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Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning again, everyone. Three days after Donald Trump left office, New York and much of the nation basically ran out of vaccines. Coincidence? Maybe, but here is President Biden's new Centers for Disease Control Director Rochelle Walensky on Fox News Sunday.

Rochelle Walensky: We don't have as many doses as we would like now for states like New York, for other states that are claiming to have run out of vaccine.

Brian: The Trump team warp sped vaccine development, but as with so many things, did not create detailed plans for ramping up production and distribution. President Biden is putting the wheels in motion for more syringes, more vaccinators and more, but as with economic growth, more alone will not necessarily mean better. On ABC this week yesterday, the new Surgeon General, Dr. Vivek Murthy, told George Stephanopoulos, success has to be gauged not just by the number of vaccines we deliver, but also by how fairly we deliver those vaccines, how equitably we deliver them.

Dr. Vivek Murthy: We already know from the COVID crisis over the past year that there are certain communities that have been hard hit by this virus. The rural communities have had a harder time getting access to resources. Communities of color have experienced more cases and deaths. That seniors have struggled, especially those in long-term facilities. What we've got to do here is not just, again, increase supply, which we can do, using the Defense Production Act, making specific syringes that can extract more vaccine from the Pfizer bottles, but we've also got to set up the kind of distribution channels, like mobile units, like strategically placed community vaccination centers that can reach people who traditionally are hard to reach and don't have access to healthcare.

Lastly, George, we got to track our progress. We've got to make sure that we have data on where the vaccine is being administered so that we can ensure that it in fact, is being distributed equitably.

Brian: That was the new Surgeon General, Dr. Vivek Murthy, with George Stephanopoulos on ABC this week. As America waits for vaccines and starts to see new variants pop up that are more contagious, and apparently more deadly, as the limits on our lives that we thought might last a few weeks last March, drag on in their second winter, it all also takes a toll on our mental health. We are now living at the intersection of psychology, inequality, and COVID-19. My next guest has a plan to steer us through all three.

Dr. Ashwin Vasan is president and CEO of the mental health network, Fountain House, and he has released a report called A 100 Days Mental Health Agenda for the Biden Administration. We'll talk to him about that and other COVID issues. During the Democratic primary season Dr. Vasan, was health policy adviser to the Pete Buttigieg campaign. Dr. Vasan, always good to have you on. Welcome back to WNYC.

Dr. Ashwin Vasan: Thanks, Brian. Good to be with you.

Brain: By way of background that predates COVID, you write in your report that we have been mired for decades in a mental health crisis that intertwined with economic inequality, including racial injustice. Can you start out with some of the biggest markers of that long-standing intersection?

Dr. Vasan: Yes, that's right, Brian. For 20 years, prior to 2020, prior to the pandemic, we've seen an increasing burden of what sociologists and public health officials called deaths of despair. Those are deaths due to suicide, due to the long-term effects of alcoholism, and due to drug overdose. For 20 years, we've seen a persistent increase in those rates of deaths, and then over the last 6 to 7 years, we've seen a dramatic inflection point due to the opioid crisis, and all of that was prior to the pandemic. Deaths of despair have been implicated as the main driver behind the first sustained loss of life expectancy, the multi-year loss of life expectancy over the last three years.

Now, we'll likely approach four years since World War I and the 1918/1919 flu pandemic. All of this is before coronavirus hit. Now we're seeing, as you mentioned in your lead-in, a dramatic and universal stressor created by the pandemic in the attendant social isolation and distancing, and lack of congregation that were forced to put up with. We're seeing rates of depression increase. A survey in September suggested that depression symptoms were three times as high as they were pre-pandemic.

A CDC survey from July suggested that 43% of Americans were experiencing significant anxiety, depression, or suicidal ideation, and that's just at the very beginning of the pandemic. That says nothing about the long-term impacts of economic insecurity, joblessness, homelessness, and the social and other attended health effects of the pandemic that we're going to be reaping for years to come. I've been referring to it as the long tail of the pandemic, the second pandemic of mental health issues.

I'm an epidemiologist. The reason I'm working in mental health is because, by all definitions, this is an epidemic. Now, that we have a stressor like the pandemic, like the coronavirus pandemic, I think we're going to see this really affect us globally. This is not just a New York City issue. This is not just a national issue, this is a global issue. Our mental health is being put under significant strain and it's about time we centered it in our recovery.

Brian: By the way, if I can digress for just a minute, those of you who are listening to our last segment on the military, this just in from the Washington Post. Headline, Biden Lifts The Ban on Transgender People Serving in the Military, reversing Trump's controversial policy. Not a big surprise, but he hadn't done it yet. He did it today, here on day six. Thought you'd like to know but we continue with Dr. Vasan.

What you're describing is really a microcosm of our entire national economy, and how it intersects with COVID. I think you, as a mental health professional, relate it to the mental health crisis in America, to anxiety, depression, opioid addiction, as you were referencing, all contributing to a decline in life expectancy on average. A lot of Americans don't realize that.

They think, "Oh, we're living longer and longer all the time in this country." Well no, in recent years, which is rare and shocking for the richest country in the history of humankind.

I'm struck by how much of your 100 days mental health agenda for Biden isn't just things like more psychotherapy or drug rehab, but you begin with monthly direct cash payments as part of an expanded COVID stimulus package. You say this is the single most important mental health remedy there can be. Can you describe what you have in mind?

Dr. Vasan: Yes, that's exactly right. I think when it comes to mental health, when it comes to health in general, we tend to focus our thinking on healthcare as the principal way we respond to that and that's fine. We certainly had a mental health care and have a mental health care crisis in this country. One out of three Americans lives in a mental health professional shortage area. That means that when they need care, when they needed mental health care, they weren't able to get it. That was pre-pandemic, through a variety of reasons.

In 2018, another survey reported that under half of Americans living with more serious mental illness received treatment for that, and so we certainly need better, and more accessible, and higher quality mental health care. Part of the reason as I said, I'm an epidemiologist. I'm a public health person working in mental health, is because if we're not talking about the drivers, if we're not talking about the underlying causes, and we're just focused on the back end treatments, then we're going to continue this endless cycle of not really addressing the issue at its root.

Yes, our 100 days plan focuses, first and foremost, on the stimulus. The connections between financial insecurity and mental health are really well-described in the literature. Too many Americans, prior to COVID, were already living paycheck to paycheck. 44% of Americans were living paycheck to paycheck before the pandemic, and that's increased to 63% as of December.

You have people who are always in this precarious situation, and that has a chronic accumulative effect on people's stress, on people's anxiety, on people's mental health, and make no mistake, this leads to the development of long-term, persistent mental health challenges. That's why we say the number one thing we can do to address this long tail of the pandemic, the second pandemic of mental health concerns is to actually meet people's basic human needs. Get them the cash that they need to get through this most difficult of times, and ensure that it's sufficient to actually ensure that they're not worried about putting food on the table.

They're not worried about staying in their homes. They're not worried about paying their utility bills, that they can actually hunker down and make it through this difficult period. Unfortunately, our healthcare and mental health care conversation is so siloed into services and healthcare, we need to really bring it back into the center of American life or bring it into the center of American life, and connect it up with economic relief and affordable housing.

All of the drivers, what we would call in public health, social determinants of health, those are really social determinants of mental health as well. That's why we really focus on the stimulus as perhaps the most important thing that the new administration can do to stave off the worst effects of our looming mental health crisis.

Brian: Listeners, do you have, or do you know people who have mental health issues that you see as related to COVID or related to economic and racial injustice, or maybe the intersection between COVID and injustice? Call in and help us humanize and personalize this segment with your stories or ask any question of Dr. Ashwin Vasan, CEO of Fountain House, and now the author of A 100 Days Mental Health Agenda for the Biden Administration, 646-435-7280, 646-435-7280 or tweet @BrianLehrer.

Staying on this intersection between mental health and economic justice, looking longer term, you propose job training, especially jobs that can be done remotely, again, focusing on the Black and Latino communities. What's the relationship between that and mental health?

Dr. Vasan: Again, I think long-term unemployment has been linked to the development of chronic mental illness, increased risk of suicides. People who are long-term unemployed have mortality rates that are at least 1.5, 1.6 times higher than people who have gainful permanent employment. Again, I think we need to start looking at the root causes, going to the drivers of ill health, and ill mental health, and starting to address those at the root and talking about them as health and mental health interventions.

We've lost 140,000 jobs in this country. Many people are not going to have jobs to go back to, when they come back. The economy is changing. It has led to further automation. Sorry, 140,000 jobs just in December alone. People are not always going to have jobs to come back to for those who lost them. We're going to have to invest in training and workforce development, because we can't just allow people to persist in this state of underemployment for years to come or we're going to be reaping those effects both socially, from a health perspective, and economically.

Again, we tried to focus this report, and we try to focus a lot of our thinking in terms of policy and advocacy at Fountain House on going to those root causes. Not just focusing on, "Yes, let's change mental health care," and certainly we need more of it and better, but how do we actually go and attack those social and policy factors that are driving our health, that are creating ill health. If we do that, then we have to go squarely into the bones of public policy, public administration, and politics.

Brian: I want to let the listeners know that you reference one particular proposal that's now before Congress, as an example of something that could be done. You say they should adopt a version of the so-called baby bonds program proposed by Senator Cory Booker and Congresswoman Ayanna Pressley. Why bring up that specific proposal?

Dr. Vasan: I think the reason to mention that, and of course, it's a sound proposal in terms of pilot programs, but it's to really bring up this notion that-- I mentioned at the lead that we've had 20 years of increasing deaths of despair. Well, what's really driving that, and what's really driving the inequity that we're seeing, the racial and social disparities that we're seeing in our mental health epidemic? Why are low income people, why are people of color suffering more? It's because of long-term economic insecurity, it's about massive structural changes to our economy that are leaving vast swaths of the population behind.

Unless we address that by investing in intergenerational economic stability, particularly in communities that have had the effects of intergenerational divestment, disinvestment, we're not going to hope to create long-term opportunity and futures for the next generation coming up. This is an investment, not only in short-term recovery, but in the long-term economic stability and security and opportunities that I've just described, are really drivers of our health and our mental health. We need to be thinking of it that way, instead of talking about it in this siloed approach that is distinct from its impacts on our bodies and our minds.

Those are not de-linked. I think we can all appreciate that when we have money in our pocket, food on the table, when you got gainful employment and purpose in life, when we've got a stable place to live, when we've got safe streets and places to move around that we're healthier. That's a pretty common sense kind of insight. Then we have to match public policy to make that a reality, especially for communities that have been historically disadvantaged, and as we're seeing more recently, disproportionately burdened by the pandemic, as well as the next generation.

That's why we bring up the baby bonds proposal, because it's just one of a few that we see out there that are really talking about getting to intergenerational causes and effects.

Brian: Put a certain amount of money in every baby's bank account at birth, they're more likely to be able to go to college on the growth of that fund without taking out loans, and start out life on a more equal footing to people whose families may have had more money privately. That's the baby bonds' theory.

Dr. Vasan: If that's not a health intervention then than what is?

Brian: Amy in Maplewood, you're on WNYC with Dr. Vasan. Hi, Amy.

Amy: Hi, how are you Brian? My question is for Dr. Vasan and basically, I'm a professional mediator, and I find that there's a big stigma still in the Latino community regarding getting mental health assistance. It's not just a money issue. It's more of a mindset. I was wondering if they're doing anything to address this, because when I recommend people seek out therapy and things like that, I always get the response, "Well, I'm not crazy, so I really don't need it." I see commercials in English, of course, and I've haven't seen that in the Spanish channels or within the Spanish community. I wanted to know if anything is being done to address the stigma of the Spanish community with mental health care.

Dr. Vasan: That's such a good point and a good question. I'm a child of immigrants and I've seen firsthand in my family, and in my lived experience, how mental health is deeply, deeply stigmatized, and how that stigma leads to systemic discrimination. I think our policies, the resource allocation, the choices we make about what's a priority in our society is actually a reflection of that basic stigma and discrimination we have at the interpersonal level, at the human level. Our choices that we're making at the policy level are very much informed by and driven by the basic stigma we still have a lot of in our country and in our society about mental health conditions.

You're absolutely right. It's particularly true in linguistic and cultural minorities when it comes to, for example, making access to care, making mental health care more accessible. A big focus has to be placed on culturally competent care, so it's not just about more mental health providers, it's about more mental health providers that are from the communities that they serve. More than any other type of healthcare, mental health care requires a really strong therapeutic alliance and trust. That trust is very hard to build. It's hard to build at baseline, it's even harder to build when there isn't any shared lived experience.

Absolutely right. A lot of what we do at Fountain House is working with immigrant communities. We have a large number of the people we serve, who come from those backgrounds, and we make every effort to ensure that what we do is tailored to their needs, but it has to be much more mainstreamed in our mental healthcare system that we're taking into account the very specific needs of immigrant communities. Because again, we'll just perpetuate people being left behind, unless we do so.

I think that the caller raises a hugely important point. We can't just change policy. A Biden 100 days set of recommendations are really important and the data's very compelling, but unless we're also attacking stigma, culture, and discrimination, we're not going to get policy to meet the moment. We have a couple of hills to climb when it comes to mental health.

Brian: My guest if you're just joining us, is Dr. Ashwin Vasan, CEO of Fountain House, out now with a 100-day mental health agenda for the Biden administration. Here's a Dr. Eras from Northern New Jersey, calling in. Dr. Eras, you're on WNYC with Dr. Vasan. Hello.

Dr. Eras: Hi, thank you so much for taking my call, Brian. Nice to speak with you Dr. Vasan. I'm a psychologist myself, and I do outpatient psychology or outpatient mental health with adolescents, and adults and families. I also consult with schools. My main push is for mental health education in the schools. This is a way that I feel is a way to mainstream mental health, to really get to the root of it.

My focus is primarily on anxiety because anxiety is at the root of any mental health issue, especially depression, I mean, any mental health issue really. Unfortunately, anxiety is severely misunderstood. I come from the theory that anxiety is, in general, any uncomfortable feeling that we experienced. It could be anger, sadness, irritability, feeling scared, any uncomfortable feeling, that's anxiety. Is our body's way of saying, "Something is not right, I don't feel like my normal self."

Through my clinical work and research, I found that anxiety is really rooted in a lack of control. Whether it's something personal that we're going through or something more global, like a pandemic, there's so many factors that are out of our control, which limits our personal sense of control. That lack of personal sense of control skyrockets our anxiety.

We want people to understand how anxiety works and what we can do to tackle it.

This is something that can be applied across cultures as well. I've used this across cultures in different schools, and across ages as well. From elementary schools through college age and adults. It's something that also destigmatizes mental health because every single person has anxiety. It just looks different from one person to the next. There are a million different symptoms of anxiety, not just the ones listed in the DSM, but we all have our own physical symptoms of anxiety or on behavioral or mental aspects of anxiety, but we all have it. Anytime that we're experiencing a lack of control, that anxiety increases.

If we can educate people on these basic concepts and provide specific, concrete tools for students, they can learn how to manage their anxiety in the moment and moving forward. Which also helps prevent them from getting to a place where their anxiety is so intense, that they engage in maladaptive behaviors or substance use, or self-injurious behaviors, you name it.

Brian: Dr. Eras, I'm going to leave it there-

Doctor: Comprises anxiety.

Brian: - for time. Thank you very much for all of that. I'm going to take one more call and then Dr. Vasan, I'll let you comment on both. Kelsey in Brooklyn, I think another practitioner who works with students. Kelsey, you're on WNYC.

Kelsey: Thank you for having me and thanks for the topic and the subject matter. I was just going to say, related to the social inequity of mental health, it's really hard. I'm a parent myself and I work with kids and adults, but I've lost a lot of kids who are from families of color, that don't have the resources to have the adult on the Zoom with the older sibling, and then helping them set up with the younger sibling. Developmentally, it's just not an appropriate way to do therapy for kids below a certain age group. It's just very challenging.

I think all the kids I work with and teenagers that are suffering greatly, especially the ones that were juniors last year are now going to become seniors. I do think that there has been a real inequality in the clients that have dropped off and just don't have the ability to stick with it.

Brian: Kelsey, can I ask you, and then I'll ask Dr. Vasan? If you've seen the stories in recent days about the Las Vegas School District, planning to go back in-person now after going all remote because there've been suicides at a greater rate than in the past among students?

Kelsey: Yes, I have weekly check-ins with clients that they let me know. They're like, "I don't have an active plan, you don't need to alert anyone," but it is really hard. I just don't want to wake up tomorrow, not necessarily, because I don't want to die, but because I don't want to be here anymore, I don't want to do it again. I've been in my house for months, I don't see my friends, and just try to honor that yes, that's developmentally not normal. That you're supposed to be individuating, separating, making new friends and wearing your whatever clothing style you are to represent who you are, and test new skills. You're not doing that when you're at home.

Brian Lehrer: Kelsey, thank you so much. Dr. Vasan?

Dr. Vasan: It's just amazing comments from both of the doctors. I'll just pick up on a couple of threads. Number one, absolutely, we should be focusing on school-based mental health and early intervention. One of the things that makes me encouraged, as we were talking about stigma and discrimination, is that younger people are talking about mental health in a much more open and transparent way than older generations. I feel like that's just the beginning of the change that we need.

Absolutely, in all respects, whether it's for long-term outcomes, early intervention, prevention, we need to be intervening, identifying mental health issues early, intervening early, and preventing the worst secondary effects and long-term effects. A lot of the people we serve at Fountain House have been failed by the system for years and years, and we're able to help them rebuild their lives by providing community infrastructure and a safe clubhouse to go to. Imagine if we were able to prevent a lot of that by identifying mental health issues early.

Schools are a tried and tested way of doing that. We need a massive expansion of mental health services in schools because that's where problems often appear in a very nonspecific way. I think the first caller is right, it can often just appear as anxiety, loss of control. It doesn't have to fit into a diagnostic bucket, it can just be "Hey, I'm really struggling with function here. I'm really struggling to do my schoolwork. I'm struggling emotionally, socially."

Some of the most rewarding work we do at Fountain House, for example, is with college students that drop out of school as a result of loss of function due to often nonspecific mental health issues. Absolutely, expansion of school-based mental health is key. I also want to just pick up on what the caller-- the caller did such a good job of articulating exactly why we wrote this 100-days policy. She talked about the lack of control. Just imagine the lack of control you feel when you don't know where your next paycheck is coming from, when you don't know whether you can make rent, or whether you can pay your utilities. Can you just imagine that lack of control.

Brian: Back to economic inequality.

Dr. Vasan: Exactly, right. If we're not making those tie-ins with those really important core public policy debates, and our short and long-term epidemics of mental health and ill health, then we are missing an opportunity to really take into account the needs of today's generation and future generations, and how we structure our society.

Brian: Then let me ask you one last question, which I think off the content of your report for Biden's first 100 days, before we run out of time, do you have an opinion about degrees of economic lockdown in the context of your thinking about economic inequality? Because we see such a variety of policies in different states, but lots of COVID everywhere. In a way the reopening argument that conservatives make intersects with your class-based lens on the pandemic.

They say professional class people can work from home and call for maximum safety, no skin off their backs. More working class people and small business owners are the ones who get socked with mass layoffs. Is this a complex question for you in equity terms or not so much?

Dr. Vasan: It's definitely a complex question, but it's a much harder question to solve when you've got no federal leadership. For the first 12 months or 10 months of this pandemic, really 12 months, since before we knew it was actually here, we haven't had a coordinated federal policy of relief and support to states, to businesses, to families, to individuals. It's been all very slipshod and heterogeneous.

I think we've talked about this at length on the show before, and this is the one time, when you have a mass casualty event, a pandemic, you can't have a decentralized approach. We do so many things in this country that are decentralized, left up to states. This is one of those rare events where, no, you need strong, coordinated federal leadership. You need to pay people to stay home, you need to pay people to avoid congregate settings, but you need to provide them with the economic relief and social relief that they need to ensure that they can do so safely, and do so without threat to their family and their livelihood, and their ability to sustain through this difficult time.

The lack of that, the lack of those policies, the decentralization of the approach has left states to decide this on their own, and of course, unsurprisingly, has left a whole bunch of people aside, has cast a whole bunch of people aside. You see, not only those inequities by job category, by sector of the economy, but you see it different in different states that have some have chosen to make stronger relief, to offer stronger relief than others.

It is tricky from a public policy standpoint, but it's made all the more tricky without any central or coordinated leadership. Thankfully, I hope we're emerging into a different time, but that's still 10 months, almost a year of effects that we're going to be digging out from underneath for years to come.

Brian: Dr. Ashwin Vasan is CEO of the mental health network, Fountain House, and now the author of A 100 Days Mental Health Agenda for the Biden Administration. Thanks so much for joining us.

Dr. Vasan: Appreciate it, Brian. Thank you so much.

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