Ashwin Vasan, MD, PhD, is a primary care physician, epidemiologist, and public health expert dedicated to improving physical and mental health, social welfare, and public policy for marginalized communities. Early in his career, he worked with the nonprofit Partners in Health and the World Health Organization, focusing on combating the spread of HIV/AIDS in the U.S., Rwanda, Lesotho and Uganda.
In 2021, Dr. Vasan was appointed commissioner of the New York City Department of Health and Mental Hygiene. When we spoke with him at HLTH 2024 in Las Vegas, he had recently stepped down from this role. Our conversation covered his career achievements, his efforts to address the mental health crisis among children and youth in New York City, and his leadership in tackling the COVID-19 Omicron variant in the nation’s most densely populated city.
See this podcast on the Nemours YouTube channel!
Guest:
Ashwin Vasan MD, PhD, primary care physician, former Commissioner, New York City Department of Health and Mental Hygiene
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer:
Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast produced by Nemours Children’s Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.
Carol Vassar, host/producer:
Each week, we’re joined by innovators and experts from around the world exploring anything and everything related to the 80% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar, and now that you are here, let’s go.
MUSIC:
Let’s go, oh, oh, Well Beyond Medicine.
Carol Vassar, host/producer:
Dr. Ashwin Vasan is a primary care physician, epidemiologist, and public health expert who has spent his career working to improve physical and mental health, social welfare, and public policy for marginalized populations. Early in his career, he worked at both the nonprofit Partners in Health and the World Health Organization, fighting the spread of HIV AIDS in the U.S., Rwanda, Lesotho, and Uganda.
In 2021, he was appointed commissioner of the New York City Department of Health and Mental Hygiene. It’s a role he had just left when we met up with him at Health 2024 in Las Vegas to talk about his career, the inroads he’s made in the mental health crisis affecting children and youth in New York City, and fighting the COVID-19 Omicron virus in the nation’s most densely populated city. Which got our team to thinking, “What inspires a man to such heights?” It turns out for Dr. Vasan, his passion for health and public health comes from a healthcare hero right in his own family.
Ashwin Vasan, MD, PhD:
My mother is, in many ways, my healthcare hero, and watching her career has been a massive influence on my trajectory. She came from south India, Chennai, also known as Madras, and came from a family where women didn’t go to college at a time when women didn’t go to college regularly. She was born in 1940, and so we’re talking about the late 50s into the 60s. So, was on a path to get married and join another family, and education was paramount for my grandfather, her father, but not necessarily for this other family. And, thankfully, she was able to take a different path where she was allowed to pursue her dreams to study. She studied botany first and then went to medical school and went to the top medical school for girls in India and graduated at the top of her class, then started OB-GYN residency in India and then moved to England in the mid-60s.
And at the time, it was very clear that career opportunities were not there, not only for immigrants but also for women in medicine, and it was clear to her that she was going to hit a glass ceiling and also an immigrant ceiling. And so, in 1970, they came to the U.S., and, she, by that time, had switched her discipline to pediatrics and to neonatology. And what I got to see as a kid was her serving low-income communities, vulnerable communities, the same way that she would treat anyone else. And she had a very diverse mix of patients at her hospital. She practiced mainly at Rush University but also at others around the city. And that had a huge imprint on me, just the fact that she treated everyone the same, and you know, you don’t really understand what that means when you’re a child. But also what left an impression on me was just her dignity and how important she felt patient care was.
She spent her whole life trying to rescue these premature babies, and I got to spend time with her in the hospital and in the NICU, shadowing her, just walking around largely because of childcare issues and she needed to bring me in, but also to show me what it looked like. Not only did she provide just the best and warmest care to families at their gravest hour when they’re at risk of losing their precious babies, but followed those babies until age five.
And each year, we would get these Christmas cards to watch the babies grow into kids. It was such an inspiring thing to see our mantle place, our fireplace. We had strings of Christmas cards every year. And it was just remarkable to see what an impact she had on so many lives to the point where I wasn’t even sure I should go into medicine because-
Carol Vassar, host/producer:
Live up.
Ashwin Vasan, MD, PhD:
… I didn’t think I could live up to that up.
Carol Vassar, host/producer:
Yeah.
Ashwin Vasan, MD, PhD:
But I did, thankfully, and that ethos, that ethic of really equity and service, things that leave an imprint on you at time, but you don’t really know until later, that has really carried with me as I do my role.
Carol Vassar, host/producer:
I’m impressed when I hear this story because the next generation, yourself, you went into global health. You spent 10 years working on global health issues such as HIV, equity, diversity. You did so in Rwanda and Uganda. Tell us how the work you did there shaped the experiences in your career moving forward and were shaped possibly by your childhood experience.
Ashwin Vasan, MD, PhD:
Well, so much as I saw my mother treat everyone the same. She practiced on the west side of Chicago in a pretty challenging area of the city with a lot of inequity and a lot of poverty nearby, and then we got to go home to our relatively safe and comfortable suburban life. The same was true for my family. We would travel to India and see the same conditions that family members had here, like diabetes, for instance. My mother developed gestational diabetes with me and has never had an issue. Has been well-controlled, mostly diet-controlled, minimal medication. She’s totally fine, never had an issue. I have similar family members in India with gestational and other forms of diabetes who have kidney failure and losing eyesight, and you see these differences, and you wonder why does it have to be that way. But part of the insecurity of not knowing if I could live up to my mom also drew me towards bigger-picture issues.
I studied economics going into college and completed a degree in economics with a focus on development. And thought I was going to go work at the World Bank because I was interested in these inequities, and I was interested in why certain societies were just set up in different ways and what we could do in the U.S., in particular, to help. But I discovered public health late in my undergraduate career, and for me, it was the perfect marriage of the study of these large-scale forces, economic forces, social forces, and how they converge on the lives of people and their health.
So, for me, it was a marrying of my desire to go into medicine and study health and focus on that, but also stay bigger picture. And I was coming up around the time when global HIV was the last pandemic, the really salient public health issue of our time, and I was just captured by that work and the work of global health practitioners and activists and nonprofits and the UN to do our best to get people in the developing world, access to the kind of care and treatment and medications that were more readily available in the United States and Western Europe and so forth.
So, that’s what I dedicated a better part of 10 years of my career to was trying to use the relative resources and skills and organizations that I worked for to try to affect change where I felt it was needed the most and where we felt it was needed the most and probably the most salient part of that was the 3 by 5 Project that I worked on, which was an effort to get 3 million people on treatment by the end of 2005, from a starting point of around less than 400,000 people who were on HIV treatment.
In the beginning, we were laughed out of that room, and my mentors were kind of thought to be a little bit unrealistic to say it kindly. But what happened was that ambitious goal-setting really galvanized the world. The UN, nation-states, ministries of health all came up with plans to try to increase access. It unlocked massive funding in the form of the global fund to fight AIDS, TB, and malaria, and then later PEPFAR from the U.S. government. And so coming together in this big global movement to save as many lives as possible, that to me was just such a beautiful expression of solidarity, of ambition, and the best of what we can do when we pull ourselves together to fight to save lives.
Carol Vassar, host/producer:
What I’m hearing is have audacious goals and collaboration on the ground. Does that sum it up?
Ashwin Vasan, MD, PhD:
Yes. I think health is very much a team sport, and you need everyone playing their role. But if you don’t have goal setting and you don’t have a game plan, then it’s hard to know. You can’t act like a team. Because there are lots of different perspectives that you need to take into account, but when you set out an audacious goal, even if you fail, you fail forward, you fail trying, and you fail in unison rather than in the kind of disparate and often chaotic way that we operate when we don’t have those goals. I mean, we’re at this conference. It’s largely a technology and private sector-focused health conference, and I’m glad to be here learning a lot, meeting a lot of great people. But it’s an embodiment of the fact that our healthcare systems are so fragmented and that there aren’t really unifying goals that are driving everyone in the same direction, and that demands leadership.
Carol Vassar, host/producer:
Let’s talk about your leadership in New York City. What are you most proud of of the initiatives that you have undertaken during your time in New York City?
Ashwin Vasan, MD, PhD:
Yeah, so it’s been three years of just incredible work by my team, and I’m just so proud to have had this role. It’s really the dream of a lifetime. It’s probably the best job in public health I can think of. I came in at a time when Omicron was the variant raging. We had tens of thousands of cases recorded a day, but it was clear that something had changed in the virus, and we could start to maybe see a light at the end of the tunnel. Transitioning out of that then, we were hit by the Mpox outbreak where New York City was the epicenter, and then successive kind of waves of health challenges, whether it was the health needs of new asylum seekers and migrants or we had our first case of polio in more than a decade in New York and trying to ramp up vaccination rates.
So, we were dealing with the projects of the day and the challenges of the day. All the while, what I’m really most proud of is that we plugged in the GPS coordinates for a health agenda for the future called Healthy NYC, which is focused on extending life expectancy to its highest-ever level in a time when we’ve lost life expectancy due to COVID and many other reasons, many other causes, and also improving health spans along the way. And we managed to not only lay out an ambitious agenda with measurable numerical goals to reduce premature death and mortality rates and risk rates but also we managed to get that passed into local law so that every year we have to report back and every five years we have to go back into our data and say, “Are these the right goals?” And that means it’ll live out long after me and long after any administration.
We’ll keep planning in this unified concerto with bringing public, private, nonprofit, and philanthropic pillars of our civic infrastructure together. I’m really proud of that. I’m also proud of the way we stood up to the pressing health issues of the day. We strengthened data privacy to protect patients in the event that legal challenges from restrictive states and from other illegal actors can protect their health data against those potential attacks. We addressed underlying crises of affordability. We’re in the process of clearing $2 billion of medical debt for 500,000 low-income families across the next three years, and we got that process underway and launched that initiative. We launched an office of healthcare accountability, which is promoting price transparency in healthcare, so that… There’s this phrase in New York. There was a guy who ran for mayor. It says, “The rent’s too damn high.” Well, healthcare’s too damn expensive in New York, and all across this country, and sunshine sometimes is the best disinfectant, best medicine.
So these are just some examples. We launched fantastic maternal health programs like our Citywide Doula Initiative. And perhaps the thing that’s most meaningful to me personally is our mental health work. We focused on youth mental health, launching NYC Teenspace, which is a virtual front door to our mental health system for all New York City’s teens free of charge. In its first year, we’ll have enrolled about 20,000 New Yorkers into licensed therapy and a gateway to higher levels of care if needed. We expanded care for people with serious mental illness and overdoses and, for the first time, announced that our overdoses are bending down. Small. 1% drop.
Carol Vassar, host/producer:
That’s the right direction, though.
Ashwin Vasan, MD, PhD:
But it’s the right direction and the first time in years, and it’s the green shoots of progress. So I’m very proud of so many things, and we did a lot. And it’s because we instead of… My team was really beaten down when I arrived after two years of COVID being on the front lines. We had a one-third vacancy rate. We reduced that down over three years to less than 10%. Morale was low. And every instinct said, for many of them, “Let’s just pause and hunker down and take care of each other.”
But what we realized is that actually, if we push and push hard, we can reconnect people with the mission and why they come every single day to be the best public health workers in the country in the best city in the country, if I can say so, because they care. There’s deep mission-oriented people there. So, even though I’ve left, I feel very confident in the leadership and the 7,000 staff of my department who wake up every day to serve people.
Carol Vassar, host/producer:
You talk about pushing hard in all of these areas. What were some of the barriers you faced and you had to push through or go over or go under?
Ashwin Vasan, MD, PhD:
Yeah, I mean, I’m certainly a big fan of asking for permission later. But we faced an environment of real fiscal contraction coming out of COVID. We had expiry of massive amounts of federal funding, emergency funding. We built programs using those emergency funds that we want to stick around. We don’t want them to just disappear. And yet, who is going to fund them? Right? Where’s the money coming from? So, we had to get creative. We had to really think creatively, especially in an environment where, in New York, the budget wasn’t growing. In fact, we had to sort of get it under control after the pandemic and after the emergency. So, very challenging resourcing environments.
As I said, staffing and morale was very tough, but investing in people and getting those folks back to work and back to their mission was really, I think, a positive benefit. So, initially, a barrier that we then overcame. Frankly, a lot of mistrust, and disinformation, and misinformation still abides. When I arrived, within weeks of starting, we pulled down the mandates and left a few restrictions on until vaccination was available. Just weeks later-
Carol Vassar, host/producer:
You’re talking about COVID?
Ashwin Vasan, MD, PhD:
COVID, yeah, yeah. And man, I had protesters at my home.
Carol Vassar, host/producer:
Oh, my.
Ashwin Vasan, MD, PhD:
I had to get restraining orders on people all because I think for two years they had been so afraid, pent-up so much of their anger and trauma, and then they found someone they could direct it at. And look, I’m not unique there. Public health officials all across this country faced things even worse than that, death threats and other things. But it was definitely challenging personally, but also challenging fiscally and operationally.
Carol Vassar, host/producer:
New York, it’s almost obvious to say, is a very diverse city, and as we look at the diversity of New York, very significant health disparities exist there. How did you and your team work on that during your time as commissioner?
Ashwin Vasan, MD, PhD:
Well, our health agenda, Healthy NYC, doesn’t happen unless you focus on closing inequities because we will not reach our life expectancy goals or reach those mortality goals unless we center the needs of people who… Premature death, people who are dying below the age of 65. And when you look at the data, clearly and systematically, it’s consistently black and Latino and other New Yorkers of color that are dying below the age of 65 at disproportionate rates to their white counterparts. So, it’s not an either-or equity or not equity. It’s equity is foundational to the overall strategy to lift the entire city. And that’s true for this country as well.
Equity is not a byproduct or a side project. It’s foundational. We have such vast disparities. Whether those inequities are by race or by wealth or by rural-urban, we need to really center equity in the future. In our city, that meant putting resources into exactly the neighborhoods and the zip codes where we knew we could have the biggest difference, make the biggest difference on premature death, premature mortality, premature disease, and, as you might imagine, given the sort of legacy, policy, and structural inequity and racism, those went to communities that are predominantly Black and brown in New York City. So, we use data to really push forward an equity approach as foundational to lifting the entire city rather than as an either-or.
Carol Vassar, host/producer:
As we sit here at a health innovation conference, have you been able to, or were you able to leverage some of the technology, especially AI, to help analyze and implement that data to bring about closer to equity or to bring about life-saving changes from a public health perspective?
Ashwin Vasan, MD, PhD:
Absolutely. And another thing I’m proud of is the work we did in data modernization. During COVID, in New York, like many places, our website was the place everyone went to every morning to check what’s going on with the pandemic and to maybe make even decisions about what they were going to do. “Am I going to go out that day? Do I need to wear a mask? Am I just going to stay home? How scared am I? Am I fearful? Should my family come over? Should I do a gathering? Are cases rising?” So on and so forth.
On the front end, that looked really nice for New Yorkers and anyone else visiting the website. On the back end, it was scotch tape and string and seven-day work weeks and 20-hour work days and thousands of analysts diverting attention from their daily work into manipulating data and getting it to work in this kind of antiquated, retrograde system that public health has for using data. That’s just unsustainable. It led to high rates of burnout, mental health issues amongst staff. So we said, “Look, we need to focus on data modernization,” and the CDC put out some initial funds, but we pumped a lot more-
Carol Vassar, host/producer:
You went all in.
Ashwin Vasan, MD, PhD:
Turn the temperature up on that. We went all in, and we built something that we call the Center for Population Health Data Science, bringing in technology, informatics, and really learning from the private sector as well about best practices in building a centralized data ingestion engine, data lake, centralized analytics, automated analytics, and leveraging the tools of AI to bridge gaps between the massive amounts of data we have and the understanding that it builds to drive our planning, to drive our resourcing, to drive action. We’re about a year plus into that journey, and already, we’re starting to see really important changes.
As you can imagine, it’s a massive shift in data culture, data governance, even staffing, and that’s going to take years to build, but I’m proud to have put the first stakes in the ground. And to your point about equity, only when you have a single point of truth and a very clear sense of the inequities at a more granular level can you drive the resources exactly where they need to go into the interventions that’ll make the biggest difference.
Carol Vassar, host/producer:
As we look at New York City, which was, if we go back to the 80s and 90s, highly impacted by HIV AIDS and then COVID-19 in 2020 through 2023, and even today, do you think that the city is ready for the next major epidemic or public health concern?
Ashwin Vasan, MD, PhD:
I think we are as ready as ever, and we’re on our way to establishing the kind of systems, the data and having a resilient workforce capable of standing up to whatever comes. But we still have more work to do. One of the things that hampered public health departments all across this country was just speed, speed of getting money out the door, contracting, managing supply chains, making sure that we had all the tests and supplies we needed. And what we’re doing now is really developing a readiness capability based on administrative preparedness and getting those contracts in place so that we can just jump as soon as things happen. It sounds unsexy, but it is the act of manipulating government in the direction you need fast in an emergency.
As I said, investing in our workforce. We need our workforce to be resilient and well cared for and well paid, well-supported, so that they can manage crises when they come and not get burned out, not leave the field. But I think the work we’re doing in peacetime to close equity gaps, to invest in the communities hardest hit by COVID and many other parallel pandemics, is the work of building a foundation of health that will protect us from the next pandemic. During Omicron, for instance, we saw a two-to-one ratio in black-to-white hospitalization. A lot of that is due to underlying health status as well as vaccination rates and other things.
So, how can we improve those things in peacetime so that the next time there’s a war on another pathogen, we can be healthier at baseline? And so those are amongst the steps. I think the data work will help us make decisions faster with clear insights. And it’s complemented by work that the CDC’s doing and the federal government’s doing to ensure that we’ve got the funding we need, which makes me very worried, for instance, that Congress is trying to cut the budget of the CDC at a time when we’re vulnerable, but also that they’re working on things like laboratory capacity. We all remember the early days when we couldn’t get tested, and we couldn’t scale up testing fast enough.
Well, I do think that the White House, HHS, and CDC are making some really important steps to ensure that those lags are nowhere near what they were in 2020. And so we are, I think, learning the lessons. The last thing I’ll say is now is not the time to be cutting public health infrastructure and resources. Now is the time to be doubling down and improving and strengthening those systems because this is a national security issue too. Right? This is a Democratic issue, too. If we start to see widely divergent outcomes by red or blue states or by threats from new pandemics or even bioweapons, which are the growing security threat of the time, there are bigger things at stake. Right? Not only people’s lives, but The American Project.
And so we’ve got to invest into public health now, not divest or divert attention, and here at Health, it’s good to be here in part because what we learned during COVID is that the private sector is a huge role to play, a huge role to play, and bringing them into partnership early instead of having to build those partnerships on the fly as we did during COVID, will help us for readiness next time.
Carol Vassar, host/producer:
We’re a pediatric podcast. I have asked very little about the children of the city of New York. But you have children. You live in the city of New York. As you look at your children, do you feel that the public health structure is in a good enough and a strong enough framework to benefit them long-term? Not only your children but all the children of New York?
Ashwin Vasan, MD, PhD:
Well, two things worry me about our children’s health, which we are working to remedy, but is going to take all of us, not just one department or one commissioner. One is routine child health and the kind of decrements we’ve seen in routine child immunizations, routine health screenings in children going down. That’s still a lingering hangover from the pandemic that we need to really address. We need to get at the core of what’s preventing them from getting their child immunized and protected and cared for in the ways that we have become so accustomed to and are the reason that in the past we’ve relegated these diseases to the past and now they’re coming back, things like measles and so forth.
Number two is mental health. Our kids are most definitely hurting. We’re starting to not only see rising rates of things like depression and anxiety and suicidality in teens, and particularly teen girls, we’re starting to see that march out into younger and younger age groups. One of the priorities I didn’t mention, but I’m very proud of, is the focus we put on social media as a public health toxin, as a public health crisis. We did just about everything that a local jurisdiction can do. We declared it a public health emergency. We conducted great research, unique research that only a city can do.
We surveyed 20,000 families on the relationships, their patterns of use, and the relationships between that use and mental health. We did trainings and put up guidance for parents, for teachers, for the young people themselves. And we launched a lawsuit against the four largest social media companies. And we’re in the process of exploring through research whether we should be removing phones from schools next year. So, that’s about all we can do at a city level.
Ultimately, we will need the federal government. We’ll need Congress to step up and regulate social media and put some guardrails in. We’re not saying get rid of it. We’re saying make it safer, make it safer. It’s like seatbelts. No one said, “Get rid of the cars or get rid of the highways, but put seatbelts in that make it safer so we can avoid these preventable tragedies.” And that’s what’s happening. So, I worry a little bit about our children’s health in this environment of health misinformation and social media as a public health threat. But we have, by stepping up in this way as a city, I think we are making that clear and present for parents and providing them with as many tools as possible to make healthy decisions for their kids.
Carol Vassar, host/producer::
Dr. Ashwin Vasan, thank you so much for joining us on the Well Beyond Medicine podcast.
Ashwin Vasan, MD, PhD:
Thank you so much for having me.
Carol Vassar, host/producer:
Dr. Ashwin Vasan served as the Commissioner for the New York City Department of Health and Mental Hygiene from 2021 to 2024. He is currently on the faculty at the Columbia University Mailman School of Public Health and continues to see patients as a primary care internist.
MUSIC:
Well Beyond Medicine.
Carol Vassar, host/producer:
Thanks to Dr. Vasan for joining us in Las Vegas at HLTH 2024 for the Nemours Well Beyond Medicine podcast. And thanks as always to you for listening. The leaders of health and public health and what they’re doing to affect positive change for children and families across the world, just one aspect of what we cover on the Nemours Well Beyond Medicine podcast. Have an idea for an upcoming episode? We are all ears. Visit our website, nemourswellbeyond.org, and leave us a voicemail. You can also go there to catch up on past episodes you may have missed. That’s nemourswellbeyond.org.
Our production team for this episode includes Cheryl Munn, Susan Masucci, Lauren Tata, and Sebastian Riella. Join us next time for an update on all things electronic health records and artificial intelligence from the federal head of the Office of the National Coordinator for Health Information Technology. I’m Carol Vassar, and until next time, remember, we can change children’s health for good, well beyond medicine.
MUSIC:
Let’s go, oh, oh, Well Beyond Medicine.
