Fifteen months ago, Dr. Ashwin Vasan took the helm as Commissioner of the Department of Health and Mental Hygiene for the nation’s largest city, with a budget of $1.9 billion and more than 6,000 employees. When he was tapped for the position by Mayor Eric Adams, Vasan announced that “fixing our broken mental health system” would be his top priority – after stopping the spread of Covid-19.

Vasan, an MD and epidemiologist, came to the agency after two years as president and CEO of Fountain House, a 75-year-old New York-based nonprofit that pioneered “social practice” – efforts to reduce loneliness and economic isolation for people with serious mental illness by creating “clubhouses” where they can connect with peers, develop their skills and seek employment.

This is his second stint at the city’s health department. From 2016 to 2019, he directed the Health Access Equity Unit focused on the intersection of health, clinical systems and social welfare of marginalized populations.

We spoke in the 6th floor conference room at the agency’s headquarters in Queens, where large windows offered dramatic views of the city’s skyline. The interview has been edited for length and clarity.

Rob Waters: In terms of mental health this is both a fraught time for New York City and a moment with a lot of opportunity. On the one hand, you have a public mental health crisis playing out publicly – large numbers of seriously mentally ill folks on the streets and the killing of subway performer Jordan Neely. On the other hand, you have more federal and state dollars going into mental health than ever. As health commissioner, how do you see this moment? What course do you want to set the city on in terms of mental health policy?

Ashwin Vasan: From the moment I came in, I’ve been focused on centering mental health in the public health agenda, not keeping it siloed or separate, but bringing it into the center of our discussion around how to make this city healthy, especially coming out of the worst public health crisis in a century. What we’re dealing with in mental health is a second pandemic. 

When I think about setting us on a better course, I think about a couple of things. One, emphasizing a public health approach. Too often, the conversation around mental health focuses on access to care. By the time you need care, you’ve had a number of drivers worsen your mental health. How do we balance the conversation around the social determinants of mental health in a more comprehensive public health approach, which means emphasizing prevention as well as intervention and care? 

We need to start looking at mental health as a cross-cutting issue that often manifests in conditions or causes of death we would otherwise not refer to as mental health. We have to see it almost in the groundwater.” 

Two, centering equity in our mental health agenda. As a child of immigrants, my family faced mental health challenges. The language of mental health was alien to my family and culture. We won’t be able to recover and improve mental health unless we meet the mental health needs of this diverse city that has deeply embedded structural inequity. I don’t often see equity and mental health centered in planning.  

Lastly, looking at the ways mental health connects to other health challenges. We’re in the midst of the largest drop of life expectancy that we’ve faced as a city and country in a century. COVID, obviously, is one explanation. But there are many other reasons – overdoses, rising rates of chronic illness, premature deaths from birth inequities, increased rates of violence, suicide. All these link to mental health, either directly, like overdoses, or indirectly. We need to start looking at mental health as a cross-cutting issue that often manifests in conditions or causes of death we would otherwise not refer to as mental health. We have to see it almost in the groundwater. 

This agency and this city is going to launch an initiative to take back those years of life expectancy, identifying the main drivers and causes of death, and putting together plans to course-correct. And mental health is present through all of the principal drivers.

As you pointed out, mental health links to all these other issues. So in order to succeed, you have to have  buy-in from multiple agencies. In terms of this broad public health agenda, who’s driving the train, and how do you see The City, the mayor, the bureaucracy generally collaborating and/or conflicting?

Part of the reason I became commissioner and agreed to work under Mayor Adams was because I knew he was going to center mental health in the city’s recovery. And that he really understood the basics of public health and the need to balance upstream and downstream prevention and intervention. The health department and I as Commissioner have very much been the health strategists for the city, laying out a comprehensive strategy for mental health. The mental health plan that we released in March was the product of this agency’s leadership, and of organizing other agencies in alignment with what the city needs and the mayor wants. I’m proud that we’re back in that seat. 

They call me the city’s doctor. I have 8.8 million patients. That means I have to see the whole field; I can’t think about institutional interests. I have to think about communities and the entire city, and aligning what on the surface might feel like disparate interests behind a common agenda. The only way to do that is to have clear goals, measurable goals, ambitious goals – even if they’re not hit or attained – that drive conditional alignment and common work. 

Every time we see someone on the street, suffering with untreated or undertreated mental illness, it’s a systems failure.”

In terms of the mental health crisis on the streets – homelessness linked with serious mental illness – the mayor’s plan is built, in part, on forcing more people to be taken to hospitals for evaluation. But what happens next, considering the lack of capacity for both ongoing treatment and, more importantly, for housing?  How does getting evaluated solve the problem?

Let’s start with the truth that this system is broken, and that every time we see someone on the street, suffering with untreated or undertreated mental illness, it’s a systems failure. There are a host of failures upstream in our clinical delivery system, in our community systems, in our housing systems. The mayor has said that is a collective failure. But one thing we can’t do is take our eye off the person in front of us. In this city and in cities across this country, it’s become all too common for us to just walk past people in crisis. Because we feel paralyzed, we feel like we don’t know what to do. 

Who do we call for help? We’re afraid to call law enforcement but we don’t know if there are alternatives. Where do our mental health hotlines leave us? The average citizen feels helpless and like that’s not the quality of life I want to see for that person or in my community. We find ourselves in this paralysis and we never really get to the root of the issue. The mayor has said that city and city workers are no longer going to walk away from people in crisis. The goal is to make sure that everyone voluntarily decides to leave the street or the subway or encampment. But in a small fraction of cases, if they don’t agree, voluntarily, we’re not going to just walk away. Instead: Engage, engage, engage. Build trust. Determine insight. Determine need. Determine acuity. And in a small set of subset of cases, get a person to the help that they need. And sometimes that’s in a hospital.  

But you rightly raised that once they arrive at the hospital, there’s a whole set of conditions that push people back to the streets. And that is down to financial incentives. That’s down to training and culture. The for-profit health care systems that we’ve built in this country have to start creating space for caring for the most vulnerable, indigent people with complex medical and social needs. Mental health is at the center of that. I’m proud we’re unpacking it. But it’s not clean. There’s no perfect set of interventions that will somehow change the system – we’re talking about decades of structural neglect, disinvestment and stigma infecting our policies around serious mental illness. That’s not going to change overnight. but we’re making progress. I know people want to focus on the conversation around removals, whether they be voluntary or involuntary. That’s a fair set of questions. My goal is zero people with unmet mental health needs living on the street. That’s where I try to keep in my focus.

Photo: Rob Waters

And what about the housing piece? If you can’t address housing, it’s hard to keep people stable. 

We have an affordable housing crisis in our city. We just don’t have enough affordable units. One of the things I’m proud of in this administration is we understand how the system works. We’re not pumping unrealistic amounts of city dollars into systems that are highly dependent on state and federal laws. To that end, when the governor announced $1 billion for investment into a continuum of care, primarily focused on people with SMI, $900 million of that is towards supportive housing. So that’s a great start. Recently, the mayor removed the 90-day rule for shelter. Before that, you had to be in shelter for 90 days before you could transition into housing. We’re making progress. But there’s a lot to unpack in the way we do housing in this city, this state, and this country. We piloted “housing first” here — “street to home” is the name of the pilot, it’s essentially a housing first model. I know as a clinician, it’s impossible for my patients to recover, to have a fighting chance for rehabilitation or stability, without a roof over their head. And a roof doesn’t necessarily mean a congregate shelter. It means a place of their own to stabilize.

You mentioned crisis response efforts. Around the country, there are these growing alternative crisis response efforts. But the New York effort, B-HEARD, seems to be ramping up slowly and handling just a fraction of the calls that police are handling through 911. Where do you want to see that go, and how do you get it there?

We all are inspired by the CAHOOTS program in Eugene and programs in other jurisdictions. Law enforcement officials, including the NYPD, want mental health professionals as much as possible to be leading on these issues. It’s a process, it’s about unwinding old systems. This city is going to transition in the coming weeks towards exclusive use of 988. NYC Well will glide-path out and 988 will be the exclusive line. Hopefully over time it will become the destination for people to call immediately. 

Are you going to ramp up a communications effort to publicize 988?

Correct. We’ve been working on the back end with Vibrant and others to streamline behind the scenes. It’s going to be relatively seamless for the end user. But we need to create that default link for people to say, who do I call for help? How do I get them a health first response? This is a workforce issue. Where are the social workers and mental health clinicians? People act as if there’s a pool of them sitting around doing nothing who could be on the streets. That is not my experience or what the data tell us. This needs to link to workforce development. How do you create incentives to draw people into this most difficult work, where you’re in the field, making immediate judgments? We have a pipeline issue. 

Yes, we do. It takes a long time to train new clinical social workers. But you can train community health workers, you can train peers, which is what CAHOOTS does. The city uses community health workers…

And we use peers…

So do you see a big expansion of that coming? 

I see that as a direction to move. The timing, we’re in discussion. But I certainly see the incorporation of peers into our B-HEARD teams as the future. 

It’s a 5-alarm fire. We’re losing a New Yorker every three hours to overdose. We need all hands on deck.”

Two other things I’d like to talk about — youth mental health and substance use disorder. On substance use, the South Bronx remains the epicenter of opioid overdoses in this country. How do you want to address that more aggressively? I heard recently that at Lincoln Hospital, patients treated for addiction have to go a mile away for their mental health counseling, because the two aren’t integrated. 

It’s a 5-alarm fire. If it wasn’t for COVID, this would be everyone’s top-of-mind public health crisis. We’re losing a New Yorker every three hours to overdose. Fentanyl is leading to a rising tide of dependence and unexpected overdoses. Xylazine is complicating matters even further. And it’s all driven by underlying mental health concerns, social and economic strife and need, and structural inequities. We’re behind the 8-ball as a city and a country. We set an ambitious goal to reduce overdose deaths by 15%. The only way to do that is all hands on deck. That means an entire continuum of services including supervised consumption and other harm-reduction techniques.  We launched public health vending machines last week because we recognize that people are going to continue to use, and they need to be able to do so safely. We need to bring that out of the shadows where most people are dying and normalize both the service and the conversation. Our supervised consumption sites are overdose prevention centers. They have intervened in hundreds, probably close to 1,000 overdoses that had a high chance of fatality. They haven’t had to call 911. There have been no fatalities. And you’re doing it in a site that’s surrounded by mental health care, primary care, basic needs like food and social supports and benefits and temporary shelter and the chance to stabilize. Bringing that out of the shadows is crucial. 

But it also requires mass distribution of naloxone, we’re ramping up our efforts to get naloxone everywhere and anywhere, increasing our efforts around non-fatal overdose response in our hospitals, expanding our Relay program throughout all emergency rooms in the city. (Note: The Relay program offers peer support to people who survive a drug overdose in an effort to prevent future overdoses.) And then all the way down to treatment. We need primary care providers to start using MAT – Suboxone, buprenorphine – much more commonly. Right now, it’s still not acculturated within primary care practice. We have a lot of incentives within healthcare to push the hardest-to-reach patients out. We don’t reimburse well enough for substance use care, MAT included. And for our primary care clinicians, those are amongst the hardest patients to care for, because of the complexity and the need to form trust and relationships. That’s why we’ve seen this proliferation of addiction medicine practices, as well as a shift towards public hospital systems. That can’t go on. This is too big. We need all hospital systems to step in. Anyone who deals with substance use issues needs to step in and make treatment more widespread.  

And what are the carrots and sticks on getting private hospitals and insurers to jump in?

I don’t have all the answers. We have a safety net system that cares for everyone regardless of ability to pay, but where taxpayers and others end up paying for it on the back end through uncompensated care. So long as that exists, we will have this incentive for non-academic medical centers and other hospitals to shift patients to the safety-net system. That has to change. Part of that is about establishing parity, which is why within our mental health plan, we have a policy agenda that starts with parity. New York State is better than most, but it’s not great. And prevention: Do we have an incentive, as a healthcare system to keep people out of hospitals? 

Can we reimburse and pay for prevention? 

That’s the Holy Grail. It’s tough. There are foundational business incentives within our for-profit health care system that make social care, prevention, and population health extremely hard. So, our safety-net system ends up catching a lot of the issues, and it’s very hard for them. It’s going to require federal leadership.

Let’s shift to youth mental health. Everybody is aware of the youth mental health crisis. How do you want to address it here?

The mental health plan that we launched takes a public health approach. One thing that means is focus on the most vulnerable. In the past, there has been disproportionate focus on the worried well – like on awareness and stigma-busting. We’re in the midst of a youth mental health crisis. The statistics are damning: 38% of New York City High School students reported during the pandemic that they felt sad or hopeless for more than two weeks. Suicide rates: up. Suicidal ideation: up. School performance, social isolation – every metric is clear that our kids are hurting. I have three small kids. I’ve seen how the pandemic has impacted them. We need to bring care more care to where kids are – so focus on schools. 

For teenagers, focus on digital health and removing adults as middlemen in kids’ relationship with therapists. We’re creating a digital mental health front door, essentially, on your smartphone so kids can say, “I need help, I’d like to talk to someone.” I don’t want to have a school administrator or parent interfere with that relationship. We’re launching that before the end of the year, and we’ll have something in the hands of over 350,000 New York City high school-age students.  Last week, we hosted a national summit – people and young people from all across the country – focused on social media as a digital toxin, digital tobacco. That’s what public health does well. It identifies environmental exposures and learns the impact of those exposures on health through research and evaluation. Then it develops strategies to mitigate harm through education, harm reduction, stakeholder engagement and awareness or through litigation, regulation, and policy. 

Guns and social media seem to be the two most unregulated sectors in our economy. And we’re playing games with our kids as a result.”

Right now, it’s the Wild West. Guns and social media seem to be the two most unregulated sectors in our economy. And we’re playing games with our kids as a result. As a doctor, as a parent, as the city’s health leader, I don’t think I can allow that. We’ve done this before: tobacco, air quality, water quality, lead paint, this is tried-and-true public health. We’re going to treat it like an environmental toxin and develop an action plan to address it through all of those tools that I mentioned. We’re focused on school-based health care as well. The governor did a good thing by equalizing commercial and Medicaid payments for school-based mental health care. We’d like to see those sites expand. We know that kids might want to start getting care in schools, but ultimately, they need a connection in the community. We’re doing both site-based care as well as telehealth. It’s a start, right? We’re learning as we go, and we’re approaching it with some humility.

Final question: New York City just had this massive toxic air event. Looking at youth surveys, kids are in despair about the future of the planet and the future of their health. And that impacts their mental health. How do you see that issue?

Well, it’s a public health issue. If there was any question mark, last week brought it home to roost for all of us. We ignore that at our own peril, at the planet’s peril, and at the peril of our children and the next generations. We have to continue our work to mitigate harm from extreme weather and air pollution. But we also have to be the loudest voices representing our local communities. Your point is well taken. Young people are saying to us that adults are not doing anything about climate change..

And gun violence…

And gun violence. That’s discouraging. It frustrates and angers them, so youth movements are rising up. Shame on us if we don’t step into the fray here. We’ll continue to be a leader for improving our local climate, but 30% of the PM 2.5 particulate matter that we face comes from industrial pollution coming from the Midwest. The smoke event last week came from thousands of miles away. It’s a global fight. At a time of great division and fragmentation and polarization, we have to have the kind of leadership that pulls us together in a global fight. And that can talk openly and clearly about how this comes to our doorstep day after day and impacts our health and mental health. You used the word despair. I think if I was a young person, I’d be equal parts despair, anger and motivation. But that’s a lot to ask of our kids. We need to step up as adults and do the work they’re asking us to do.

This story was reported and published with support from the van Ameringen Foundation and the Commonwealth Fund.

Type of work:

Rob Waters, the founding editor of MindSite News, is an award-winning health and mental health journalist. He was a contributing writer to Health Affairs and has worked as a staff reporter or editor at...