By the numbers

By the numbers

Vermont has been cited as a national model for how a state should respond to the coronavirus. Mark Levine, the state’s commissioner of health, was at the crossroads of efforts to plan for the coming crisis, to collect the data as the pandemic hit, and to keep the state focused on the long view of getting back to normal.

It would have been a bigger surprise if Vermont had failed.

Think of Tropical Storm Irene in 2011 and how Vermont and Vermonters rose to meet the challenge. Why would we expect anything less when COVID-19 came along?

We wouldn't, of course, which is why Vermont has been a leader in dealing with the COVID-19 pandemic since it first reared its ugly head at the beginning of the year 2020.

The state's leadership was recognized when, in September 2020, Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Disease, video-visited a Vermont press conference with Gov. Phil Scott and Commissioner of Health Dr. Mark Levine.

Fauci called Vermont “a model for the country.” In response to that week's state COVID-19 statistics, Fauci said, “I would wonder whether I could bottle that and take it with me when I go around talking to other parts of the country.”

He saved his most enthusiastic praise for the people of Vermont when he approvingly observed that, for the most part, we wear masks, stay physically distant, sanitize our hands, and exercise outdoors.

“Wasn't that validating?” Levine said, laughing, earlier this year. He was proud at how quickly Vermont had formulated a plan to respond to the virus.

That process began back in December 2019.

“It was across all sectors of state government, just as if we were planning for Irene,” Levine said.

It was a different kind of disaster drill - “very health-focused,” he said - while most similar statewide interagency responses address health as an issue secondary to the threat at hand.

From the beginning, Vermont was navigating dark and muddy waters. And through it all, the state has performed at the highest standard.

Citing his leadership in the pandemic, Vermonters overwhelmingly elected Scott to a third term as governor in November. And even more people believe that Levine - a very tall and sort of wonky man; a smart, accessible, calm, earnest, and surprisingly witty man - has been the right man in the right place at the right time.

Scott certainly believes so. He calls Levine, whom he appointed to be health commissioner in 2017, “Vermont's own Dr. Fauci.”

“Dr. Levine's expertise and talent was clear from the start - that's why we wanted him on our team,” Scott said. “But I think what makes him so well suited to help us navigate this once-in-a-century health crisis is his even-keeled style and his ability to explain and offer solutions to complex problems in a way that the everyday Vermonter understands.”

“His counsel has had a huge impact on Vermont's nation-leading response,” Scott continued. “We're fortunate to have him, and I know I definitely made the right decision when I appointed him. And I think Vermonters have been able to see that for themselves.”

“So I'm just gonna sit here and gush for 15 minutes,” Mike Smith said as he prepared to discuss Levine.

The secretary of the Agency of Human Services met Levine when he came to head the Health Department.

“And immediately, he impressed,” Smith said. “This is pre-pandemic, and I was impressed by him at that point. He's very knowledgeable about public health. We became very close working together once the pandemic hit. He's risen to the occasion. He's providing solid, analytical data advice to me and the governor.

“It's funny how it happens, but he is the right man at the right time. He has the right demeanor. He has the trust of Vermonters. And he has an analytical mind that just puts all of this together in a very understandable way.

“And he has great communications skills. Mark is at the head of the parade, along with the governor and myself and [Commissioner of the Department of Financial Regulation] Mike Pieciak in terms of this pandemic response. He's done a marvelous job.”

How did the Scott team resist the many pressures on so many fronts - from high school athletic programs to the ski resort and restaurant industries - over the emergency shutdown orders?

“Well, we were fairly confident in our data early on,” Smith said. “Early on, we didn't have a lot of the analytical tools that we have now. The forecasting was very rudimentary.”

“We needed a little bit more data to see where this trajectory was going and catch it in time before it started to get out of control.”

In what Smith called “a critical decision,” he said that Levine pushed to keep testing, to “get the data in so that we can make a rational judgment” - even with only two days' worth of testing supplies on hand.

“And as you know, Vermont has proved to be one of the best in the nation,” Smith said, calling the call to keep testing “a gutsy decision.”

“ That's been the whole thing here with our response, just trying to figure out where the virus is going to be and reacting that way,” he said. “And Dr. Levine's contribution has been immense in that area.”

Working without a net

Vermont's government was hobbled by the fact that for most of the pandemic, there was no effective national leadership.

“It's really been such a challenge,” Levine said. “To have every state operating independently, and to have the phenomenon of states on your borders where you don't often have consistent political thinking? Everyone's doing something different. And the inability of us to be like Alaska or Hawaii?”

“We're not an island here in Northern New England. We like to behave like one, and I think we've come as close to being an island in this country as any state, based on our statistics. We've done so remarkably well compared to every other state. But the reality is, you can't be an island.”

The distortion of the national dialogue remains a large problem.

“It's been so incorrect, so loaded with dangers sometimes, with a lack of a uniform message or lack of a cogent and cohesive set of policies, and program for dealing with the virus,” Levine said. “It's a huge challenge, especially when you're trying to get just the population of your own state believing what you believe and adhere to the guidance you provide, because you firmly think it's the correct thing to do.”

The governor and the commissioner, along with Pieciak, have become rock stars on local television. At twice-weekly press conferences filled with data, dashboards, and charts, they explain what's happening and answer every question that's put to them.

“I think it's helped us that the governor and myself have become the trusted messengers that we are,” Levine said. “We rarely hear that people think we're pulling something over on them or giving them some misguided information.”

“They're almost always commenting on the stark contrast between our messages and what they heard coming out of Washington - at least until Jan. 20,” he said. “Vermonters really have embraced what we've been telling them. They've embraced the way we embrace science and data when we make our decisions.”

As the first news of COVID-19 started coming out of Wuhan in China in December 2019, Levine went on the alert.

“We opened up our Health Operations Center in early February last year, full scale, and it pretty quickly became the primary work of the Health Department,” said Kelly Dougherty, Deputy Health Commissioner for alcohol and drug abuse programs. “Most of the staff in the department are involved in some COVID-19 work in some shape or form.”

Her colleague, Deputy Health Commissioner Tracy Dolan, said that Levine has elevated the role of public health in governmental policy.

“Dr. Levine is shoulder-to-shoulder with the governor twice a week talking about the role of public health in the pandemic,” Dolan said, noting that Levine and senior staff “regularly recommend policy up to the governor and provide data to help the governor make decisions.”

The key strength Levine brings to his job, Dolan said, is his ability to “listen to all sides and to the experts.”

“For example,” Dolan said, “he's not someone who shoots from the hip. He wants his opinions to be informed by the data and best practices of public health science. In addition to listening and data-driven decision making, he likes to build consensus.”

“He's also calm, measured, and a quick study,” she said.

Vermonters' respect for Levine pays off in many ways. For example, if someone asks him about drinking bleach or exposure to X-rays or “some other cockamamie therapy that they've heard might be good for Covid,” Levine said, “We can say, 'No, there's no data. This is what the data shows.' And we get listened to, which is refreshing.”

Levine admitted that he would not want to be doing public health in some states.

“I have colleagues whose population has been a bit brainwashed,” Levine said. “Many of them have governors who have been acolytes of the former president, and their population is not actually being given the full truth on anything. It makes it very hard for their state health officials to actually get things to move in the direction they want to move them. It's very frustrating.”

It can be more than frustrating for his colleagues - it can be dangerous. In some states, according to The Associated Press, public health officials have been “vilified and threatened with violence.”

An “astounding” number of health commissioners are no longer working at their jobs, Levine said, characterizing them as “a casualty of the pandemic.”

“They either quit, or they were released because there were differences in their thinking, or they were used as scapegoats for poor performance by their state, or their population camped out on their front lawn because they were against what they were saying,” he said.

Vermont's success has been internationally recognized. For example, a news story in, of all places, the Sydney (Australia) Morning Herald, is headlined “Picturesque and unpolarised: How Vermont Crushed the Coronavirus.”

“Over the past year Vermont has gained national recognition as the US state that has done better than anywhere else at keeping the coronavirus pandemic under control,” the newspaper said.

When Vermont is celebrated in Australia, you know the world has taken notice.

Taking the reins

When Harry Chen resigned as Vermont's health commissioner in 2017, Levine was interested in the job but painfully aware that it would be the end of his clinical practice that he ran for many years in Essex Junction.

“It was challenging, because I had so many years of direct patient contact,” Levine said. “And that defines you in many ways. Not only do you value those interactions, you feel good about what you can bring to them. You also worry about what will happen if you leave the practice - all these patients still have to be taken care of.”

The government job was enticing because it represented the nexus of several interests that Levine had been developing over the years.

“I was developing an interest in that place where health care, individual health, public health, population health, and health policy all meet together,” Levine said. “I really felt that I could bring a lot to the population in the public health arena, because there, when you make an impact, it's on a very large population-wide basis.”

When 2020 began, Levine knew about the new virus before it even had a name.

“We heard about these coronavirus and pneumonia cases in China,” he said. “The bottom line is that they were starting to spread in a region. And this was a novel virus. We thought, 'We ought to be worried about this. Let's start planning now.'”

He briefed the cabinet sometime in January. “There's something going on that you ought to know about,” he told them. “I'm afraid you might hear about it again.”

Early on, Levine knew his life was about to change and that his job would evolve into something he never knew he was signing up for.

“At the same time, someone's got to do it,” he said. “And it's almost an honor and a privilege to be the one who's thrown in the middle of it all.”

By the beginning of February, “we were having regular meetings of our Health Operations Center and our State Emergency Operations Center.”

By March, when the first case was recorded in the state, “we were all kind of poised,” he said. “But again, you never know how things are going to go until things happen.”

The whole health department became one anti-COVID-19 team, and the first priority - one that Levine and Scott agreed upon early - was to protect the state's most vulnerable populations.

“I think we had the right sets of priorities from the start,” Levine said.

He used growing data to illustrate the state's plans and show how well they were working.

“The data was looking good,” he said. “It was a little bit of a self-fulfilling prophecy that if you could show the people that their behaviors were paying off, then, well, of course they're going to buy into that more. They can see the results of their labors. And then they heard us not act insane.”

Many states got fed up with lockdown and opened everything up. Vermont was not one of those states.

“We basically said, 'We're not doing that,'” Levine said. “We said, 'We're going to be very, very gradual. We're going to do it in a phased and sequential way.'”

The plan was to wait two weeks after each change in the plan.

“That way, we got to watch and make sure that we didn't do anything harmful before we moved on to the next reopening,” Levine said. “I think people have understood that our approach allows economic recovery, but not at the expense of public health.”

Dealing with multiple unknowns

Handling the virus was difficult, given the number of unknowns.

“It was hard because we didn't have great coordination at the federal level,” Levine said. “Need I say more? We didn't have any coordination at the travel level. Things could keep coming into the country without anybody even thinking about them. And we didn't have any state-by-state coordination.

“It was sort of every state for themselves, whether it be diagnosing their first case, whether it be how to deal with the public health emergency, whether it be the absence of PPE (personal protective equipment), whether it be the absence of ability to test and understand if we were actually seeing this condition or not.

“So all that had to be put together really fast, and a lot of it needed federal support that just wasn't there,” he said.

When a wave of panic hit the country over a ventilator shortage, Levine went to Vermont manufacturers that could adapt to produce the equipment. He got “a great response,” he said.

“That's the kind of stuff you can actually do when people can't suddenly do what they were doing but still have all the technological expertise to help in a different direction,” he said.

In the end, extra ventilators were not needed. And even with the post-holiday surge, hospital care for patients with COVID-19 has improved.

“We're doing a lot better with how to take care of patients,” Levine said. “Ventilators are not actually the answer. It's way before ventilators that is the answer. We have medications, we have protocols for helping with breathing and oxygenation that don't require people to be put on a ventilator quite often.”

Although no one wants to catch COVID-19, the disease isn't as fatal at it once was.

For 80 percent of people who are infected with the coronavirus, they will do fine.

“But the other 20 percent could have a more serious course,” Levine said. “It could include being in the hospital.”

Many people who recover from acute symptoms continue to have health problems, including coughing, fatigue, debilitating joint pain, inability to walk, tightness in the chest, and an “endless list” of other problems, he said.

“There might be up to 10 percent of people who recover that we end up calling long haulers,” Levine said. “It's a syndrome poorly defined and poorly understood.”

“It's kind of frightening. And we're seeing it on a large scale because so many people in the country have come down with COVID-19. But certainly, people do not have normal lives for months after having been through the illness.

“We expect everyone to be back to normal, and these people aren't, and they can't shake a lot of very serious symptoms.”

Maintaining economic health

In general, Vermont is one of the healthiest states in the country, Levine said, with its residents seeming to prioritize health.

“So when you confront them with a pandemic, you can enlist their collaboration and cooperation and compliance,” Levine said. “It's a little easier to do because they've started from a good place already.”

He acknowledged that the opinion is not unanimous among a cluster of “disbelievers” in the state.

“Not as many [as in some other states], thank god,” he said. “And we have so many who actually do listen and are compliant. And without that, I don't think we could ever have gotten anywhere.”

The state can have health, safety, and economic recovery, Levine said.

“You can do it,” he said. “But you have to do it in a very graduated way. We wanted to make sure that the level of suppression of the virus, after we closed everything down, was sufficient to allow us to start up in this way. But there's science in the data behind everything we've tried to do.”

Take the retail sector, for example. Stores have remained open, as long as Vermonters “respect the distancing and the masking and all of that.”

“You can buy anything you want,” Levine said. “It's pretty rare that you go to a store and you have to wait outside because of some public health reason. But occasionally, if it's a small store, they'll say, 'We've reached our capacity. You can't come in 'til the next person leaves.'”

The fact that this worked out successfully is a sign that you can have retail business and public health simultaneously, Levine said.

“We started outdoors, then we moved indoors,” Levine said. “But it's all worked.”

The pandemic has caused major and minor shifts in the foundations of the state's economy.

Construction, for example, has not been hard hit by restrictions, state officials have seen.

“Major developers have been able to do well,” Levine said. “People are actually hiring them more because they're home and they want to get things done around their house or their property or what have you. All of that works.”

The hospitality sector has been much more difficult.

“Especially restaurants, just because of the association of bars and restaurants with people indoors in a crowded way, interacting in a multi-household fashion,” Levine said. “And they're not wearing masks because they're eating and drinking.

“It makes it very challenging,” he said. “But again, we've tried to go as far as we could, and we've not demonstrated a lot of case transmission with the guidance we provided. But of course, a lot of those places aren't open to capacity.”

When summer comes...

Vermonters, whether they're vaccinated or not, will still have to wear a mask, sanitize, and stay 6 feet apart from one another as we enter the spring and summer months.

“We're saying probably towards the summer,” Levine said. “But two weeks after your second dose [of vaccine], you will definitely be safer. It's not light years away.”

Is Levine concerned about people who are already vaccinated relaxing and becoming bad role models for everyone else?

“There's so many things I'm worried about,” Levine said, laughing. “That one hasn't crossed my desk.”

“I'm not so worried about that, especially not in Vermont,” he added. “I guess I would worry about it elsewhere, because there's so many people that aren't doing those right behaviors, even now.”

When Vermonters finally come out of quarantine, they will find a different world - one in which they will have a hand in making.

One thing the U.S. must do is use the COVID-19 experience to build a better public health system and to learn from the experience, Levine said. The state needs more robust and sustained pandemic and disaster preparedness.

“Public health has suffered for so long,” he said. “And it needs to be respected more than ever before.”

There is a strong probability that more viruses like COVID-19 will be coming down the pike.

“I'm hoping it's another 100 years, but everybody predicts it's going to be way [sooner] than that,” Levine said.

Within Levine's own lifetime, outbreaks of other deadly viruses have been brought under control far beyond Vermont. “We had H1N1. We had Zika, Ebola, SARS, COVID-1, MRSA.The fact is, they keep occurring.”

As for his immediate future, he plans to see Vermont through the pandemic as long as he is needed.

“I'd like to see us exit the pandemic, and provide a helping hand in that in that pursuit,” Levine said.

“I would like to get us out of this and return to those sort of dreams and visions we had for moving on as a Department of Health in Vermont,” Levine said. “Trying to do some more of those really good things that would benefit the lives of Vermonters and make Vermont even a healthier state.”

“It would be great to see that happen,” he said.

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