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Brian Lehrer: Brian Lehrer on WNYC. Back with us now Dr. Ashwin Vasan, who is in the position that we usually shorthand as New York City Health Commissioner, but for his appearance today, I'm going to make sure to say the full title of it. He's really the Commissioner of the New York City Department of Health and Mental Hygiene. I say the whole thing because the mental hygiene part was added 20 years ago this summer, July of 2002.

Dr. Vasan was running a mental health organization Fountain House before being tapped by Mayor Adams as commissioner. Last week, Dr. Vasan delivered a mental health agenda vision speech for what he hopes to accomplish on that front in his new job. Of course, a mental health agenda is seen by just about everybody as more vital than probably ever right now in relationship to dealing with aspects of the pandemic, reducing gun violence, reducing homelessness and other economic insecurities, and more.

We'll talk to Dr. Vasan about that agenda now and a bit about the state of COVID in New York right now at this time of an official high-alert status. Maybe you've seen the TV spots that feature him, that are running now encouraging New Yorkers to avoid large indoor gatherings, get vaccinated and boosted, and wear masks indoors as well. Dr. Vasan, always great to have you on. Welcome back to WNYC.

Dr. Ashwin Vasan: Good to be back, Brian.

Brian Lehrer: How do you start as health commissioner in 2022, to even assess what the challenge is on the mental health and hygiene front? I know you have the three categories of people and we'll get into those, but you say we're in a crisis and you sometimes call it a second pandemic. Maybe start with why that term?

Dr. Ashwin Vasan: Thanks. Yes, it's a good question. I really came into this job for many reasons, obviously to lead us through COVID and our recovery but especially building off of the work I've done over the last several years to center mental health in the public health agenda. What I mean by that is to really treat it as the public health issue and crisis that it is by bringing to bear all the different tools that public health has on offer, which is to say, education and awareness-raising, prevention strategies, as well as care treatment and long-term rehabilitation and recovery supports for a range of populations.

There's never been a more important time to center it in our public health agenda. Just look at the data. I mean, rising rates of anxiety, depression, suicidality, especially amongst young people, greater rates of loneliness and isolation. These are not data that will rear its head in the next weeks or months necessarily, but over the next months and years, we'll be facing those effects, so I think it's incumbent upon us as a city government to really make this a central priority.

I know that it is for the mayor, and that's why we're trying to get our arms around it now. That's why I made the speech last week. It's really to put a stake in the ground to say that this administration is centering mental health and here's where we plan to focus.

Brian Lehrer: Your vision speech identified three main groups, or areas of main focus, children, people with serious mental illness, and what you call the overdose crisis. I thought we might start with serious mental illness, because everybody is talking about the relationship between serious mental health problems and gun violence.

No matter where anyone is on gun control, I think it's fair to say they also agree mental health has been an issue for the mass shooters in Buffalo and Uvalde and on the N train and other of the worst headline crimes recently, and yet, the vast majority of people with serious mental health issues don't ever have a violent impulse and are more likely to be victims than perpetrators of violence. How do you begin to form a framework for understanding the relationship between mental health and violence that doesn't sugarcoat but also doesn't stigmatize?

Dr. Ashwin Vasan: Yes, I think you said it very clearly. People who live with chronic severe forms of mental illness are much more likely to be victims of violence than they are to be perpetrators, but we can't be pollyannaish about the fact that there are unmet mental health needs amongst people who are facing homelessness, are facing a whole host of challenges.

It becomes incumbent upon us to try to build a system that is not only about addressing crises, reaching out to the people who are on the street, addressing mental health crises, looking at non-police responses to mental health crisis, but also saying what are the crisis preventives? What are the infrastructure that we need to invest in to keep people connected, to keep people out of isolation, and to keep people from decompensating into crisis? And that's-- The work I've done over the last several years was about creating social infrastructure, creating the places where people can form community as a keystone towards long-term recovery.

That means staying engaged in health care and psychiatric care. It means staying stably housed, and of course, it means more aspirationally, seeking employment and seeking educational goals. I think we have such low expectations for people with serious mental illness, because all we see on the news and in the papers is the violence and crisis that is either rightfully or maybe wrongfully linked to mental illness, and so the public's perception is that these are hopeless people and there is no hope for them, but there truly is. The vast majority of people, as you mentioned, in New York City, there are nearly 300,000 people with serious mental illness.

They live in isolation, but they don't live lives on the street or certainly not lives of violence. There are 14 million people in the United States who live with serious mental illness, and the vast majority of them are just trying to live their lives and recover and to deal with a set of diseases that can lead to serious debilitation. I think we need to really address it like a public health crisis, and frankly, to explicitly address the issue of guns. It's such a red herring to keep putting mental health solutions up as a solution to a crisis that we have very clear answers to, which is our gun crisis. We may not have the will to put those solutions into place, but we have solutions.

Brian Lehrer: Is it not both-and? It looks like they may be heading towards some kind of bipartisan bill in Congress that supports red flag laws, which would take away guns from people who are deemed to have serious mental health issues that could leave them a threat to themselves or others, as well as other behavioral reasons or actions the person may have taken that make them a threat that's not related to mental health but includes mental health. Is it not a both-and approach, mental health and gun laws?

Dr. Ashwin Vasan: Certainly we need to strengthen our mental health system and we need to strengthen our gun laws. The challenge becomes when we start to insert the mental health solutions in lieu of addressing the gun laws, so yes, I think, as you said, it is a both-and, but I'd like to see us address both things in their lanes, and they will converge upon the gun violence epidemic. I'm confident that if we have the will to address both in earnest that we'll see results, but addressing one without the other, it's not going to work.

Brian Lehrer: In fact, some of your speech seems to frame the mental health crisis of today as evolving over the last 20 years, which is different than how many people may think of today's crisis that it started with a pandemic just two years ago. How much is a 20-year view, your main lens?

Part of the reason I ask out of our little exchange about guns is that Texas Governor Greg Abbott the other day in defending assault weapons availability after Uvalde, said, "The weapons have been there for many decades, mass shootings however have increased more recently, so the issue isn't the guns, it's deteriorating mental health in our country." I'm curious if you accept that at all, or why you use a 20-year frame for some stuff?

Dr. Ashwin Vasan: It's a good question. In medicine, when we sometimes take care of people in the hospital, we talk about acute and chronic issues. Then sometimes we talk about acute on chronic issues, meaning you've got a chronic illness and then you get acutely ill from a complication, a kidney failure or something like that. This is really an acute on chronic crisis. We've had 20 years of increasing, as sociologists call it deaths of despair, which are really the lagging indicators of a whole host of social, economic, political forces that have converged disproportionately on the lives of the poor in this country, also the lives of the rural poor but as well as urban poor.

Those are the populations that have been hardest hit by those converging epidemics of suicide, overdose, and the effects of alcoholism, and so that's the background on which this all lives. Over the last 10 years then, we've seen the introduction and the widespread availability of opioids. If you look at the curve of deaths of despair, you see this inflection point in and around 2013, 2014. Then you had the pandemic overlay on top of that, and in this city in particular, you've seen fentanyl drive overdose deaths as well so you've got this inflection upon an inflection.

I think it is helpful to be able to separate the short-term, near-term drivers of an increase that we're seeing with the long-term structural, social and economic and inequality drivers that are really worsening mental health in this country. As far as the Governor Abbott's claims that somehow the guns have always been there and it's just mental health is worse.

We've had mass shootings since Columbine, and that was many years ago, so I don't know that I agree with his supposition that somehow-- it's simply people are taking advantage of or it's simply that mental health is driving these mass shootings. It is the widespread availability of guns combined with people who are hurting, and we also just can't disaggregate this from the dissemination of information, disinformation, misinformation on digital media and social media. It is a complex problem.

It would be remiss as a public health person to say that we can somehow solve it by positioning one solution in and above another. It is really a holistic set of solutions that we need to take on, but certainly guns are the most downstream and end result of a whole host of upstream crises in mental health and otherwise.

Brian Lehrer: The opioid crisis, people with serious mental illness and children, and I noticed that one of your central proposals with respect to children's mental health is a strong and stable school nurse workforce. Why that and what else when it comes to the crisis that children are in, in the city?

Dr. Ashwin Vasan: Yes, our children are really hurting, as I said in the speech, and we're seeing this in terms of rates of depression and anxiety and suicidality. We're seeing those rates not only increase but also appear in younger and younger populations. We're seeing it present in terms of social and emotional development and academic performance and so they're hurting.

I think the pandemic has just been this confluence of trauma, isolation, and a whole host of factors, and kids in their vulnerability and in their development have really been impacted in ways that we're just starting to unpack and understand. When we think about how to intervene then, it's helpful to think about where do kids spend their most time. We're not going to treat our way out of this problem. We're not going to do this through our healthcare system alone. This is not going to be solved by people in white coats. It's going to be solved mainly by the people who care and support and love our children day to day, that's parents but it's also our teachers and the school environments.

I think that school nurses are an incredible workforce that have been put under incredible amounts of strain and stress during the pandemic in terms of keeping our schools open and safe and really leading a lot of the COVID surveillance work in our schools in order to keep them open, but they have a really important role in being one of those first lines of contact of assessment and diagnosis or at least suspicion of underlying mental health needs in students and the ability of those nurses not only to be well trained, well supported, well staffed, well paid, and to be able to then make those assessments and referrals to higher-level care, to more specialized care is an essential piece of building a mental health system for kids because they spend so much time in school.

It's also a team effort with teachers. It's a team effort with administrators and principals and staff at schools as well, and we can't forget as well 160 plus public schools have school-based health centers as well, which students and the community depend on for more advanced healthcare services. The schools are really an important pillar of a youth mental health delivery system. I think it's time that we really focused in and invested in them, and I know that the chancellor and I are really in lockstep on this.

Brian Lehrer: Do you have any thoughts on the intersection between mental health problems and racism?

Dr. Ashwin Vasan: Certainly. I mean, at the health department, we've really been out in front on the issue of racism as a public health crisis. We issued a Board of Health Resolution last year declaring it as such and as a result, creating conditionality on our programs and the Board of Health's oversight of our programs. The city itself has been very forthright and forward looking in terms of its focus on race and equity in all of its programs with Executive Order 45 in 2019 I think.

I think we're all reckoning with the impact of structural racism on our society and on all of our programs. Mental health is no different. It's not only racism as a driver and a social determinant of mental health, it's also racism and inequity in our response, who gets access to care, who's able to get psychiatric care, behavioral health care, addiction support when they need it. There's baked-in structural racism in our systems, including our healthcare systems, and we need to intentionally work back against that phenomenon in order to ensure that mental health supports are readily accessible to particularly people of color who are most impacted.

Our jails and our prisons, including Rikers Island, remain the largest providers of mental health treatment in our country and in our city, and the vast majority of people who are locked up in Rikers and in jails and prisons all across the country are people of color, and so it begs the question of why aren't these folks with real mental health needs getting care in the community? That is in part a product of structural racism. That's how we frame it from a public health perspective. I think it requires really an intentional inclusion in all of our programming and in our discussion in order to begin the hard work and the long work of trying to redress it.

Brian Lehrer: We have just about three minutes left before he has to go, with New York City Health and Mental Hygiene Commissioner Dr. Ashwin Vasan. Because you have to go in about three minutes, I'm going to characterize our caller board rather than take some of these people for you because we've been talking about your mental health agenda, not COVID per se but the predominant thread on the board, do you want to guess the topic?

Dr. Ashwin Vasan: I have a guess but why don't you just tell me?

Brian Lehrer: It's masks, and from both sides, we have some people calling in to say you're not requiring masks anymore in indoor public places even though you go on television and say, "People should wear masks in indoor public places," and other people calling and saying the masks are really harming the mental health of our children. How do you enter?

Dr. Ashwin Vasan: I think that, let's just start with the state of play. We remain in an environment of high COVID transmission, and that puts us at a high-risk alert. We're encouraging and recommending strongly that all New Yorkers mask up in indoor settings regardless of age, stage, place, and to avoid large indoor gatherings. We're also of course as ever advising New Yorkers to get vaccinated, tested, and treated frequently.

We are also looking at the data, and obviously it's coming out of a holiday weekend and there's always blips and variations in the data and testing patterns. We're watching for cautious optimism in terms of whether we're reaching or nearing the peak of this current wave that we're in, and so we should know more in the coming days about that. What is clear about let's say loosening restrictions is that it's best to do that in a time of decreasing risk. It's best to do that in a time of decreasing transmission and not at a time of increasing transmission or high transmission. That's just common sense.

Brian Lehrer: Are you advocating that to the mayor?

Dr. Ashwin Vasan: Certainly. We talk every day, and we review that data, and I think that's why we've made the strong recommendations that we have. We've issued guidance to providers as well as to all New Yorkers about masking up in public settings.

It's also why we haven't additionally relaxed existing remaining mandates, whether they be our vaccine mandates or masking mandates because we know that it creates a wall of protection, but I will say specifically when it comes to relaxing mandates for children, we're looking for the first opportunity to do that safely, and I think once we see, once we're confident that there's an environment of falling cases and falling risk, is the time to start revisiting those mandates.

Now, to the folks who are saying we should be putting in mandates everywhere, we are at high risk, I think it is exactly a byproduct of how polarized this issue has become, and what people don't recall or I think because the pandemic is often the first contact that people have had in any public sense with public health, is that public health is not just about mandates. We use mandates in extreme cases where we see risk, where we see emergent risk, and where we see opportunities to protect everyone, because we've known from the beginning of this pandemic that it's not just about you, it's about taking hard decisions at times to protect everyone.

A lot of public health, and we see this across issues, across diseases, is about providing education, about making healthy choices easier and affordable and accessible, about giving guidance and about helping people and helping New Yorkers make smart healthy choices for themselves. We're in this tricky phase between emergency, where we've been for 18 months or two years [unintelligible 00:22:04], whenever and if ever that comes.

I think trying to navigate that time in terms of our recommendations is a challenge, but I think making those strong recommendations and assuming that New Yorkers are going to continue to, as they've done for so long, do the right thing and do the thing that'll protect others. I think that's a pretty good bet as far as we're concerned.

Brian Lehrer: Well, Dr. Vasan, we always appreciate when you come on, and I particularly appreciate today you coming on to share the ideas in your mental health agenda vision speech. I think you're the first commissioner of the department who has such a mental-health-centered background, and so needed at this time, so please keep coming on with us and talking through these policy pieces as they get implemented. I know it's really helpful to people.

Dr. Ashwin Vasan: Of course and it's always a pleasure to be here with you, Brian. Thank you.

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