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Brian Lehrer: Brian Lehrer on WNYC. As usual, there's a lot of coronavirus news including very low positivity rates in New York, almost shockingly low. A new big survey in New York of people with or without antibodies that shows a surprisingly high number of people have had the virus in New York City and where, and that has implications for who might or might not get the virus in the second wave. Also, the Centers for Disease Control has found that COVID-19 has caused a spike in anxiety and depressive disorders. No surprise there. Also substance abuse and even suicidal thoughts among young adults particularly among essential workers, caregivers, and people in lots of communities, in the larger BIPOC communities. I should say we will talk a little bit about suicide ideation in this segment. If that's a trigger for you, you might want to turn this off and come back later, but that will just be a small part of what we talk about among various coronavirus news developments. Joining us to analyze that CDC report on mental health and more is Dr. Ashwin Vasan, epidemiologist, and professor at Columbia University. He's the CEO of Fountain House, a community-based mental and public health organization if you don't know Fountain House. He was also the public health advisor to the Pete Buttigieg campaign when that was a thing. Dr. Vasan, always a pleasure. Welcome back to WNYC.

Dr. Ashwin Vasan: Thanks, Brian. Thanks for having me.

Brian: Let me start on some of this local news. The latest New York State positivity rate from tens of thousands of tests earlier this week was almost unbelievably low. Less than one-quarter of 1% came back positive. Back in April at the peak, I think it was over 40% in New York. These states that are having outbreaks have 5%, 10%, 15% of the tests coming back positive. Now in New York State, it's one-quarter of 1%. Do you even believe the number and if so what does it mean?

Dr. Ashwin: I do believe the number because I do think that New York has done a really excellent job even though we may have been a week or two late in marshaling a response back in early March. We did an excellent job thereafter and really marshaling a complete public health response. That test positivity rate really reflects a number of things. Number one, that we have had a really impressive marshaling of basic public health strategies including masking and distancing and hand-washing. We've had a phase, the stage reopening which has been sensible and data-driven and of course, it is summertime more people are outdoors. More people have left the city and even maybe left the state or gone to more rural areas. I think one cannot discount as well. There is no really clear seasonality with coronavirus unlike flu, influenza but clearly there's an impact on our behavior with being outside. What we know about outdoor transmission versus indoor transmission is that up to 80%, 85% of transmission is happening indoors. Being outdoors is protective. I think all of those factors taken together, has really led to that. What I would argue currently is a success. As well, I think the city public health authorities, the state public health authorities have marshaled a testing, contact-tracing, and isolation and quarantine strategy that has been good, smart, targeted, data-driven, and is expanding. I think our contact-tracing workforce is expanding and is proving to be-- despite its fits and starts, in the beginning, proving to be increasingly effective. I think taking all that together, I think we should be proud as New Yorkers that we are in the state we are in and that we have achieved a level of suppression that we've achieved but we cannot get complacent. All it takes is a slight laxity. One of those responses, and we can start to see increases.

Brian: In that context, I'm curious if you have a take on all these indoor space policy debates that are breaking out and I'm curious if you see them as a group where they're really very different individually. The Restaurant Owners Coalition is asking New York City to allow indoor dining. I'm sure they're going to want immunity from lawsuits if they don't adequately clean and space people and new people get the virus. The legal question is another show. Also, Governor Cuomo just reluctantly allowed gyms and bowling alleys to open. 30% capacity for the gyms. Rules like every other lane maximum for the bowling alleys. I'm curious if you would feel safe working out today in a 30% capacity gym. Obviously, what about reopening schools? These are all the same question or do we need three different one-hour shows for each of those?

Dr. Ashwin: On some level, they are the same question in that we're talking about indoor congregated spaces, Most of them with poor ventilation or limited capacity to really change their ventilation. On some level, yes. We're talking about groups of people coming inside versus being outside. Any of those activities is higher risk than having those locations closed and being outside. Obviously, that's not a sustainable path forward. We have to find a smart and safe way to reopen. The difference I think, of course, is that dining involves taking off masks and eating for extended periods of time. I'm sure there are people out there who take off their mask just to have a bite of food, but in the main, I think people are just having their meals without masks on and maybe putting them on when a wait staff approaches and so forth. I think that's an higher-risk activity compared to gyms or bowling alleys where you can engage in your entire workout or the entire activity with the mask on. We know how protective masks are and in both indoor and outdoor settings. It isn't the same conversation, but I have a ton of empathy for the restaurant owners. I know that they're also threatening a lawsuit against the governor, against the state and it's because they want clear guidance. I understand both sides of this. What the state is looking at is places like Michigan and Rhode Island and Washington DC that had pretty low suppressed positivity rates for many weeks, and then started to reopen up indoor dining, and saw an increase. Then they went back into shutdown and those rates went down. Those were in states that had, again, a strong public health response, had lower community transmission. The state is being incredibly cautious, particularly with New York City which has an incredible density of restaurants in close proximity, much more than upstate and other parts of the state where those locations are spread out over greater distances. To be honest, you've also seen higher rates of violations. There was a spate, I think a few weeks ago of something over, I think, 100, 150 violations in a three-day span. I think it's just hard to adhere as a business owner. It's hard to adhere as a restaurant owner. It's hard to adhere as a client to the standards in a place like New York City, which is densely populated. I understand the abundance of caution that the state is proceeding with. I also understand the need for clarity and the need for guidance on the part of restaurant owners because outdoor dining is scheduled, I think to end October 31st and it's already not clear how long people will want to dine outdoors and how much business will return, even if there is indoor dining. I understand that there's a lot of concern here for these businesses and for the economy. This is a really tricky one. I think a little bit like schools, we have to really-- Number one, we have to continue to suppress community transmission. As long as we're at the rates we're seeing, we can safely reopen schools, but once we have, we are going to get some cases with school reopening. We are going to see some increase in that test positivity rate. The question is, how do we respond to that? Are we able to really encircle those cases with public health control strategies that we've discussed already and prevent those from becoming outbreaks, prevent those from becoming outbreaks that can then throw sparks and lead to wider community transmission? As we see schools reopen, that will give us a good sense of how nimble our public health response system is to be able to respond to that. My sense is that restaurants could flow from that, could learn a lot from schools reopening, and then we can think about reopening of restaurants and indoor setting. As a public health professional, that's how I would think about it rather than trying to open things on different tracks at the same time, all of which we know will be higher increase activities because they're indoors.

Brian: That's a really interesting answer. Really interesting answer. Let schools be the test case for restaurants, which would presumably be higher-risk with indoor dining because it's harder to just space but if that's really what you're saying.

Dr. Ashwin: I run a Fountain House and we're a congregative care setting. We've talked about this in the past, Brian. I'm waiting to see what happens with schools before we undergo a significant reopening of our congregative care setting, which I know is a particularly high-risk environment. Despite all the changes to our operating model that we're making, I'm waiting to see what happens with schools because I want to know not so much what the increase in cases is, but how able is the city and the state able to really marshal a nimble and effective public health response to be able to suppress those cases and break chains of transmission so that they don't become bigger outbreaks. That's an important point for anyone operating an indoor business.

Brian: Really interesting and of course, so much sympathy to the restaurant owners who are dealing with the sudden collapse of almost the entire industry. Many people going out of business, are on the verge of going out of business. I know some of those people and it's just horrible and yet the public health decisions that affect indoor dining, so far they don't agree, but so far the government is deciding doesn't work in their favor. Just let me ask you one more thing about schools and then we'll get to the Centers for Disease Control report on mental health. The way you describe it, it's almost like, "Okay, let's go with this big social experiment with all the kids and all their parents and grandparents and other caregivers and the teachers," but the teachers union, the principals union, they don't feel that the system is ready and they're asking for a few things. They want everybody to get tested before they come back into school and have that available on a regular basis. They also want teachers to be able to opt-out. Just if they prefer to opt-out and teach remotely, just like the families can opt the kids out. They don't need a medical excuse, but the teachers need a doctor's note and a medical reason to not go back in the classroom. Do you have any opinion on any of that?

Dr. Ashwin: This affects me personally. I'm the parent of two school-aged kids and I desperately want to see them go back to school in the main because of their social and emotional development and learning, which they've missed out on over the last six, seven months. Yes, I really want schools to reopen as a parent. As a public health professional, I completely agree with teachers wanting more protections. My kids happen to be under 10 and based on the data we know, limited as it is, kids under 10 are less transmissible than kids between 10 and 19 in school. I feel comfortable from that perspective, but remember this is a congregation of adults and kids. What are we doing for teachers? What are we doing to protect these incredibly important essential workers in our society? Are we offering them enough resources? Are we offering them enough protections? Are we making testing and quarantine support and other supports accessible to them? As far as an opt-out, it's hard for me to make a clear judgment on that. I think there's a fairness in there, of course, in a teacher who feels unsafe wanting to be able to participate mainly in remote learning, but also protect their job. I think there's an inherent fairness there. I can also understand it from the school's perspective. You need your workforce to be there. What I would say is that we need to be really investing in teachers, investing in schools and making that a linchpin, a centerpiece of our reconstruction or recovery or reopening. If I was in a position to do those things, I would make that really central because this is bigger than-- Schools are, yes, it's another indoor environment, but it's central to our society across the life course. It affects kids and their learning and their development. It affects parents and their relationships with their kids, their ability to work, their ability to go to work. It affects caregivers. It's just a whole host of knock-on effects from schools being open or not open that I think this requires really dedicated resources, dedicated time, dedicated strategies. You're seeing the private sector reopen in some cases with these contract-testing companies. You're seeing Hollywood sign up with contract-testing companies to be able to shoot films again. I would like to think that as a city, understanding that we have resource constraints and other constraints that we should be at least exploring how to deploy strategies like that for this incredibly essential workforce.

Brian: With respect to the teachers, I think they need a medical reason, or if they're over a certain age, I think at 65, they get to opt out too if they choose that. We'll talk about that more tomorrow listeners with Mayor de Blasio when he comes on as the mayor. We're talking now with Dr. Ashwin Vasan, epidemiologist, and professor at Columbia, and he's the CEO of Fountain House, a community-based mental and public health organization. As you heard him say, it's both a residential facility and an outpatient facility. I want to move now to the Centers for Disease Control report that found, not surprisingly, a big spike in mental health issues around the country in these months of COVID. What's most important from that report as you see it?

Dr. Ashwin: What we have to keep in mind is that mental health conditions like anxiety, depression, suicidality, substance use were on the rise prior to COVID. I think your listeners will probably be familiar with the notion of depths of despair that's from suicide, overdose, violence. Those were on the rise for the last decade, basically. We had our three consecutive years of falling life expectancy in the United States for the first time since 1918 and the influenza pandemic and World War I. Mainly driven by these depths of despair. We had a rising, bubbling, emerging mental health crisis on our hands prior to-- Really a public health crisis on our hands prior to COVID. Like many things in our society, COVID has come through and really shattered that and broken open those figures that already existed. Almost 45% of the adults in this survey reported struggling with a mental health or substance abuse condition in the last month. 30% experiencing anxiety, depression. 11% considering suicide. That percentage increased to nearly 26% amongst young people, 18 to 24. More than half of the respondents classified themselves as essential workers. We are not only seeing what a lot of us--

Brian: There's the disparate impact again because we know who the essential workers are disproportionately, right?

Dr. Ashwin: That's correct. That's correct. It's falling on the backs of lower-income people, people of color, people from areas of concentrated poverty in our country. It's concerning, of course. Number one, we're seeing the rates-- These are rates of mental health conditions, far higher than we saw at baseline prior to COVID even though we were seeing increases. Number two, we're seeing the disparate impact on young people and on essential workers. A lot of us who work in this field have been calling this a second pandemic and in a way it is. I think we are going to see a global mental health crisis that will far outlast COVID. We saw this with SARS. We saw rates of PTSD and other conditions spike in the years subsequent to the SARS epidemic in Asia. I think you see this with mass casualty events and disasters all around the world. I think we're going to see the same long-term mental health crisis in this country that we're going to have to finally address at the highest level of the public and private sectors in our country because this isn't going away.

Brian: Why do you think it would be worse among young adults than older adults? Because I could make a case that theoretically older adults see what's going on, know how vulnerable they are to the worst effects of the virus if they get it and think, "Gosh, I'm on lockdown for the rest of my life," or limited activities and get depressed. Whereas younger adults would think, "This stinks, but it's going to go away in a few years and I'm going to have the rest of my life."

Dr. Ashwin: I think this is where it's really important to understand the trends that were happening in mental health before COVID. A report issued in 2019, which was out of Blue Cross Blue Shield, which was one of the largest mental health surveys of millennials issued back in spring of last year, showed that 6 of the top 10 conditions of people under 30 were behavioral health conditions, mental health, substance use disorder. We have a population of young people in this country who are--

Brian: Oops. Did we just lose Dr. Vasan's line? I think maybe we did. We do have Dr. Vasan back. Go ahead and finish that thought that you were in the middle of before we got cut off regarding young adults and what was going on even before the coronavirus. Then I want you to tell us what you think policy responses could be to this long-term mental health challenge you're laying out and then we're out of time.

Dr. Ashwin: Perfect. Sorry about that. The connection issue. We have a population in millennial, people under 30 and young people, who were already feeling a burden of mental health conditions that far outweighed any other population group in the country. Some of the drivers of that are things like the economic climate that young people are entering in, the job climate people have been entering in over the last-- Basically since 2008, it's not been a rosy picture for young people getting jobs out of college. Educational debt, lack of access to education. I think there's been a general hopelessness amongst young people for the future that is coloring what we're seeing in mental health rates in that population. As well, you have a population that's mental health is much more a lingua franca for them. They're able to talk about it and able to express their mental health needs and their emotions in ways that frankly generations prior have been suppressing and stigmatizing and keeping under the covers. We have an opportunity to intervene early with policy responses for young people, for essential workers in order to stem the tide. What are some of those responses? Number one, and I think all of what I'm about to say is colored by the fact that we know that people of color, particularly Black-Americans have higher rates of certain mental illnesses, particularly serious mental illnesses, and have lower rates of access to care. The listeners should see that inequity lens across any of these responses. Number one, mental health care is far too hard to access in this country. Around a third of Americans live in what's called a mental health professional shortage area, which is a HRSA designation. That basically means when they need access to care, they can't get it. That's a real problem. There's a host of factors behind that. It starts in part with things like parody. Meaning, how do our insurance companies pay for mental health care relative to physical health care? Basically, on average it's around $0.83 on the dollar for mental health care versus physical healthcare. As you can imagine, that leads to a whole lot less revenue in the system in order to build mental health centers, expand the workforce, basically make care more accessible. We've had a Parody Act, the Wellstone Parody Act for years now. It's just not being universally enforced across the country. That's one issue. Another issue is one of the ways in which we can respond and have responded in COVID, is to increase the use of telehealth and telemental health services. Prior to COVID, it was really difficult to get those programs off the ground and they weren't paid for or reimbursed at the same levels as physical in-person visits but now New York, in particular, has been really good on this. Expanding access to telehealth services, allowing for service providers and plans to cover those at equal rates through Medicaid and Medicare. We need to make those changes permanent and that can go a long way to making mental health care more accessible. Number three, we obviously need Universal Health Coverage. As you see essential workers facing the disproportionate burden of mental health complaints, these are also people who are more likely to be uninsured. Restaurant workers, delivery people, grocery store workers, and the like. We need to push quickly towards universal coverage. At the end, the other and the final piece I'll highlight is really--

Brian: We've got 30 seconds left. I apologize.

Dr. Ashwin: No, it's okay. Our stimulus has to be intersectional. Not in the way we think about identity, but in the way that we think about what are the drivers of mental health. If you don't know how you're going to pay your rent, or where your job's going to come from, or if you can send your kids to school, those are all going to affect your mental health. When we start to talk about stimulus release and the Health Act and the CARES Act and the like, we need to be centering mental health as one of the-- This is prevention for a mental health crisis in the future. If we make economic and social relief the centerpiece of our reconstruction on our recovery a new deal, a social contract, then we can actually begin to stave off this crisis, which is bound to last for the next decade or more.

Brian: Dr. Ashwin Vasan, CEO of the community mental health organization, Fountain House, and a doctor at Columbia. Thank you so much for joining us. It's always so insightful.

Dr. Ashwin: Thank you for having me, Brian.

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