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

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