide food or resources to the elderly, that can simply call
    to check in on people who may be living alone, they can play a
    powerful role in helping people feel more connected in
    difficult periods of their life.
        Addressing isolation that seniors experience, this is an
    all-in challenge that, yes, it does require Government
    attention, but also it requires communities to be engaged and
    recognize that they have incredible power when it comes to
    helping their seniors. But this is an area where I would love
    to certainly focus on with you and with your colleagues.
        Senator Rosen. No, I appreciate that. I know in my home
    community, there are groups at our university, there are groups
    in our faith based community that have just created these phone
    trees to call and check in on people. It was something everyone
    could do during the pandemic. So you are right, sometimes there
    is a grassroots solution to help for some of the problems.
    Thank you. I have gone over my time. I appreciate you both
    being here.
        The Chair. Thank you very much.
        Senator Braun.
        Senator Braun. Thank you, Madam Chair. During the whole
    COVID challenge, my observation has been especially coming from
    the business world so recently in a place like Indiana where I
    think we did a pretty good job with the navigation through the
    whole process, maybe didn't take so much a one size fits all
    approach, differentiated it a little bit by counties within the
    state, I thought that was something we should have done, and I
    think it did unfurl that way. I got a few questions about what
    you were able to do in your home state.
        The idea that you treat all counties the same, both rural
    and urban, to me didn't quite make sense. And have you actually
    looked at the results of the approach that was taken in your
    state in terms of that tradeoff between fighting the disease
    itself and the economic impact that would be concomitant with
    it if you took an approach that was going to be too draconian
    but didn't make sense. Have you been able to get through the
    data to see, are you happy with the way you handled it in your
    home state?
        Dr. Levine. Well, Senator, thank you very much for that
    question. I appreciate our discussion about this and other
    issues a number of days ago. You know, with this novel
    coronavirus, COVID-19, in the spring, there are basically three
    tools in the public health toolbox in order to address it. One
    is containment, which involves testing, contact tracing. The
    second is mitigation, at its heart mask wearing and social
    distancing and washing hands, but also some of the closures
    that you are discussing.
        Then the third are medical countermeasures, including
    medications and vaccines, which, of course, were not available
    in the spring. Testing was also not particularly available in
    the spring. We had lack of personal protective equipment. So it
    was quite a challenging situation in the Northeast and in the
    mid-Atlantic. So mitigation was one of the biggest tools in the
    toolbox that we could use.
        Pennsylvania actually did take, under Governor Wolf's
    leadership, a very sequential, iterative approach in terms of
    the business closures that we did. We did go county by county
    in terms of whether the businesses would be closed or not, and
    eventually the entire state did get closed. But it did go in
    that iterative approach. We also took a sequential iterative
    approach in terms of reopening with a red, yellow, green schema
    that did go county by county.
        Senator Braun. Then have you actually done any metrics or
    compared--where is your unemployment rate currently in your
    state?
        Dr. Levine. Well, sir, I actually don't know the current
    unemployment rate.
        Senator Braun. I think you will find if you look across the
    country that there is a direct correlation. You look at a place
    like Florida that got a lot of heat early on, figuratively
    speaking, ends up having the most vulnerable population. And
    you did have an approach there where I thought it took a dual
    perspective of trying to keep the disease at bay and respected
    for all the peculiarities it had shown us, but also with the
    most susceptible population, has done a good job when you look
    at doing both. What about, very quickly, how has your
    vaccination rollout gone? Have you been pleased with the
    performance of getting vaccinations out in your state?
        Dr. Levine. Pennsylvania, like many states initially had
    significant challenges in terms of the rollout of the vaccine
    over the holidays and then into a January, etc. Of course, I
    left the Pennsylvania Department of Health in January, so I
    have had no contact with the Pennsylvania Department of Health
    and don't really know what exactly differently they are doing
    now. I think Pennsylvania has had successes and has had
    challenges in terms of the vaccine rollout, but things are
    continuing to improve.
        Senator Braun. Thank you. Dr. Murthy, just a question to
    the point. Do you think guns present a public health emergency?
        Dr. Murthy. Well, Senator, I think that gun violence, like
    any other form of violence, is a concern to me as a doctor who
    has taken care of many patients who have been the victims of
    violence, but I think the way we approach that issue, Senator,
    should be driven by science. I am grateful that Congress has in
    a bipartisan basis put funds to study the origins of gun
    violence and how best to address it. But I will tell you that
    my focus, Senator, is not on this issue. It is, and if I am
    confirmed, it will be COVID, on mental health, and on substance
    use disorders. These are the issues which I think are front and
    center in this moment. And it is where I would put my
    attention, if confirmed.
        Senator Braun. I am about out of time, but since we have
    gone through and it looks like the health care crisis is, thank
    goodness, ebbing with the results we are seeing, this is an
    issue that I am sure will come to the forefront. And I will get
    with you later on that subject.
        Dr. Murthy. Okay, I look forward to it, Senator. Thank you.
        The Chair. Thank you.
        Senator Lujan.
        Senator Lujan. Chair Murray, thank you so very much to you
    and to our Ranking Member, Mr. Burr. Thank you for this
    important hearing. Dr. Levine, it was a pleasure visiting with
    you recently. And Dr. Murthy, I look forward to our
    conversation. Dr. Murthy, understandably, the Federal
    Government has focused the bulk of its resources on slowing the
    spread of the COVID-19 pandemic.
        However, we have simultaneously addressed the secondary
    impacts. We have to get this done the pandemic, including a
    reported increase in opioid overdoses. As Surgeon General, you
    are considered the Nation's doctor. How will you guide
    discussions and scientific investment so that individuals who
    live with acute or chronic pain can get appropriate treatment,
    including non-pharmacological treatments such as physical
    therapy, and also if they do need pharmacological treatments,
    that they are not addictive?
        Dr. Murthy. Well, thank you, Senator, for that question. I
    think you are raising a critical issue here, which is how do we
    treat pain appropriately given how many Americans are living
    with some form of chronic pain? You know, I cared for many of
    these patients, when I was practicing medicine. I noticed how
    that pain can affect not only the quality of life of an
    individual, but their family as well. And I think what we have
    an obligation to do is to take what research currently tells
    us, which is that there are multiple strategies for addressing
    pain that are effective.
        They include physical therapy, cognitive behavioral
    therapy, and, yes, in some cases, pharmacologic therapy with
    medicines. And we have to make these treatment strategies
    available to people. But right now, many people don't have
    access to physical therapy or cognitive behavioral therapy at
    the level that they need to help address chronic pain. And even
    when it comes to medications, these decisions have to be
    tailored or based on a patient's individual situation. And
    there is not a cookie cutter, one size fits all approach that
    we have to take here.
        That is why we have got to empower clinicians to with the
    right knowledge, with the best and latest data so they can make
    good decisions with their patients to help ultimately address
    their pain.
        Senator Lujan. Appreciate that, Dr. Murthy. Dr. Levine, we
    had a chance to visit about mental, behavioral health. And you
    have been asked that question by several of our colleagues
    today. It matters to all of us across the country, especially
    in rural communities. So I am interested in what we can count
    on with your advocacy to increase access to mental behavioral
    health and then also a project that you are familiar with and
    that our Chair has championed in project ECHO in telehealth and
    telementoring, what your thoughts are with how we can expand
    those programs and also ensure that there will be reimbursement
    for both telehealth and telementoring services?
        Dr. Levine. Well, thank you, Senator, for that question.
    And I particularly enjoyed our discussion about this and other
    issues a number of days ago. Clearly, mental health issues are
    going to be forefront as we work through the pandemic and
    afterwards. And this would include mental health issues for
    children and adolescents, as we have spoken about previously,
    but also adults and seniors, as was talked about as well. This
    is a particularly difficult issue in rural areas where there is
    lack of access to mental health services. And so I think
    telehealth is going to be very, very important. And that
    includes telepsychiatry and telepsychology. Of course, as we
    discuss broadband is often critical.
        Access to broadband is critical to that success. I did want
    to highlight the program we talked about, which is called
    Project ECHO, which was founded by Dr. Arora in New Mexico. And
    I know that you actually know him. And I have had really the
    fortune of meeting him. There is a Project ECHO program in
    Pennsylvania, which is spearheaded by the Penn State College of
    Medicine and Penn State Hershey Health. And they have been
    using that in particularly for the Opioid Crisis and expansion
    of medication assisted treatment, but also other medical issues
    and mental health issues.
        I think that telehealth and programs such as Project ECHO
    need to be further expanded. And if confirmed, I look forward
    to working with you and other content experts and Dr. Arora on
    expanding it.
        Senator Lujan. I appreciate that. Dr. Murthy, populations
    that live in rural regions of the United States face unique
    challenges in accessing health care. These barriers contribute
    to the rural, urban divide phenomenon that leaves rural
    Americans with lower life expectancies than their urban
    counterparts. I believe everyone deserves access to high
    quality, affordable care, no matter where they live, what
    health insurance they have, or how much money they make.
        One of the first areas I think we need to address is the
    current caps and other limitations on rural residency programs
    that have put rural America at a disadvantage. Dr. Murthy, how
    can we work together to address the shortage of health
    providers in rural areas and increase Federal support for rural
    residency programs?
        Dr. Murthy. Well, Senator, thank you for that question. I
    do think that we do--we have critical workforce shortages in
    rural areas and those include primary care shortages, but also
    specialists. And I think programs like Project ECHO, which I
    had the privilege of visiting, you know, in New Mexico when I
    was Surgeon General, are programs that can actually help to
    close that gap to some extent. But we have to do more because
    virtual care, while critical, is only part of that solution.
        We need to train more clinicians and bring them to rural
    areas. And we can do that in part through expansions of the
    National Health Service Corps. We can do that, actually, I
    believe by also better utilizing the U.S. Public Health Service
    Commission Corps, which I was privileged to oversee as Surgeon
    General, which as it is, provides a lot of care in rural areas,
    but certainly is poised to step up and do more.
        I do think that there are ways we can do this and with
    residency programs as well, I think we can strategically work
    to train residents and place them ultimately in rural parts of
    our country that are in desperate need of medical providers. I
    would certainly love to work with you on this issue. I think
    health care providers get into health care wanting to relieve
    suffering and to serve. I think the areas that so often need
    service our rural areas, but they are not getting the providers
    that they need.
        Senator Lujan. Thank you for the time today, Madam Chair.
        The Chair. Thank you very much. We will now turn to Senator
    Romney, who I understand gets the patients award today for
    sitting there.
        Senator Romney.
        Senator Romney. Don't seem to be able to get there. My mic
    goes on--the light doesn't but the mic does. Thank you for
    being here today. I appreciate Senator Murray giving me this
    opportunity. Dr. Levine, are there school districts that are
    open in Pennsylvania and some that are closed?
        Dr. Levine. Well, Senator, thank you for your----
        Senator Romney. We are short of time, so are there school
    districts, some open, some closed?
        Dr. Levine. There are some school districts which are
    remote and some school districts which are in person.
        Senator Romney. Okay. Has there been a public health
    analysis to see those that have been opened? Has there been a
    massive spread of COVID that is different than those that have
    stayed hybrid or are all remote?
        Dr. Levine. I am not aware of that analysis, but----
        Senator Romney. Okay, that is my impression as well, which
    is across the country, we have had some school districts open,
    meaning kids going to school, others absolutely closed, kids
    only going on remote. The evidence doesn't show so far that
    those that have been having kids in classrooms aren't seeing a
    spike in COVID cases. There are also countries that kept their
    schools open. They haven't seen a spike in COVID cases. I don't
    understand why our schools are still closed.
        There are some of us who feel it is a submission to the
    teacher's unions, and because they are such big donors to the
    Democratic Party that the Administration is saying, oh, we are
    not--it's at state levels and at the Federal level we are not
    going to push to get our schools open. But, grocery store
    workers are working, drugstore workers, taxi drivers, EMS
    workers, health care workers. But there is just as much a
    priority for our kids to be educated.
        I just can't understand why, given the fact that the data
    doesn't show that there is a problem for teachers or for
    families having kids going to school, we have to get our kids
    into school. The Administration is proposing $170 billion going
    to education as part of the $1.9 trillion COVID program, but
    only 5 percent of that is getting spent in this year. 95
    percent is for years down the road. It has nothing to do with
    getting our kids safe and our schools open again. I just--I
    don't understand why the Administration does not directly
    encourage all of our school districts to open again. And if we
    are going to send out $170 billion, which I don't support, but
    if we are going to send $170 billion, it ought to be linked to
    them agreeing to get the doors open and get the kids back in
    the classroom.
        That is my chance to make a point and hopefully you will
    take that point to the Administration in the responsibilities
    you have. Let me ask a question, Dr. Murthy, and that is, you
    have had concern, as I have, about kids vaping. And the
    analysis shows that about one quarter, I guess, of high school
    kids are vaping on a regular basis, tobacco products and in
    many cases marijuana as well, particularly at the higher grades
    for marijuana. What can we do to get the flavored vaping
    products off the market? That is what kids are getting into.
    This has been slow rolled by the prior administration.
        I think the prior administration was so concerned about the
    vaping shops and the adults that wanted to use the flavored
    products that they slow rolled this. But how are we going to
    get vaping products that are flavored off the marketplace, so
    we don't addict our kids to nicotine?
        Dr. Murthy. Well, Senator, thank you for that question, and
    it is good to see you. You were my Governor in Massachusetts
    when I first moved there for medical training. So it is nice to
    see you.
        Senator Romney. I take full credit for that.
        [Laughter.]
        Dr. Murthy. Thank you. Listen, I share your passion for
    this subject. When I was Surgeon General, I issued the first
    Federal report on e-cigarettes and youth. And I still am deeply
    concerned that while we have seen some improvement in numbers,
    that there are still millions of children who are exposed to
    nicotine through vaping. I think that while we have taken some
    steps, especially at a state level, to restrict access to
    youth, and while we have laws saying that kids shouldn't be
    using this, that they are still a lot of loopholes through
    which kids are accessing e-cigarettes.
        I also worry about the advertising, Senator, especially
    online advertising, which is the easy way for these companies
    to get their products to kids. So if I have the privilege of
    being confirmed, I will certainly look forward to working with
    you and with the Administration in ensuring that we are taking
    steps to protect our kids from advertising to enforce these
    types of rules. And even though the Surgeon General doesn't
    have policymaking authority, I do think that there are parents
    that I encountered all across this country who are concerned
    about exactly what you said about why are there kids using
    nicotine based products.
        This would be an area I would love from a public education
    standpoint to work with you. And I think there is a lot of
    progress we have made, but so much more we have got to do to
    protect our kids.
        Senator Romney. I appreciate that. And I know that part of
    this process is typically some throw away lines that we all
    use, which is look forward to working with you on something,
    but then we never see each other. But this is one I really do
    care about. And I really hope that you will be able to work
    with the Administration and the FDA that obviously has
    regulatory authority in this regard to say, guys, you have got
    to push this faster, we have got to move ahead.
        The analysis paralysis that goes on in Government is
    something which the private sector could never abide. And we
    have to get this addressed because it is a public health
    emergency. I am sorry, Dr. Levine. My time is up. I couldn't
    get you to respond to that as well but thank you. Madam Chair,
    back to you.
        Senator Burr. Senator Hassan.
        Senator Hassan. Thank you very much. Let's try that--
    better. Thank you very much to our Chair and to our Ranking
    Member and to our nominees. Thank you for your service. Thank
    you for your continued willingness to serve and thank your
    families for us too because it is a joint commitment, I
    understand. I wanted to start with a little bit of a follow-up.
    Senator Lujan asked you about the opioid epidemic, and this is
    a question to both of you. The COVID-19 pandemic has
    exacerbated what already was a devastating mental health and
    substance misuse crisis in our country.
        I am encouraged that you both have knowledge and experience
    in combating the Opioid Crisis through expanding access to
    substance misuse treatment and services and working to diminish
    the stigma that is still too often associated in particular
    with heroin. Dr. Levine, as Secretary of Health for
    Pennsylvania, you led the state's effort to combat the opioid
    epidemic for several years. Can you please speak to the
    importance of continued robust Federal funding for states as we
    work to turn the tide of the opioid epidemic?
        Dr. Levine. Well, Senator, thank you so much for that
    question. I appreciate our discussion about this and other
    topics tremendously a number of days ago. You are entirely
    correct. The opioid epidemic, the Opioid Crisis and overdoses
    continues. It has been exacerbated during the COVID-19 crisis
    and we have to continue to address this robustly. In
    Pennsylvania, we worked on prevention with a concept I call
    opioid stewardship, with opioid prescribing guidelines, a
    robust prescription drug monitoring program, etc., with rescue,
    we have the medicine naloxone, and an expansion of treatment,
    particularly medication assisted treatment.
        We do have to get past the stigma associated with that. All
    of those programs required funding. We needed funding for our
    prevention efforts. We needed funding for naloxone and for
    further distribution of naloxone, and then we needed funding
    for treatments. One of the programs we founded was called
    Pennsylvania Coordinated Medication Assisted Treatment, a hub
    and spokes model funded by the SOR funding.
        If confirmed, I look forward to working with you, with the
    rest of the Members of Congress, and with SAMHSA on continuing
    the absolutely essential, sustainable funding for the Opioid
    Crisis.
        Senator Hassan. Thank you very much. And Dr. Murthy, if
    confirmed, how would you use your role to combat the Opioid
    Crisis and address the challenges in that crisis that have been
    exacerbated by COVID-19?
        Dr. Murthy. Well, thank you, Senator Hassan, for that
    question. You know, I think the opioid epidemic continues,
    unfortunately, to be a dire crisis for our country. I think
    that there are a few things, if I was confirmed, I would look
    to focus on building on the 2016 Surgeon General's report that
    we issued on alcohol, drugs, and health. One would be to
    continue to focus on public education, recognizing that there
    is still an extraordinary amount of stigma around the Opioid
    Crisis, which prevents people from coming forward and getting
    help. The second thing that I would look to do is to take some
    of the core recommendations around treatment, particularly
    access to medication assisted treatment, but also integration
    with primary care and work with policymakers to see how we
    could advance treatment. And third, I would say, is to focus on
    prevention.
        Senator, in that report in chapter three, we actually laid
    out a number of prevention programs which have been proven to
    work to be cost effective as well, to return far more dollars
    in terms of reduce health care costs, criminal justice costs,
    and economic productivity losses than the initial investment in
    those programs. But those are still not well known, and they
    don't always often receive the investment they need. So those
    would be a few areas that I would love to focus on with regard
    to addressing the Opioid Crisis.
        Senator Hassan. Thank you for that and I look forward to
    working with both of you on it. I want to turn to a different
    question, Dr. Murthy. Even as we expand access to COVID-19
    vaccines, we face the continued risk of additional spread
    within communities and the emerging threat of new COVID-19
    variants. Experts have been clear, one of the best ways to
    bring an end to the pandemic is to continue to wear a mask in
    public, avoid indoor gatherings, and maintain social
    distancing.
        Dr. Murthy, given the pandemic fatigue many people are
    understandably experiencing, how do you plan to use your
    platform to ensure that Americans continue to adhere to public
    health guidelines even as vaccinations continue until we are
    really, truly able to get the virus and its variants under
    control?
        Dr. Murthy. Senator, it is a great question. And I think,
    to be honest, a lot of us are experiencing the fatigue from the
    pandemic. I certainly am as well. I know a lot of us have been
    struggling for the last year, although, many certainly much,
    much harder that have had much more difficult experiences and
    others. I think there are a couple of things that I would seek
    to do, Senator. Number one, I think we do need to be consistent
    in our communication around the value and the importance of
    masks and we have to follow--we have to lead by example in
    demonstrating that they work, and they are important to ware.
        But the second thing I think is recognizing that fatigue is
    real, and it is not a reason to judge people. It is real. We
    are human beings. We are tired. That means that the faster we
    can also get people vaccinated, the more quickly we can return
    to a state where we can see each other. Where we don't have the
    distance, or we don't have to wear masks all the time.
        That is why I would also focus my efforts on the vaccine,
    on getting it to people, and making sure people understood
    clearly what the benefits are so that they can make good
    decisions for themselves and their families.
        Senator Hassan. Well, thank you for that answer. Thank you
    to the Chair and Ranking Member. I will also just add that I
    would love to work with you and Senator Romney and others on
    the vaping issue, because I think people are not understanding
    the connection now we are seeing between teenage vaping and
    cigarette use later in life. And I very much look forward to
    working with both of you on that. Thank you.
        Senator Burr. Senator Tuberville.
        Senator Tuberville. Thank you, Ranking Member. Thank you
    for being here today. Most of them have asked most of my
    questions. I will try to make it short, make a little bit of
    statement. I have been in education for 40 years. I have seen a
    lot of words put into protecting our kids from drugs, opioids,
    marijuana, all those and we don't seem to do a lot about it.
    And I am glad, Dr. Murphy, I heard you say something about
    education. And after 40 years of experience, that's what has
    got to be done. We have got to put education--we have got to
    put money behind it. And it is getting worse and worse. Now
    that we have opened our borders it is going to get even worse.
    And I feel for our kids. I really do. They are looking for
    something else, something different.
        Again, dealing with 17 to 24 year olds for 40 years. It is
    different every day, but we got to find an answer. We have got
    to find a solution because it is not going to get any better by
    just saying it will go away on its own. We are losing 50,000 to
    60,000 kids a year dying of overdose. And that is--we talk
    about COVID and it is our biggest problem now, but we have to
    do something. I live in Alabama.
        We have lost 14 rural hospitals in the last 10 years
    because we are losing nurses and doctors. We don't have enough,
    we don't have enough hospitals to take care of our patients.
    Dr. Murphy, for you, other than telemedicine, which we are
    using, what can we do? You know, the thing about it, the only
    thing we have now in our rural areas is our pharmacies.
        Now those are starting to go under because if you think
    about it, that is really our hospital and our doctor and our
    consultant for healthcare in rural areas. But these PBMs are
    absolutely putting our pharmacies under because they are the
    middleman between the drug companies and the pharmacies, and
    they are taking all the profits. But what else can we do in the
    rural areas?
        Dr. Murthy. Well, Senator, I think this is such an
    important point. And I realize that the challenges that you are
    speaking to in Alabama are likely being experienced in other
    rural areas in our country, too, that are struggling without
    enough health care providers, without--and they are watching
    rural hospitals closed down as well. There are a couple of
    things, Senator.
        You know, in addition to telehealth, which you mentioned,
    the couple other areas I think we need to focus on is
    strengthening our rural health workforce. Where we see often
    clinicians get trained and then they relocate or stay in urban
    areas, and we don't have enough nurses and doctors in rural
    areas, but we can address that, I believe, through a
    combination of the National Health Service Corps, using the
    United States Public Health Service Commission Corps more
    effectively and expanding their role. I think we can do more
    there.
        But the other place where I think we can do more Senators
    in supporting the rural hospitals themselves. I think the cost
    structure in rural areas, as you know, is different for
    healthcare than in urban areas. And you have to sometimes put
    more into base infrastructure to serve a smaller population
    because that is the nature of rural areas. If we apply a one
    size fits all model to rural and urban areas, rural areas will
    come up short and they won't get the support that they need. I
    think we have got to recognize that and build that into our
    funding support models as well.
        Senator Tuberville. Thank you, Dr. Levine. You have worked
    in mental health and of course, being a football coach and an
    educator, I worked in mental health for 40 years because I see
    a lot of it. You know what I am talking about. And we seem to
    have, over the last 10, 12 years, more and more problems with
    mental health, with our young people. What do you think is the
    answer to that? And what is your first direction in your job
    would be to overcome some of that?
        Dr. Levine. Well, Senator, thank you for that question. We
    do share a concern about young people and their mental health.
    And at Penn State Hershey Medical Center, I ran the adolescent
    medicine program where we saw many young people with medical
    issues as well as mental health issues. I think that we need to
    work on prevention, and we need to work on access for
    treatment. I think we need prevention programs to prevent
    mental health problems in our schools.
        I think we need prevention programs in our communities and
    community health centers as well. And I think we need to
    increase access to treatment, whether that is in urban areas,
    suburban areas, or rural areas. We need more mental health
    professionals. We certainly need more child and adolescent
    psychiatrists, but not only psychiatrists. We need
    psychologists, psychiatric social workers and really the whole
    spectrum of mental health workers to be able to treat our young
    people who are suffering from these mental health issues.
        Senator Tuberville. Basically, what you are saying is we
    need a plan.
        Dr. Levine. Yes, sir. We need funding.
        Senator Tuberville. We need funding. We need a plan. And I
    have never seen that in mental health in all my years and in
    being around kids. You know, we had to look for somebody to
    help with mental health problems. One other question, Dr.
    Murthy, you have been through this job one time. What is your
    number one priority that you have feel like that you can do
    better at this time?
        Dr. Murthy. Well, sir, I have had the privilege of serving
    once before, you are right. And the reason I am back, Senator,
    is because my priority first and foremost is to address COVID,
    to turn this pandemic around. There are issues that have been
    worsened by COVID, mental health and substance use disorders,
    and those are my accompanying priorities as well. But we have
    got to turn this pandemic around first and foremost.
        Sir, to me, this is very personal. I have lost seven family
    members to COVID, most recently my uncle in Dallas a few weeks
    ago. I look at my children, my older one, my son is doing
    remote learning as well, desperately wants to be back with
    other kids, but can't. And there are many families I know that
    are struggling much more than we are. I want those families to
    be able to get back to their lives. I want our kids to be able
    to get back to school.
        I want people to be able to go to work and not worry every
    day that they are going to catch the virus and get sick. I want
    us to be able to come together as a community again, Senator.
    That is what has brought me back to public service. It is why I
    hope to have the opportunity to serve our country once again.
        Senator Tuberville. Both your jobs are very important. And
    COVID is--I have lost friends. It is sad what we have gone
    through. We can see the light at the end of the tunnel, but we
    have seen drugs and mental health problems just continue to
    soar. We have to put money in education. I think Dr. Levine
    will agree with me on that. We have to do something, but we
    can't continue to say it will go away.
        COVID, hopefully we will get it go away. These other two,
    they are not going anywhere. And it is all about educating our
    kids at a young age, at a very--and not starting when they have
    already had a problem. Thank you all today. Thank you very
    much. Thank you, Madam Chair.
        The Chair. Thank you very much. Senator Burr, I will turn
    it over to you for closing.
        Senator Burr. Thank you, Chair Murray. And I want to thank
    our nominees today for your time, for your personal stories,
    and for the expertise that you bring to the nomination. Senator
    Murray, I would like to ask unanimous consent this time to put
    into the record, even though I don't have it in my possession
    while I sit here, one of the latest high school data relative
    to marijuana use and to vape products. What I think that latest
    data showed was that in high school students, marijuana was
    used more than vape product. That vape product in that category
    by high school students, that the least used flavor was
    menthol. Today, menthol is the only flavor on the marketplace.
    All the rest of them are gone.
        The decision by the last administration to allow menthol to
    remain was in hopes that those that use combustible--adults
    could use combustible products could make the transition off of
    combustible cigarettes to a vape product as a way to fulfill
    harm reduction, which is the full intent of the vape products
    and other cessation programs. So, Senator Murray, I would ask
    unanimous consent that when I can get that data today, I can
    put it into the record.
        The Chair. If you have that information, so ordered.
        [The information referred to can be found on page 228.]
        Senator Burr. Thank you. Thank you, Madam Chair.
        The Chair. Thank you so much. That will end our hearing for
    today. Dr. Murthy, Dr. Levine, thank you both for joining us to
    talk about your experience and your thoughtful answers on how
    you will work with all of us to end this pandemic and improve
    health equity and make progress on so many other public health
    challenges. I would like to thank all of my colleagues on the
    Committee for participating in today's hearing as well.
        Given the urgency of this moment, I will be pushing to get
    both of these nominees confirmed quickly so they can hit the
    ground running. And I hope colleagues from across the aisle
    will be with us to do that.
        For any Senators who wish to ask additional questions of
    the nominees, questions for the record will be due by Friday,
    February 26 at 5 p.m. The hearing record will remain open for
    10 days to Members who wish to submit additional material for
    the record. We will have a hearing on the ongoing response to
    COVID-19 pandemic soon. Details will be announced in the coming
    days. With that, the Committee stands adjourned.

                              ADDITIONAL MATERIAL

       LETTERS OF SUPPORT FOR THE NOMINATION OF VIVEK MURTHY TO SERVE AS
    MEDICAL DIRECTOR IN THE REGULAR CORPS OF THE PUBLIC HEALTH SERVICE AND
                  SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

      LETTERS OF SUPPORT FOR THE NOMINATION OF RACHEL LEVINE TO SERVE AS
                ASSISTANT SECRETARY OF HEALTH AND HUMAN SERVICES
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                          ranking member richard burr
        Based on 2020 data, 35.2 percent of high school seniors reported
    using marijuana in the past year. By comparison, 34.5 percent percent
    of high school seniors were using e-cigarettes in the past year. Our
    public health decision-making should be based on the products that are
    the most popular among our children and are increasing in use.
    Marijuana use rivals e-cigarette use among our children and our public
    health decision-making should reflect these realities.

        DATA FOR THE RECORD:

        Since 1975, the Monitoring the Future (MTF) survey has measured
    trends in the prevalence of drug and alcohol use among adolescent
    students across the United States. The MTF survey is funded by the
    National Institute of Drug Abuse (NIDA), a component of the National
    Institutes of Health (NIH), and conducted by the University of
    Michigan. The most recent MTF data tracks trends in prevalence of
    various illicit drugs and other products used illegally by 8th graders,
    10th graders, and 12th graders from 2017 through 2020, including
    marijuana and vaping products. \1\ The data collected measured use
    during the following timeframes: lifetime, past year, past month, and
    daily.

        \1\  Data collection for MTF was cut short in 2020 (on March 14,
    2020) due to COVID-19 concerns. Therefore, the population surveyed for
    2020 is about 30 percent of the size of a typical annual MTF data
    collection. The data collected, however, does represent a wide
    geographic range and included students surveyed in each of the 9 U.S.
    Census geographic division. Analyses of this data indicate that the
    results of the 2020 MTF data collection did not differ from the results
    of previous years that included a larger population.

        Overall, data indicate that daily marijuana use increased between
    2017 and 2020 among 10th and 12th graders while daily vaping amongst
    10th and 12th graders decreased between 2019 and 2020. \2\
    ---------------------------------------------------------------------------
        \2\  Daily vaping use data was not collected prior to 2019.,
    https://www.drugabuse.gov/drug-topics/trends-statistics/monitoring-
    future/monitoring-future-study-trends-in-prevalence-various-drugs.

    ---------------------------------------------------------------------------
        Marijuana

        In 2020, across the three grade levels, daily marijuana levels are
    at or near their highest level of use in almost 20 years. \3\ Daily
    marijuana prevalence rose in all three grade levels in 2020.

        \3\  http://www.monitoringthefuture.org//pubs/monographs/mtf-
    overview2020.pdf.

        Table 1:
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Data in brackets indicate significant change from the previous year

        Source: https://www.drugabuse.gov/drug-topics/trends-statistics/
    monitoring-future/monitoring-future-study-trends-in-prevalence-various-
    drugs.

        As seen in the Table 1, marijuana use in 10th graders has increased
    in all categories measured (lifetime, past year, past month, daily)
    since 2017, with daily marijuana usage increasing the most out of all
    four categories.

              Lifetime marijuana usage for 10th graders increased
            from 30.7 percent in 2017 to 33.3 percent in 2020.

              Past year usage for 10th graders increased from 25.5
            percent in 2017 to 28 percent in 2020.

              Past month usage increased from 15.7 percent in 2017
            to 16.6 percent in 2020.

              Daily usage of marijuana increased from 2.9 percent
            in 2017 to 4.4 percent in 2020.

        While data shows that between 2017 and 2020, lifetime, past year,
    and past month marijuana usage for 12th graders decreased, daily
    marijuana usage increased from 5.9 percent in 2017 to 6.9 percent in
    2020.

        Vaping

        Prevalence of daily vaping decreased for all across grade levels
    from 2019 to 2020.

        Table 2:
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Data in brackets indicate significant change from the previous
    year.

        Source: https://www.drugabuse.gov/drug-topics/trends-statistics/
    monitoring-future/monitoring-future-study-trends-in-prevalence-various-
    drugs.

        Daily Use

        As seen in Table 2, 10th and 12th graders reported a decrease of
    daily vaping between 2019 and 2020 of all vaping product categories,
    including vaping of nicotine, marijuana, and flavoring only products.

              Daily vaping of nicotine products:

                    Y  10th grader use decreased from 6.5 percent in 2019
                    to 5.6 percent in 2020.

                    Y  12th grader use decreased from 11.6 percent in 2019
                    to 8.6 percent in 2020.

              Daily vaping of marijuana products:

                    Y  10th grader use decreased from 3 percent in 2019 to
                    1.7 percent in 2020.

                    Y  12th grader use decreased from 3.5 percent in 2019
                    to 2.5 percent in 2020.

              Daily vaping of flavored only products:

                    Y  10th grader use decreased from 2 percent in 2019 to
                    1.6 percent in 2020.

                    Y  12th grader use decreased from 2.8 percent in 2019
                    to 1.9 percent in 2020.

        Past Month Use

        Monthly vaping also decreased amongst 10th and 12th graders between
    2019 and 2020.

              Past month usage for 10th graders decreased from 25
            percent in 2019 to 23.5 percent in 2020.

              Past month usage for 12th graders decreased from 30.9
            percent in 2019 to 28.2 percent in 2020.

        Past Year Use

        Between 2019 and 2020, the percentage of 10th and 12th graders that
    had used a vaping product in the past year decreased.

              Past year usage for 10th graders decreased from 35.7
            percent in 2019 to 34.6 percent in 2020.

              Past year usage for 12th graders decreased from 40.6
            percent to 39 percent in 2020.

        Additionally, the most recent 2020 data from the National Youth
    Tobacco Survey (NYTS) indicate a decrease in electronic cigarette use
    from 2019 to 2020 in high school students, from 27.5 percent to 19.6
    percent, as illustrated by the figure below. \4\ Of the high school
    students who currently use any type of flavored e-cigarette, the most
    common flavors were fruit (73.1%), mint (55.8%), menthol (37.0%), and
    candy, desserts, or other sweets (36.4%). \5\ NYTS is a cross-
    sectional, voluntary, school-based, self-administered survey of middle
    and high school students in the United States. The Food and Drug
    Administration (FDA) collaborates with the Centers for Disease Control
    and Prevention (CDC) to administer the survey each year.
    ---------------------------------------------------------------------------
        \4\  https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a1.htm.
        \5\  https://www.cdc.gov/media/releases/2020/p0909-youth-e-
    cigarette-use-down.html.

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Source: https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a1.htm.
                                     ______

        [Whereupon, at 12:29 p.m., the hearing was adjourned.]

                                      [all]