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As Covid-19 cases surge to record levels and threaten to overwhelm already strained health care systems, Mark Levine, Vermont’s commissioner of health since 2017, continues to parry and navigate through the pandemic storm.
Vermont has led the nation in vaccination rates, but it has nevertheless endured significant losses. From March 2020 to December 29, 2021, more than 63,000 Vermonters have contracted Covid-19, and 468 people have died from the disease.
“Omicron is an inflection point. We are going to see marked increases in case counts,” said Levine, who was a professor of medicine at the University of Vermont and associate dean for graduate medical education prior to leading the state health department.
As at-home antigen tests become more widely used, the state will no longer have an accurate count of infections since many positive results will not be reported.
“The days of case counts being the primary endpoint to look at are over for sure,” he said. The challenge now is to be “laser-focused on … preserving the capacity of our health care system, making sure that we know day-to-day, hour-to-hour, where we are in terms of hospital beds, ICU beds, etc.”
In the face of spiking infections, Gov. Phil Scott has been criticized for refusing to impose indoor mask mandates. Levine acknowledges the criticism, including from two previous health commissioners, but pushes back.
“Public health doesn’t exist in a vacuum [and] isn’t the only leadership in the state. There are many other factors that have to be factored in, across all sectors of society, across all sectors of state government. … It doesn’t mean that every single public health recommendation is taken to the utmost degree,” he said.
“It’s been a pandemic, and that’s not gone that easily in many parts of the country, with lots of polarization, as we all are aware,” Levine said. “Vermont has been by and large protected, and I believe Vermonters are willing to listen to us about the science. We present the data to them in a very transparent way. And we make decisions, I think, in a very compassionate manner that allows people to understand that we’re not just throwing something at them, but we thought about it a lot and looked at the benefits and risks and weighed them all in the balance.”
Below is a partial transcript, edited for length and clarity.
David Goodman: In the two years that you’ve been overseeing the response to the pandemic here in Vermont, there have been a number of inflection points. There have been new variants, the advent of vaccines, changes in guidance about how to protect ourselves. With the arrival of the Omicron variant, it seems we’re at another one of those inflection points. I wonder if you could start by talking about where you see the pandemic right now — and if, in fact, we are at an inflection point, and what you see ahead?
Mark Levine: Sure — because I agree with you, there is no shortage of inflection points in the last two years. The media keep trying to remind me that we are entering year three, which sounds just beyond what I can even begin to think about. But Omicron is an inflection point. And in some ways good, in some ways bad.
We’ve been really forecasting to the entire state that we are going to see marked increases in case counts with the arrival of Omicron. It is just so infectious. It transmits so easily, from one person to four or five people or more.
We just got a report from the CDC from Nebraska, showing how in a family — basically, the index case was discovered. And between 33 and 73 hours, all four other members of the family became positive. So it’s a very brief window of time. It’s very infectious.
David Goodman: How is that different from what Delta would have done in that family?
Mark Levine: It’s supposed to be about twice the infectivity of Delta, which of course was twice everything previous. So it keeps getting exponential, if you will.
But having said that, we are really making a significant effort to distract people from case numbers. Because one thing about the constant ability of viruses to mutate and to cause new variants is that the virus wants to survive above all other things. So most of the new variants aren’t causing more severe illness or more lethality. They’re actually just causing more infectivity.
And we’re finding with Omicron that this is a milder virus — if we believe everything coming from South Africa, the U.K. and the early experience in our country. The cases are milder. They’re involving people who have been vaccinated, but the vaccines are doing just what they’re promising to do — which is not necessarily reduce your ability to test positive or become infected but reducing your ability to get so sick that you need to be hospitalized or go to an ICU. And that’s exactly what’s happening, what we’re finding around the world and now starting in this country.
So focusing on cases makes it look like some wildfire’s wildly out of control. But the reality is, if more people than not are getting colds and mild flu-like symptoms and are better in a few days, that’s adding to the immunity of the population at large. Putting that together with vaccine-mediated immunity, getting people to a level of immunity where this will become, for our future, a more endemic virus — part of the background, just like a common cold, and hopefully nothing more serious will come.
But I don’t want to minimize Omicron. We’re going to see a huge spike in cases. The large numbers alone will mean more people may end up in the hospital, but not as a percentage or rate — just the fact that there are more numbers. So we do need to get through this.
And then I’d like people to think about what the flu has been like every year since they were born. We don’t enter the flu season with tremendous fear and trepidation. We don’t disrupt our lives in remarkable ways. We hopefully get vaccinated, and we get through the flu season. Some of us may get a mild flu-like illness. Some who aren’t vaccinated may get a more severe illness. And there are some who are very vulnerable — that, even with vaccine, may get a severe illness. But we kind of see that happen year after year after year. And we’ve adapted to living our lives knowing that every year, there’s going to be a flu season — with, of course, the exception of last year, where everybody was isolated, masking, etc., and we saw hardly any flu at all.
So that’s how I see the best-case scenario for how Omicron will actually get through us, and then what our future with the SARS-CoV-2 virus will be like.
David Goodman: It seems you’ve avoided comparing Covid to the cold and flu until now — because we don’t mask up or social distance for the flu. We live our lives and most people don’t get the flu.
But you’ve shied away from saying what you just said. So I’m wondering, what has changed? Are you saying that the severity of Omicron for people who are boosted is comparable to the flu?
Mark Levine: Well, I don’t want to compare a virus to a virus. I’m just trying to use that example as something that is endemic in our population. It’s been around for generations and centuries, and we survive and live through it. And most of the time, it doesn’t disrupt our lives tremendously.
I am hoping, after Omicron, that that is a little bit of what life looks like with this newer virus. And I’m only using our accumulating science and data that’s happened, really, since the beginning of the month of December. Because this just happened in South Africa in late November, early December, and we’ve got about a month’s worth of experience to draw upon. So the science is accumulating rapidly.
I don’t want to minimize the virus by any means because there will be people hospitalized. There will be people who succumb to this virus. But the hope is we can minimize that by our extraordinary vaccination rate in Vermont — hopefully, by our even more extraordinary booster rate in Vermont, which we’re really pushing to get as high as possible — and sort of ameliorate whatever happens over the time course through the month of January, which will be where things really start to happen with Omicron.
David Goodman: What do we know now about breakthrough infections with people who have been a) vaccinated but not boosted, and b) those who have been boosted? Anecdotally, I know I’m hearing of friends who’ve been boosted and infected.
Mark Levine: We know a lot about the pre-Omicron. We know that breakthrough cases have occurred in about 2.5% of the fully vaccinated population. Hospitalizations and deaths, a very, very small percentage of that: 2.4%.
David Goodman: Now, when we say fully vaxed, are we including boosted?
Mark Levine: That’s just fully vaxed, with or without boosters. We don’t have as much rapidly analyzable data on the booster population at this point in time.
In terms of cases, I can give you some very interesting data regarding hospitalization and death. And clearly, looking at the last six weeks — which is really Delta, because Omicron is just entering our state — looking at Delta, which has been really the most severe part of the pandemic for everybody, including Vermont, you have a 23-fold risk of being hospitalized if you are unvaccinated compared to a boosted population. And you have a 6-times increase in your risk of being hospitalized compared to just a fully vaccinated population. So that right there tells us that boosting is really really important. The death data almost mirrors that — 23-times (for boosted people) and 4-times (for vaccinated people without a booster).
So what does that mean? What I’ve been saying every week is that you are not fully protected if you have not been boosted. I mean what I say because the impact of boosting is so substantial on reducing your risk of serious outcomes.
Some people don’t like the term booster because it makes them think that, either No. 1, the vaccine never worked at all, which is far from true. Or No. 2, that this is just an endless cycle and cascade of getting shots, and “When am I going to stop getting shots?” But the reality is, they should consider it as a three-dose primary series of vaccine. So if you got the messenger RNA vaccines, which the majority of Vermonters got.
David Goodman: That’s Pfizer and Moderna.
Mark Levine: Pfizer and Moderna — then you basically should consider that a three-dose series. The reality is that when they came out, nobody knew when you should get dose one, dose two, dose three. We kind of got them the way we got them as the data accumulated. The hope now going into the future is that you would have either an annual booster, or maybe even less than that, because of the fact that we just don’t know. We don’t have data for people a year after their booster. We know we get a flu shot every year. But we may not know beyond that.
I think this thing is so critical that I like to say to people, you are not fully protected, and you are not up to date on your immunization, if you have not gotten the three shots for the Pfizer and Moderna.
David Goodman: Omicron hit Europe before the U.S., so some of the early data we have is out of Europe. In Denmark, they found that people who were double vaccinated but not boosted had no more protection against Omicron than someone who was unvaccinated. Is that your take on it? If so, Vermont has just 55% of the population boosted. So that leaves a very large portion of our population facing Omicron who are essentially like unvaccinated people.
Mark Levine: Yes, 55% from age five and above, so keep that in mind. It’s a little higher when you look at it from higher ages. But the bottom line is, what is the outcome measure you’re looking at when you look at Denmark? Is it the outcome of serious disease? Or is it the outcome of getting an infection at all? Because I think what we’re learning with Omicron is that the likelihood of you getting an infection at all is very high, no matter what your vaccination status. But the take-home message has to be that the likelihood of you getting into the hospital, dying or getting an ICU bed is much, much lower if you’ve gotten fully vaccinated and boosted.
David Goodman: It seems to me we’re changing course here from managing the pandemic as a public matter to a private matter. By that I mean we’ve gone from these highly public management scenarios — of mass vaccination sites, and in the early days, establishing field hospitals, which did not end up getting used — to now, we’re talking about home tests and convalescing at home. People may not report infections from home tests, so we are in fact going to lose count of the infection rate.
Is that where you see this going? And if so, the rapid home tests are the key to this strategy. And as you well know, they’re running out within literally minutes of becoming available.
Mark Levine: The days of case counts being the primary endpoint to look at are over for sure. We really have always been laser-focused on the health care system, preserving the capacity of our health care system, making sure that we know day-to-day, hour-to-hour, where we are in terms of hospital beds, ICU beds, etc. So we continue to be very focused on that, even though I know both local and national media are always focused on case counts and how extraordinary they may or may not be getting at any point in time.
We will lose a lot of information on that with the advent of at-home antigen and PCR testing. And the reality is concepts like percent positivity, which really have been very helpful in managing the pandemic, will not become calculable, because we won’t have a denominator anymore. And we’ll probably only know the more positive tests. If a person is actually going to report their test results to the health department, they’re probably more likely to report a positive result than a negative result, which is great because that gives us a good idea of how many positive results there are out there, but it makes us lose a denominator in terms of calculating your percent positivity because we have no idea how many people did a test and found nothing.
So you’re right, we are transitioning to that, and there’s a really important public health reason for us to do that.
Even when you have the best operating PCR system in the world and get results back in 12 to 36 hours, you have a lot of people who aren’t finding out for longer than that. Even 12 to 36 hours is a long time when it means your potential to infect somebody else before you knew that you actually had the disease. An at-home antigen test gives you immediate results. And you can make immediate important life decisions based on that. So we are really in an era now where we want those decisions on a personal level to be made quickly, whether the person has symptoms or not, just so they understand where they stand, where their family stands, where their community stands, based on their positive or negative result. And also what they can do in their life — you know, going to work that day, going to school that day or going to an event that has a lot of people at it — these decisions will become much easier.
But you pointed out the Achilles’ heel as of December 2021: We don’t have access to a supply chain that will accomplish every goal immediately. We’ve heard the president talk about half a billion tests becoming available next year. Well, that isn’t going to be Jan. 1. That’s going to take some time. And even half a billion tests, when you think about the population of the country — it’s not a lot of tests per person. So we need to come a lot further than that. And we will. We are working with supply chains now that we have been really good to either stumble upon or be advised about. And we’re trying to get antigen tests from literally every corner that we can. And we’ll continue to do that.
We would hope, post-holidays and post-Omicron surge, there’ll be a little less demand, a little less of a frenetic basis compared to where we are now. But the reality is, we still have PCR testing — it’s just not very good for a holiday scenario when you have major things you want to go to and you have to time it very precisely. And it’s certainly not great when you’re in the middle of a big surge or at the beginning of a big surge.
So we do have issues. But the reality is this will become the sort of state of the art as we get into the next year.
David Goodman: People mine what you say for the practical takeaway. A lot of people are wondering if I want to get together with six or 10 people, if we all rapid test that day, and we’re all negative, we’re okay to get together and not mask? What is your answer to that?
Mark Levine: I would use the rule of threes and say, fantastic, you all did that test. So at least for the few hours after you did the test, you’re good to go in terms of infection. I’d like to know that those six to 10 people were vaccinated — even better, boosted. And I’d like to know, if we’re not going to be sitting at a table eating constantly, that maybe we would use a mask — if it’s multiple households getting together, use a mask at the times we’re not actively eating and drinking.
David Goodman: You said “maybe” use a mask. Would you say you should definitely use a mask when you’re not eating?
Mark Levine: If it’s not just your immediate family, but it’s a gathering of multiple households, I would definitely say use the mask right now. Because we are in an early part of the Omicron surge. That doesn’t mean for the rest of your life every time you get together with people and you’re not eating that you need to wear a mask. But certainly now, as the virus is coming through, and it’s a respiratory virus in the wintertime, definitely.
David Goodman: Let’s talk a little bit about mask policy. The Vermont chapter of the American College of Physicians urged Gov. Scott to require masking indoors. And two former Vermont health commissioners, your predecessors, Jan Carney and Harry Chen, have said they support a mask mandate in the current surge. Dr. Chen said, “To stand by and watch these numbers and watch the stress on our health care system and do nothing in terms of intervening. I mean, it doesn’t make sense.” How do you respond?
Mark Levine: I have tremendous respect for everyone that you’ve just mentioned. And the reality is, they are giving very sound fundamental public health advice. What happens though in a pandemic, as we’ve all learned, is that public health doesn’t call all the shots. Public health doesn’t make a unilateral decision, and everyone falls into place. Otherwise, we’d have a whole country that had mask mandates. The reality is we have half a dozen states, plus the District of Columbia, having mask mandates, and nobody else.
(Editor’s note: According to the National Academy for State Health Policy, nine states, plus D.C., have mask mandates.)
In fact, at least in Vermont, we have the very strongest amount of recommendation coming from the very top, within the health department and within state government, telling people, you should be wearing a mask when you’re indoors in public places. So we have all of that. We don’t have the absolute requirement that a mandate would bring.
The reality is, in the last several weeks, we have seen hospitalizations markedly decrease while we’re still in the era of Delta. Now, what did we have happen in Vermont? We did have a new law passed that allowed municipalities to invoke mask mandates if they chose. We have 10 to 20 municipalities that have done that, and a number that have gone the opposite direction. And that, to me, can’t explain any change in what’s going on on the ground. Our hospitalizations have gone down even though there was no state mask mandate, and there was certainly no uniform mandate across all regions and across the state.
So what happens with decisions of this magnitude, where you’re actually telling people what they need to do, is that we weigh a lot of things in the balance. Some of those things are very familiar to people. Like, what is the state of their mental health? How is substance use going in the state of Vermont? Are we seeing impacts of severely regulating people’s lives on them? Or on the economy? Or on the education system? Are we protecting our students and allowing them to get in-person learning as much as possible? And where is the public’s appetite for getting very aggressive or becoming more lax?
Clearly, when you look around the state of Vermont, pre-Omicron, I think you’ll agree that people were actually enjoying a lot more freedom than they’d ever had during the pandemic. People were starting to go to larger events, many of which required vaccination, which was good. Restaurants were filling up again. Bars were filling up again. People were going to gyms. The retail establishments were all doing fine.
David Goodman: But when you speak of the public appetite, so much of that is influenced by the leadership and the messaging from the leadership. I see it in my community. The Mad River Valley towns, for example, voted to have a mask mandate. So when I go into stores there — as I did last weekend — everybody’s masked. There’s no questions asked. In Waterbury, where I live, the Selectboard voted not to have a mask mandate. So when I go into the grocery store, I would say about half the people are masked.
So appetite isn’t something that just wells up from inside. It’s influenced by the rules. Early on in the pandemic, Vermont did so well by saying we are following the science. And the science is pretty clear that masking does reduce transmission. It’s a key mitigation strategy. How do we say we’re still following the science when we just leave it up to whatever you feel like when it comes to whether you mask up and protect yourself and your neighbors?
Mark Levine: Right, it’s the difference between a strong recommendation and a mandate. And the reality is, we actually know from pre-Delta that mask mandates were successful. We don’t know during the era of Delta. And believe me, I’ve looked at a number of the states that have had mask mandates, and tried to correlate what happened in their populations with having or not having a mandate in terms of their surge, or whatever, in Delta. And some of them look like the mask mandate may have done something very positive. Others, I can’t find a correlation at all.
All of the state health officials I’ve talked to in all of the states were very specific about saying enforcement was impossible — that the amount of disputes and dissension was increased by having the mandate because of the polarization and politicization in our societies currently. And they were having a lot of trouble sort of working with the population, knowing that there was very little enforcement that could be had. So that’s a little bit of a statement about the public appetite, if you will.
But I’m also saying it’s not just public appetite. It’s all these other factors that I had mentioned earlier, in terms of mental health and what have you, that really make something like this either successful or not successful, palatable or not palatable.
I do think there’s a little bit of magical thinking — that if only we had done the mask mandate, everything would have changed. Because we’re seeing changes now in hospitalizations that are very positive that occurred without having an actual mandate. And it’s just a noteworthy statement. It’s very hard, in real time, to correlate a lot of things.
David Goodman: Dr. Levine, what would it take for you to recommend that we impose stricter or mandatory mitigation measures, such as masking?
Mark Levine: Believe me, public health is always recommending pretty strict measures. Masking alone, mask mandates, the power of vaccine mandates — those are all, I think, effective public health measures.
But public health doesn’t exist in a vacuum. Public health isn’t the only leadership in the state. And there are many other factors that have to be factored in, across all sectors of society, across all sectors of state government. And fortunately, we have very capable leadership in our state that does factor all of that in as they make decisions. So public health is at the table all of the time. It doesn’t mean that every single public health recommendation is taken to the utmost degree. And anybody who’s been a health commissioner or a state health official in any state understands that dynamic very well.
It’s actually a very rational, pragmatic understanding to have because we shouldn’t be calling the shots for everything. Our job is to protect and preserve the health of all Vermonters. But we say a lot of things about our environment and how environmental health impacts individuals. We say a lot of things about various infections and sources of infection, forgetting about the respiratory viruses that impact all sectors of society. We talk a lot about what we need to do in alcohol and drug abuse, substance abuse programs. And we do a lot of things that are good. But at the same time, most of the things we’re doing are balanced with lots of other considerations across state government.
David Goodman: The CDC has just revised its guidance on how long asymptomatic people who test positive for Covid-19 need to quarantine, cutting it in half from 10 days to five days. Some critics are saying that’s politics and business speaking, not public health. What do you say?
Mark Levine: It would be hard for me to say there wasn’t an element of politics and business, knowing how this came out rather abruptly. In fact, the governor was on a phone call with the White House and all the other governors at noon on the day that this came out at 5 p.m. and had heard from (CDC Director) Dr. Walensky that they had nothing new planned at that point in time.
David Goodman: A lot happened overnight, I guess.
Mark Levine: Yes. And I’ve spoken to members of the CDC very recently, who are rapidly putting together some of the guidance that’s needed because they were caught a little bit short on that as well. So clearly, politics and economics do make a difference at times. However, there is science to back up some of what the CDC has proposed. And they have informed us that they will be showing us that science and releasing it all so that we can all analyze it and make the right decisions.
I’d like people to know that we in Vermont are already thinking along the same lines — not the precise guidance the CDC has come out with, and now we need to reconcile what we were thinking and why we were thinking it with what the CDC has done. Because you’ll recall that many times in this pandemic, Vermont has actually led. We led with how to get out of quarantine early using a testing strategy. We led with what does contact tracing mean, in terms of the duration of contact with a person over a 24-hour interval being 15 minutes, not just 15 minutes at one time. So we were going to be leading in this as well, but circumstances got the CDC to come out quickly with it. So we’ll be coming up with our own Vermont policy over these next several days, I’m sure.
David Goodman: Around the country, there have been attacks on public health officials, right on up to Dr. Fauci, who now has to travel with armed guards. Have you experienced any threats?
Mark Levine: You know, we have had just the best support from Vermonters throughout this pandemic. I think we’ve really stood out in that regard. And even though you may observe 50% of people masking in one community versus another, the reality is, we wouldn’t have gotten to where we’ve gotten to in this pandemic without the support of Vermonters. So by and large, I can say that I’ve got tremendous, tremendous support from them.
Have I gotten an occasional threat? Have I gotten negative feedback on things? Of course. That will happen to anyone in a public position. But I’m aware, unfortunately — because the community of state health officials is rather small, there’s only 50 states plus territories, plus the District of Columbia — the number of health officials that I knew in the beginning of the pandemic that are still with me now is vanishingly small. There’s been a tremendous amount of turnover. I’ve had colleagues in other states who have had people camped out on their lawn. I’ve had people concerned about their family because of the level of threats. It’s been a pandemic that’s not gone that easily in many parts of the country, with lots of polarization, as we all are aware.
Vermont has been by and large protected. I believe Vermonters are willing to listen to us about the science. We present the data to them in a very transparent way. And we make decisions in a very compassionate manner that allows people to understand that we’re not just throwing something at them, but we thought about it a lot and looked at the benefits and risks and weighed them all on the balance.
David Goodman: So I take it from your answer that you have received threats. Have any of these threats risen to the level of you asking for police protection or being concerned about your family’s safety?
Mark Levine: No. Obviously, they’ve been discussed at the level of public safety, but have not gotten there. And I am happy to say most of that was much earlier in the pandemic, at a time when people’s lives were more strictly affected by the decisions that we all made in state government.
David Goodman: Have any local public health officials in Vermont been threatened that you’re aware of?
Mark Levine: Not that I’m aware of. But you have to keep in mind, our public health structure in Vermont is a very centralized health department. We have 14 district offices that have leadership in those offices supervising the work, but it’s all coming from the central office. So they may be very visible members of their community. But usually, they’re very positively viewed members of their community because they were involved in so many of the public health efforts that we have over the course of time.
David Goodman: Earlier this month, Gov. Scott and his chief of staff, Jason Gibbs, lashed out at a public health expert from Dartmouth, Anne Sosin, who has often been critical of Vermont’s policy. Should Vermont officials be criticizing public health experts who question Vermont’s policies?
Mark Levine: We should have everything we do be critically appraised. So if we make a decision and people critically appraise it and have a reason to disagree with it — either because we did something or didn’t do something — that is their prerogative.
I will say it’s pretty hard to call the shots when you’re not really running the show. So it’s an easy thing to sort of state what works, what doesn’t work. “Why are you doing this? Why aren’t you doing that?” And it doesn’t really integrate into what I’ve tried to present during our conversation today, which is: It’s a very integrative process, taking into consideration lots of considerations that people may not have thought about.
Certainly, I don’t want to comment on whatever happened with the governor’s staff. The reality is everyone has the right to their own opinion. Everyone has the right to try to support their opinion with the appropriate science and data and have a civil conversation about it.
David Goodman: People have come to know you as a health commissioner. But many, many people, particularly in Chittenden County, may have known you as their doctor. You’ve been a longtime internal medicine doctor. Have you ever had to offer guidance as a health commissioner that you wouldn’t offer as a private physician?
Mark Levine: It’s very challenging when a Vermonter communicates with me, as they do all the time, and wants very individualized advice. And I know nothing about their whole medical background, their family, their social background, anything, to really be precise in the way I guide them. So I try to guide them from a public health standpoint but letting them know that they do have others who are responsible for their ongoing medical care and that person probably has more insight into them than I do. But I’m able to still offer a fair amount of advice, because it usually relates to all of the things we’ve been talking about in the course of managing a pandemic, and trying to navigate that as an individual citizen. So I’m able to do that pretty well.
One of the big appeals of transitioning from a practice world to this public health world, is that I can now impact a large population. If you look at things like what we call lifestyle, behavior change — you know, how much does somebody drink, or smoke, or eat, or exercise, or any of those important things that all feed into how long we may live and how healthy we may be along that time course — I can influence an individual patient, sometimes, in one visit. But more commonly, over the course of many visits, sometimes a decade. That person may suddenly quit smoking 10 years later as the accumulated impact of all the discussions we’ve been having, all of the tricks of the trade I’ve been trying to share with them in their journey.
As a health commissioner, I can, as we did in two legislative sessions ago, be supportive of and fundamentally involved in a trifecta of interventions that the Legislature enacted and the governor signed regarding vaping and smoking. We enacted a new age range for purchase of vaping and combustible cigarettes to 21. We had more of a tax, hitting people where it hurts on the vaping front, and we affected the ability of youth to purchase these kinds of materials on the internet. I impacted a tremendous number of people and — not trying to be grandiose here — potentially decades from now, we’ll see the rates of lung cancer, cardiovascular disease, emphysema, what have you, improve in a concerted fashion because of those interventions.
So it’s very challenging to separate myself because I love the interaction one-on-one in impacting a person’s life. But I also really cherish the opportunity to work across state government and in public health to impact perhaps the generation’s course of events as things go on.
David Goodman: Let’s talk about long Covid, which really seems to be the elephant in the room. You’ve said that around 30% of people with Covid may suffer long-term symptoms. I’ve seen even higher estimates than that. What do we know about long Covid in Vermont and its implications for our health care system in the coming years?
Mark Levine: We’re learning a lot about long-term Covid. And in Vermont, the rates that I’ve quoted are 10% to 30% of people who have had Covid — at least, Delta and before, we don’t know what Omicron will do to that equation, especially in a vaccinated population. Fortunately, the statistics for our youth, even those pre-vaccine, are much lower than the 10 to 30%. They may be in the 4 or 5% range.
We have worked in a concerted fashion with the University of Vermont in a research project to try to understand this better, but it’s just embarking. So we can’t give you any news yet about what we’ve learned.
But long Covid is not something that’s very pleasant. People discuss this brain fog phenomenon. They discuss profound fatigue, exercise intolerance, shortness of breath, you name it. And those can’t be pleasant things to live with, three-plus months after you thought you were done with Covid. So there’s going to be a pandemic of long Covid that our country has to deal with effectively.
I can’t tell you as much as I want to about Vermont. But I can assure you that we shouldn’t be that much different than all the statistics that are being raised, at least pre-vaccine, for that population. Hopefully, with our extraordinary vaccination rate leading the country in so many categories, we will have flattened that curve significantly just because people have been more protected.
David Goodman: Circling back to where we began, when talking about how Covid may evolve into something more like a flu or a cold, long Covid is the exception to that rule. It’s why you don’t want to get Covid — because this is something that we just don’t know about and it seems to be affecting a lot of people.
Mark Levine: Exactly. I couldn’t say it better. But the hope is, again, with something like Omicron, if it truly produces less severe illness and if it occurs in vaccinated people with a very mild and short illness, that the sequela of long Covid will not be occurring in those individuals.
I think that’s because their major organs are protected. That’s what a vaccine does. It allows the virus to get into our nose, and maybe someone else’s nose, because we transmitted it that way. But it doesn’t impact our lungs. It doesn’t impact other major organs. And we’re protected from getting not only serious outcomes that are immediate, like hospitalization, but serious outcomes that are more long term as well. That’s the wish.
David Goodman: I want to talk about our hospital capacity. We are operating in a region, the New England region, which is in crisis. In Rhode Island, the president of the Association of Emergency Physicians warned in a letter to the governor last week that “any added strain right now will lead to the collapse of the healthcare system.” That’s in Rhode Island — that’s a couple hours’ drive from here.
In Vermont, UVM Medical Center and Dartmouth-Hitchcock have canceled and postponed surgeries. And I’m hearing anecdotally of friends who have had relatives die because they couldn’t get timely care for medical problems.
Is our system in Vermont and the region strained to the breaking point? And what is Vermont’s worst-case plan for keeping hospitals functioning in this situation?
Mark Levine: These are great questions. I want to give some perspective first. Most of the hospital business, even when they were getting more Covid business, was not Covid business. Less than 10% of hospital beds were occupied by Covid patients who were there for Covid. In the ICU, at the most, around 20% of beds were occupied by Covid, when we got to the worst of Delta. And those have come down significantly since then — somewhat mysteriously, but we’ll take that.
Most of the business is either deferred medical care — people who were afraid or just couldn’t connect with the health care system during this pandemic — or lack of prevention, or screening for chronic diseases that were getting out of control because of the stress of the pandemic. So we’re seeing a lot of that business, along with surgeries that were deferred, that was occupying hospital beds, and that’s what’s causing the crisis. Covid is just sort of the straw that breaks the camel’s back. But it’s not the major cause of business.
Our Agency of Human Services has been working very hard on a three-prong strategy as a preventive. No. 1 is prevention. We’ve been making sure that monoclonal antibodies, as an effective treatment for Delta, were out there everywhere. And we were delivering them anytime they needed to be to Vermonters because that keeps people out of the hospital.
David Goodman: Although two of the three monoclonal treatments don’t work against Omicron.
Mark Levine: Right. But we’ll have as much as they’ll give us of the one that does work, believe me.
Our preventive strategy uses boosters. And we’ve gotten our booster rate really high. But as I keep telling people, it’s not high enough. We need to go even higher.
The second prong of the strategy was really making sure that hospitals didn’t have so many patients in them that didn’t need hospital care anymore and could be discharged if they had the right setting for their care. So that involved opening up nursing home and rehab bed capacity around the state. And the reason there was no capacity was not because there weren’t beds in many facilities — it was because there were no staff to take care of the patients who would occupy those beds. We’ve done a tremendous amount of work getting staffing for those facilities. We’ve had well over 100 people get discharged from our hospitals that didn’t really need to be in the hospital anymore. They were occupying beds because they required care that couldn’t be provided at home, not because they required intense resources for an illness.
And the third prong was really opening up some new ICU capacity, which has been around 10 beds across the state, providing staffing where staffing didn’t exist. And creating, if we needed, a surge site — which the National Guard, literally with a snap of a finger, over the course of days, could construct and have ready for us to utilize if we needed to offload more patients from hospitals.
So all that has been happening behind the scenes and been very effective in coming to the aid of our hospitals, as well as taking some of the patients in the emergency rooms, who — for reasons of mental health, usually — were boarding in those emergency rooms because there was nowhere for them to go. And we’ve created capacity for them as well.
So a lot has been happening in that realm. But you’re really asking, what if things really get bad during Omicron? First thing is, hospitals have been able to toggle, almost like with an on/off switch, their elective surgeries. So they have been able to cut those when they need to and allow them when they could maintain them. So they’re going to need to continue to do that. And they know how to do that very, very well.
We’re going to need to continue to make sure that there’s adequate staff because as Omicron becomes more prominent, we all know that health care workers are not immune. Even if highly vaccinated, some of them are going to get ill, which will impact those facilities. So we need to make sure that we can provide the staffing for those facilities — and use the new CDC guidance that came out before the guidance we were talking about earlier, that allows health care workers who have become asymptomatic to get back to work — using their PPE and protecting patients in a more timely fashion.
And then we need to make sure that our hospitals are all communicating well with one another. We’re creating the structures for that so that if there’s a need for a patient to get into an ICU bed or a hospital bed, we have eyes on the entire system. And no matter where in the state that person is, they can get to the right bed because we know that hospitals outside of Vermont will not be available to us.
David Goodman: One of the things I always find most instructive that helps cut to the chase is asking you about your own personal practices when it comes to navigating life in the pandemic. We’re approaching New Year’s. What’s the most number of people you’re willing to get together with in a social setting indoors right now?
Mark Levine: A handful.
David Goodman: OK, is a handful 10?
Mark Levine: No, it’s one hand.
David Goodman: One hand, OK. So five or less?
Mark Levine: Yeah. I have to say, until this point, the most has been about four or five.
David Goodman: Are you willing to board an airplane to take a flight?
Mark Levine: I have to be honest. We were headed to Memphis pre-Christmas to get together with our daughter, her family, our new granddaughter. We canceled the trip because of the fact that, not only my work was going to be becoming very busy again, but mostly because we felt the timing was very poor.
David Goodman: Going out to a restaurant indoors?
Mark Levine: I generally still support all my favorite restaurants by takeout.
David Goodman: We often see you with the governor and others not masked, but are you typically masked in most indoor settings that you’re in?
Mark Levine: Yeah, in fact, our press conferences, we all mask now. We’ve been doing that for at least a month now. Most people are hearing us, they’re not seeing us. But we are fully masked in that setting.
I would be tremendously embarrassed — which has happened once or twice — when I run into a retail establishment and have forgotten my mask. I generally have to turn around and go back to the car and fish it out. Because I do wear it in public settings as we recommend.
David Goodman: And finally, we are hearing a lot about burnout among health care providers, and I imagine the intensity of this job for you is significant. What do you do to keep yourself sane in these times?
Mark Levine: Well, my wife does a really good job of making sure that I don’t go any night of the week, no matter what time I get home, without a nice dinner that she’s prepared, which is really helpful. It’s a nice sort of chillout time.
I exercise almost every day for at least a half-hour if I can. It’s usually before the day gets started, which I think gets the endorphins up, which is really important because they carry through the rest of the day.
And I work in a great place. I have a great health department. And I’m inspired constantly by the dedication of the people that work here and their real sacrifice that they make every day to keep Vermonters safe. So all that helps tremendously. And I watch a little bit of TV at night when I have a chance just to just get my brain off of everything.
David Goodman: Dr. Mark Levine, I want to thank you for joining us on the Vermont Conversation, and have a happy and healthy New Year.
Mark Levine: Same to you, David. Thank you.
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