MR. DIAMOND: Let’s start by focusing on a topic on all of our minds: the winter cold and flu season. There have been three viruses linked to the current surge in cases: flu, covid, RSV. And just last week the CDC announced at least 57 pediatric deaths in this current flu season. Commissioner, are the confirmed cases of these viruses higher than usual this season? And if so, what is driving that trend?
DR. VASAN: Yeah, thanks for the question. The overall rates of disease we’re seeing for these three viruses are not out of proportion from what we’ve seen in previous years, but there’s a couple of things to keep in mind. Number one, our level of testing and surveillance is enhanced. We’re testing more. We have wastewater surveillance to track. Obviously, you’re talking about confirmed cases. That’s particularly important for RSV, which until recent years we didn’t have fast confirmatory testing for RSV, so often severe cases or even deaths that would have probably been attributed to RSV were unclassified as pneumonias or pneumonias not otherwise specified, but we have more advanced testing. So, it’s a combination of things. We are much more vigilant. We’re doing more testing than in pre-pandemic years. And we have better tests than we’ve had in previous years, and so we are capturing more. We’re certainly not capturing as much as we did at the height of the pandemic, but none of what we’re seeing is out of proportion. And the good news is that for all three of these viruses in New York City, like most of the nation, we’re seeing a steady decline in the past weeks.
MR. DIAMOND: You mentioned the awareness that folks have of illness now. One comment I’ve heard frequently is the thought that there are persistent coughs that might not have existed before that. People are coughing for weeks or even for months on end. Is there any truth to that?
DR. VASAN: Yeah, I mean post-viral coughs are a real thing. They’ve always been a real thing, but particularly with these three more severe respiratory viruses, a post-viral cough is not altogether uncommon. In an era where we are much more vigilant around post-viral symptoms, where we are still in the process of unpacking what syndromes encompass things like long covid, what the actual case definition is for that, it’s not a surprise that people are paying more attention. We’re also frankly sharing a lot more information about our symptoms online and through social media. You know, I’ve been asked by a number of reporters about these long coughs. And when I ask them how they’re hearing about it, a lot of it is what they’re picking up on the internet. And that’s all–that’s all a reality of how we live. But post-viral coughs are a real thing. The good news is that if those post-viral coughs are not associated with other symptoms like fever, fatigue, congestion, or other real symptoms of illness, then it’s likely that they’ll get better over time. And it can take some weeks, even up to a month or six weeks. But if they are associated with those lingering systemic symptoms, it’s a good cue to go back to your doctor and get a checkup.
MR. DIAMOND: Can you talk to us a bit about what’s known as immunity debt, the idea that after several years of avoiding viruses it’s now caught up in some way and that is leading to more severe cases for some people?
DR. VASAN: Yeah, it’s a really good question. I think that that hypothesis probably had more validity at a time when we were moving around a lot less, where we were exposing ourselves to viruses a lot less at the height of the pandemic when we were socially isolated, or forced to be, that we weren’t exposing ourselves to the routine season viruses so it may not have been a surprise, particularly last season and then the last two seasons, that we would have seen an uptick. But we’ve been going on two years her in New York and like much of the country we’ve been in a relatively normalized environment where we’ve pulled down restrictions on movement, we’ve pulled down requirements on face protection, and even we’ve pulled down a lot of our mandates around vaccines. And so, you know, that hypothesis doesn’t exactly hold in the same way that it might have in prior years.
But one thing may be true is that, number one, our kids are certainly growing up in a time of increased hygiene and protection against these routine viruses that we–that they might have been more exposed to in the pre-pandemic era; and two, that we know a lot more about the covid vaccines and how they perform. And it’s pretty clear that–and it’s partly why we’re moving to a more annualized vaccine schedule–that we need to update our immunity each year. So much as we do for flu, we will see a waning immunity as we end the viral season and then we need to update it next fall.
The last thing I’ll say is that particularly with shifting climates and shifting seasons, viral season is lasting longer and longer. And so we’re seeing pretty–we’re seeing significant transmission into April, and sometimes even into early May when in the past viral season typically ended pretty clearly year after year in March. And so taking all of those things into account is maybe why we’re seeing some of these shifting patterns. I don’t think immunity debt explains all of it.
MR. DIAMOND: That’s fascinating.
Commissioner, I want to go back to something that you just said about removing the requirement on face coverings. I’d like to go to a question that we received from Lynn in New York, and her question is “Why has New York City not permanently mandated masking in medical settings? With the winter surge infecting millions and a tool in masks that’s proven to prevent transmission, shouldn’t we be doing everything possible to protect vulnerable people?”
DR. VASAN: Well, yeah, we did put–we did bring back our mask mandates in our public hospital system. So, you know, that’s an acute care system with 11 hospitals, 50 ambulatory care sites, and over a million patient visits a year. We did that not only to protect vulnerable patients but to protect our essential frontline healthcare workers. And we’ve seen a number of systems follow suit. And so I think that’s an encouraging sign. We’ve seen the same sort of messaging coming out of New York state, which actually regulates hospitals. So that’s the other thing to keep in mind. New York City doesn’t regulate hospitals directly. That comes out of New York state. But you know, we’re trying to use these tools wisely in a non-emergency time. We are no longer in the public health emergency of covid. We’re in an era of living with these diseases and this disease. And so I think the sensible turning on and off of institutional policies makes a lot of sense.
MR. DIAMOND: You just referenced moving out of the emergency phase around covid. That caused some political consternation on whether we would be in an emergency, whether we should end the emergency. And as a result, we just lived through a pandemic where vaccines were unfortunately politicized. I’m curious what you’re seeing in terms of vaccination levels this winter. Has there been any carryover from some of the anger that was sparked during covid?
DR. VASAN: Yeah, I think more so than anger is just rampant misinformation. And we’re seeing a lot of that play out in our school vaccination rates, our routine school immunizations. While we’re still at high levels, certainly enough to create the kind of herd immunity for routine conditions like measles and like MMR and other key vaccines, polio and otherwise, we are seeing slight decrements. And so my worry is not so much about today. My worry is about the trend. Where are we going to be in five years? Where are we going to be in 10 years if we aren’t able to build back the kind of trust and confidence in this protective wall we’ve created through vaccines, routine childhood vaccines in particular? And so, you know, that is definitely a concern. Misinformation is both rampant but extremely targeted at vulnerable communities that already have some historic mistrust in both government and in institutional public health and their healthcare systems. And so I know our team here is really working thoroughly on community engagement and vaccine engagement, both as we enter and end the respiratory viral season but also as throughout the summer as we start to get parents bringing their kids back into pediatrician visits. And so we’ve done pretty extensive campaigns on these. But I think this is going to be something we’re watching for years to come. And we’d love to see more investment and attention on this from every level of government including the federal level.
MR. DIAMOND: Do you find that it’s harder for your messages to be heard by people now? Are folks more skeptical even of you, the New York City health commissioner, than they might have been before covid?
DR. VASAN: Yes. I mean, the short answer is that I think institutional trust is low. And you know, not only do we need to be saying things over and over and over again. We need to be saying them in a whole host of different fora, because we’re up against an information ecosystem that is moving second to second, minute to minute, and where messages are going viral and disseminating very quickly, where that can lead to genuine questions. We just talked about long-term cough. Those are real genuine questions, but they’re being certainly amplified by what social media platforms are able to do. And frankly, you know, government struggles to keep pace with that kind of information ecosystem. And so I know we’re doing a lot here in New York City to try to revamp our communications apparatus to try to keep up, but also it’s not just about what people in suits and people in positions of leadership say. It’s about the boots on the ground, field workers, epidemiologists, immunizer–you know, field immunizers and nurses and clinicians that we have worked in our communities every single day. That’s the bulwark here. That’s the wall of trust that we need to really build up over time, block to block, conversation to conversation. We’re so proud of programs here like Public Health Corps, which was a program we built during the emergency to basically get federal emergency dollars into the hands of small, local, community-based organizations that hadn’t historically gotten money from the city or the state to do their work. But they were essential in part, for example, in engaging Black and brown communities in New York to get vaccinated, to go get tested and to wear PPE. And over the first eight months of its activity we saw the Black-White vaccination gap close, particularly focused on our public housing. So, you know, we need to do much more of that building up of a foundation of trust through community engagement.
MR. DIAMOND: You’re talking about building trust. There has been much talk recently about tripledemic of viruses–a tripledemic in the winter of covid and flu and RSV. I’m curious, first, do you think that’s a fair and good way to describe all those viruses? And second, does that create more concern by talking about anything now that ends in “demic,” whether it’s a pandemic, tripledemic, and so on?
DR. VASAN: Yeah, it’s certainly catchy and it gets people–gets people’s attention.
MR. DIAMOND: Is it appropriate?
DR. VASAN: Well, you know, an epidemic is anything that is any disease or any conditions that is occurring out of what would be expected as normal. And for covid, I don’t know that we’ve truly defined what normal is. But for flu and for RSV, we kind of have a sense. And so we’re seeing epidemic curves for flu and RSV that are not altogether out of normal from past years. And so I don’t know that that’s an accurate statement to call it a tripledemic.
But what I wanted to say was that, if it gets people paying attention to public health and to their own health and to their health decision making, we need to find a way to take that messaging and convert it into an opportunity to get our messaging across about what are the safe and healthy choices to make as the winter comes.
MR. DIAMOND: We’ve been talking a bit about learning lessons from the pandemic. We do have an audience question that I’d like to go to from Mary in Texas who asks, “What is the most important thing you know now that you wish you had known at the beginning of the pandemic?”
DR. VASAN: Oh, wow, what a great question. Where to start?
MR. DIAMOND: We’ll let Mary ask the rest of the questions today.
DR. VASAN: Yeah, yeah, Mary’s coming for your job, Dan. You know, I think that I would have tried to understand how painful the pandemic was and then as we exited the pandemic or as we exited the worst of it, how much pain might be unleashed in terms of people’s reactions to what they had to go through over the prior two years. I entered this job in early 2022, and after more than, you know, two years of a lot of fear, a lot of uncertainty, a lot of shifting information and shifting science, and a lot of en masse behavioral changes that were required to keep people safe and that I think I couldn’t–I didn’t really appreciate but wish I could have from the beginning kind of understood how–the toll that that took on people. As someone who’s interested in and has been working in mental health for a while, I think I conceptually understood how hard that would be. But in seeing people’s reaction to the post-emergency or the post-worst of covid era, I saw a lot of pain, a lot of anger, a lot of fear. I had protesters coming to my home on a weekly basis for, you know, seven, eight months straight. And I didn’t understand it at first. You know, I didn’t understand what would drive people to act that way and to respond that way. But you know, when you really try to emphasize with others and see how much pain they’re in, I think I underestimated that. And I think that might have–whether it would have led me to make any different decisions, I’m not sure. But, you know, certainly the way you communicate, the humanity with which you communicate, the empathy with which you communicate shifts when you see people as humans first and people of all–we’ve all been through this kind of collective trauma and we’re in–we’re still in this collective hypervigilance and post-trauma state. And part of what worries me is that we want to–we don’t want to talk about it anymore. And that’s not the right way to heal from trauma. The right way to heal from trauma is to address it head on and to work your way through it, and I don’t think we’re really doing that as a society yet.
MR. DIAMOND: You’re talking about the traumatic experience of the pandemic. And New York City was at the epicenter, especially at the beginning in 2020, of America’s outbreak. More recently, New York City was the epicenter of mpox, the outbreak that happened several years ago. What is the long-term consequence in New York, Commissioner? Are New Yorkers more sensitive now to outbreaks of illness? Is there a wariness that might not have existed before?
DR. VASAN: I think New Yorkers have always been a little maybe more switched on about their health and about public health than maybe other parts of the country. We have the largest, you know, local public health department in the country. We spend more per capita on public health than any other jurisdiction in the country. It’s always been a priority. And people know the work of the New York City Health Department as really vanguard in keeping them safe, whether it’s tobacco control, the work we’ve done on nutrition, the work we’ve done in the past on TB and HIV. So I think we’ve had a highly engaged and highly activated community even prior to the pandemic.
I think what the challenge now is that even, whether they be new health challenges or old ones, the covid lens is the filter through which people are still seeing a lot of the work of public health and healthcare. And we have to start to find a barometer that more accurately reflects the challenges we face, and covid isn’t the litmus test for everything, right? It was in some ways a sui generis unique challenge that we faced, certainly first time in a century and hopefully we won’t have to face something like it again for a very long time, if ever. But you know, it has become the lens. And that was certainly true of mpox. Mpox came in such short succession from the worst of covid that the expectations that covid had created around public messaging, data, communications, the politicization of our work in public health, that was all used in some measure to kind of interpret the response to mpox. But the devil’s in the data, and the data is clear that for something like mpox we–you know, whatever the challenge is, we managed to bend that epidemic curve in a matter of weeks and through a mass vaccination campaign that was both the largest and the first in the country. And so I hope that over time we’ll begin to widen our aperture again and not see every public health problem through the lens of covid, but that’s not going to happen if we pretend covid didn’t exist and we don’t try to kind of move forward together.
MR. DIAMOND: Let’s move off covid, and I’m picking up a throughline in many of your comments about the importance of mental health. Just last month your office issued an advisory identifying the unchecked use of social media among young people as a public health hazard. Why take that issue on?
DR. VASAN: We’re taking that issue on because we’re seeing in the data an unprecedented growth in teen suicide, teen suicidal thoughts, depression, anxiety. Forty percent of New York City teenagers reported in–at the end of 2021 that they were so sad or hopeless over the last 12 months that they stopped doing what they’re doing. We’re seeing–we’re seeing rates of depression and anxiety increase earlier and earlier, and that didn’t just start with covid. That really starts–you start to see the inflection point in and around 2011 and 2012, and that marker, that date or that time period is when we saw the advent and the ubiquity of smartphones start with social media platforms on them.
And so we have to start having an honest conversation about what is the damage being done to youth mental health, to the mental health of our young people by virtue of these unregulated, unfettered access to the content on social media and what is it that we need to do, what’s my responsibility as a public health official to lift that up as a public health crisis. Well, we took the point of view that we need to bring the public health playbook to bear, which means things like education and harm reduction, which means things like training and content development to empower young people, parents, teachers, pediatricians to both counsel and reshape their relationships with social media. It means proposing policy and supporting policy, things like the Kids Online Safety Act and other laws that have been proposed here in New York state and in other states to bring some shape of regulation. It also means exploring other legal pathways and other tools at our disposal that have been very useful in the past at controlling environmental toxins like tobacco, like cleaning up our water and our air. And it means doing more research. While we know broadly these associations, what we need to do is more research to understand really who the risk groups are, specifically what type of content is worse than others, which type of platforms are worse than others, and to shed even more light here. But the data is quite compelling. And you’re really seeing a groundswell of support. And part of my job in this role is to, yes, follow the data, but also listen to what people are saying. And parent after parent, young person after young person is saying that this is a problem. We held a convening in June of 2023 at the Rockefeller Foundation where we brought in officials from around the country, we brought in experts from the APA and other professional societies, clinicians, teachers. But importantly, we did it on a day off from school where young people could come in themselves. And we started to develop a roadmap for action so that we could address this as a public health crisis. So we think this is central to our work and we have a lot of support. Since we issued the advisory–which is the first step. It’s really just a call to action and raising the alarm. We’ve just got a groundswell of support from parents, teachers, young people themselves saying thank you for lifting this up. And so more to come in this space.
MR. DIAMOND: You mentioned the groundswell of support, the public interest. We certainly heard from folks, parents, others who have questions, too, and I would like to read one of them to you now. This is from Patty in Maryland, who asks, “Rather than age, what behaviors show a child is responsible to have their own cellphone and how can parents develop a backbone to set limits on inappropriate apps and screentime with confrontational or naïve youth?”
DR. VASAN: Yeah, and thank you for asking that question. The one thing I left out in my previous answer is that I’m a dad and I have three small kids. My oldest is 10, and we’re already fighting those battles in my home around YouTube and content and how I can keep that out or limit that from her life. And I know that my other two, my two sons below her will have those same questions.
Part of the reason in our advisory we’re very clear about saying that parents and caregivers should delay giving a device to a young person that can access social media is because, one, there aren’t any controls. There are very little in the way of controls, and the controls that do exist are all really left up to the parent to try to figure out on their own, number one.
Number two, we know that the ages of eight to 14 are particularly vulnerable from a neural developmental standpoint towards things like identity formation, the formation of social relationships, the formation of confidence and willingness to take risks, and that’s when brain development is particularly vulnerable, which is why we’ve laid out the benchmark of age 14 as the minimum age to start, but that parents should reassess both the data when their child turns 14 and reassess the social and emotional development of their child to see whether it’s appropriate. Part of why we laid out 14 here in New York City is because 14 is also a time when young people are going into high school and where, in this city, they’re riding the subway along and are achieving a level of independence that may not be the same in other jurisdictions. And we know that parents want to keep track of the whereabouts of their children, so we’re mindful of that. But the data’s changing all the time, and 14 is a pretty good benchmark. So I think age is really important in this conversation. It’s also true that the U.S. surgeon general, the American Academy of Pediatrics, the American Academy of Family Physicians, have said there is no safe age below adulthood. They cannot find a safe age to initiate social media in any age group below adulthood. And so that’s a pretty damning indictment of what these technologies are.
Now if you’re a parent on the frontlines of this battle counseling their child about social media use, if you’re one of those parents who have already started giving their young person a device before the age of 14, number one, I want to say you’re not alone. Number two, there’s no reason to feel shame about this. Take this as an opportunity to start to reshape the conversations and the relationships you have with your child around social media use, not to snatch the phone away and get to zero but how do we take a harm reductionist approach where we say–how can we start to limit, how can we start to reshape, how can we start to put in a few controls around monitoring content that I know some of the platforms say that they’re building. And ultimately, also as adults, how do we model better behavior in front of our children? Because they’re learning from us. One of the biggest messages we got from our June 2023 convening from young people was almost an indignance saying to us how dare you lecture us about social media use when you yourselves can’t control your own use in front of us. And so we’ve got a lot of work to do as a society, but we need to take the power back. And I know that as a parent I felt very disempowered at times, and so part of what we’re trying to do is build up the tools and the responses to empower people.
MR. DIAMOND: Well, given those concerns and the idea of modeling good behavior, is there any irony that this interview is being promoted on social media? Are we violating best practices?
DR. VASAN: I’m not–the irony is definitely not lost on me, nor is it–you know, was it lost on me that we promoted the social media advisory on social media platforms. So, look, social media’s here to stay. No one, not in our advisory or otherwise, no one in this administration and I know even nationally is saying get rid of social media. What we are saying is that unfettered, unregulated, wild west access to social media can no longer be the norm and that sometimes regulation and even legal strategies are needed in order to get the change that you seek. When we introduced seatbelts into cars, we made it mandatory that the manufacturers include them. But then we also made it mandatory on the driver and the passengers to wear them. And so you have to create that architecture of regulation and rule-making combined with a greater awareness and understanding of why that’s the safe and healthy thing to do. And so I think we’re just at the beginning of this process of reshaping our societal relationship with this technology that is here to say. It’s not going anywhere.
MR. DIAMOND: You have taken on social media. You recently launched Healthy NYC, a goal to help all New Yorkers live longer. You have an agenda that I think you would say is focused on population health and trying to position New York for the future. Where you stand right now in early 2024, is there any goal for this year that you’re trying to accomplish for the city?
DR. VASAN: In terms of lifespan, life expectancy, is that the question?
MR. DIAMOND: In terms of you have this far-reaching agenda, is there something that needs to happen in 2024 as part of that?
DR. VASAN: Yeah, yeah. Well, let me ask–first answer why we developed something like Healthy NYC. When I came into office, you know, we were out of omicron and out of the–perhaps the worst of the covid pandemic, and what we saw during covid was, in an emergency, we are able to galvanize and focus our efforts towards a singular health goal. And we saw public/private non-profit philanthropic sectors, all the pillars of our civic infrastructure kind of move towards this common challenge. And I was asking myself how can we–what is our common health challenge as a society? What can we galvanize ourselves around in a non-emergency environment? And then I looked at our life expectancy data, which you’ve reported widely on across the country and in New York, and it’s a very damning indictment, not only of the covid era but of the pre-covid era where in the United States life expectancy has been flat-lining, where even in New York our rate of change has flattened, where we see massive racial and socioeconomic disparities, where we see political divides across red and blue states that you’ve reported on.
MR. DIAMOND: It’s a far-reaching agenda. I apologize–
DR. VASAN: It’s a far-reaching agenda. Sorry, go ahead.
MR. DIAMOND: Well, we are unfortunately running out of time, so if you’d like to finish in the next 10 seconds your thoughts.
DR. VASAN: Oh, well, I mean all we are saying with Healthy NYC is what can we get behind, how can we measure results and set out numerical goals, how can we attach those to real diseases and conditions that we can see change on, and how do we hold ourselves accountable. So today in fact a law is–a bill is aging into law which will ensure that Healthy NYC is codified into our planning every five years and that we can’t just get off the hook. So my next–my successor, the mayor’s successor will all be on the hook for this kind of planning. And so this is long work, but we wanted to lay the foundation for it in New York.
MR. DIAMOND: It’s work that we’ll have to get back together again and talk about soon. Commissioner, thank you so much for your insights into what is happening this virus season and beyond in New York City.
DR. VASAN: Thanks so much for having me, Dan. Thanks to all your–all watching as well.
MR. DIAMOND: And thank you to all of you for joining us today on Washington Post Live. For more of these conversations you can sign up for a Washington Post subscription. Get a free trial by visiting wapo.st/live, wapo.st/live. I’m Dan Diamond, a health reporter at The Post. Thanks again.
