 Hi everyone welcome. Oh my goodness. This is a wonderful crowd We had a feeling we on the program committee that this just might Attract a nice group and we're thrilled old members new members guests all of you welcome welcome welcome And I hope you had a wonderful summer Even though it feels like that today It's not supposed to be this hot Okay, let me introduce dr. Levine Dr. Mark Levine is the current Vermont commissioner of what? Hell right. I knew you'd know that Having served in this position since his appointment in 2017 prior to his appointment He was a professor of medicine at the University of Vermont and most recently the associate dean for graduate medical Education he also served as vice chair for education in the Department of Medicine and practice general internal Medicine dr. Levine received his BA in biology from the University of Connecticut and his MD from the University of Rochester He completed his internal medical medicine residency and a chief resident year at the University of Vermont He also completed a fellowship in general internal medicine at the University of North Carolina with emphasis on clinical APEDE. I knew this is gonna be say it Thank you epidemiology, I practice to Research training teaching and administration of educational programs. Please give a warm welcome to dr. Mark Levine Well, great to see such a great crowd This is working too loud too soft to whatever perfect Okay So I don't know what you came here to hear today And We'll have time in the Q&A for things you don't hear But I was asked to talk about a few things that I will talk about. I will also talk about a few things I wasn't asked to talk about and I will say a little about COVID, but it's not a COVID talk So if you need to leave now So We're gonna do a little bit of we have a little landscaping going on so there with it We have a little bit of public health 101 Talking about health and public health and the state of health in Vermont we're going to talk about how we make decisions in public health and What the fallout has been from the pandemic I was specifically asked to address that we prepared for the next public health emergency and to update the opioid epidemic And I was not asked but because it is so important and here we are sitting here on September 8th With the fan going because there's no air conditioning, but it's over 80 and we just came through a heatwave We're gonna talk about climate change as well because that is a public health issue Everybody okay? Okay, so Always feel I have to start a talk like this letting people know that Health and public health are not health care Everybody thinks health care is where the action is and believe me. I've spent a career in health care And we do a lot of good things But actually health is very different. This is a WHO Almost 75-year-old definition of health which still stands true today a state of complete physical mental and social well-being Not merely the absence of disease So something we should all be trying to achieve all of the time Public health is really Definition that has evolved over time Now it still retains the elements of the core past definition, which is Manage epidemics like we just did protect us from even more of the myriad of environmental health threats that are out there and Thirdly prevent chronic disease, which by the way is 80 plus cents on every health care dollar Hmm the contemporary definition really Understands that public health can't do everything. It's really an all-of-government all of society exercise So what can we do to collectively assure the conditions in which everyone can be healthy and for us? It's all about forming collaborations and Intersectoral partnerships Built on adherence to science data and objectivity so public health becomes sort of a catalyst we have we have the data we have all the data and The fact of the matter is we use that data to try to leverage important change that needs to occur And enlist all of our partners in accomplishing that so we are often the public lens and the catalyst for change So if I ask you what makes you healthy or not Majority of you would probably say the health care I get But as you'll see in this pie chart That's only 10 percent of what determines health Now there's a genetic component and we can debate the percent That we kind of can't intervene with too much yet though some day We probably will be doing more so But then there's behavioral patterns. So what are your lifestyle choices? Nutritionally activity wise substance use tobacco etc. They determine a huge percentage of your health and then the socio-economic and environmental parts of the Picture also determine a tremendous amount So that is where public health gets really involved to further illustrate In my three-plus decades of being a doctor and having a practice etc. Etc. I Worked from here up. So counseling and education big deal and Doesn't work absolutely, but it might take 20 years for me to get a person who smokes to stop smoking It might take 20 years for me to get somebody to adapt more healthy nutritional habits, etc Clinical interventions, that's basically managing things like I've managed every day high blood pressure heart disease diabetes chronic lung disease you name it and Then long-lasting protective interventions, which are why did you get your shots? Did you get your colonoscopy? mammography etc all Critical, but as you'll notice on the left, they have the smallest impact on health This is called the health impact pyramid for a reason So the world I live in now and that I depended on but wasn't as actively involved in as a practitioner These two bottom things changing the context, which means making One person's default decision the healthy one So if you go by a box of Nabisco crackers now You can't find it Gram of trans fat because we've proven trans fat is the worst fat for your heart And nobody's marketing any products that have it in it anymore. They've replaced it with healthier fats If you live in a community that's decided to fluoridate the water your teeth are pretty much protected And you don't have a big decision to make unless you're so against fluoride that you're going to only buy bottled water If you go to a restaurant, you don't have to worry that you're going to get lung cancer because everybody's smoking Because we've told society you can't do that So those are examples of things that change the context and really make a huge difference on a population level And then the most impact is actually socioeconomic factors Do you have access to wealth employment housing food you name it all of the usual needs? Which is what we're going to talk about next so Principles of population are to focus on the population obviously and prevention and wellness and Importantly we focus in public health on do you have risk factors that we can? Modify and improve upon so they won't be as risky to you and are there protective factors that we can actually enhance and Make a positive outcome more likely for you because of those protective factors And it all ties into linking to what we call the social determinants of health Which is really the circumstances in which people are born grow up live work learn age and eventually die And the systems that are put in place to deal with illness So we talk about these social determinants Pretty easy to understand them on the left side Are you employed? Can you earn a good living? Do you have access to wealth or are you going to live in poverty? Moving along do you have a secure place to live because housing is health care housing is everything as We've discovered in Vermont all too harshly Do you have transportation to get from a place to a place and I might mean get to a Park where you can exercise that might mean get to a job Do you have the same access to education as we would expect everybody in society should and then do you have food security? And how do we sort of put that into action? Well very common disease asthma So asthma is something that is prevalent in society It's a little higher in Vermont than most other states to be honest And it turns out The management of your asthma isn't just did you get an inhaler from your doctor and do you know how to use it correctly? And did you quit smoking etc etc? It actually has to do with these social determinants so if you study people by education status and Try to link that to the prevalence of asthma You find that there's a statistically significant relationship between having less than a high school education and having way more asthma than everybody else Same thing if you look at their Linkage to the federal poverty level The worst poverty you have the more likely asthma is really out of control So how do we use that information? Well turns out That introduces the concept of health equity Health equity means everyone has the same opportunity. That's the care work fair and just opportunity to enjoy good health and If you don't have that fair and just opportunity, it's usually because of historical disadvantages or Justices and all kinds of inequalities that add up into the words We don't like to say every day like racism discrimination bias you name it That's where we lose equity This picture tries to show on the left equality Everybody has the same Support to stand on to try to see the game But that's not equity In the middle there's actually different levels of support to accommodate the different individuals That's equity the right side. You've removed the barrier totally some people call that liberation But that's sort of helping you just if you're a good visual learner understand equity and We apply an equity lens to these kinds of problems So if we think about respiratory diseases like asthma and things of that sort We have a lot of questions we can answer We frame from focusing on the populations with health conditions to the systemic Conditions that cause these conditions. So let's again look at asthma through a health equity lens the orange line is sort of the rates of emergency Department visits for people with asthma We're using Kids and adolescents in this example low poverty medium poverty high poverty The darkest on the left is cockroaches turns out people who are living in the worst levels of poverty have The worst levels of emergency department visits for asthma same thing applies to rats dust mites all kinds of vermin if You move on to the lighter blue the things like mold and secondhand smoke the same relationship holds So obviously that leads to a whole set of questions like what are the maintenance requirements for rented properties? How do they maintain either harmful living conditions or improved living conditions are the resources for mold treatment and Removal etc. Etc. But this again illustrates housing is health care Doesn't matter how well managed these kids are by their pediatrician or pulmonary specialist Where they live is determining why they're so sick Stark example So we'll keep these concepts in mind as we go on through the rest of this talk I was asked to address. What is the state of health in Vermont and broadly speaking? We are always one of the healthiest states. We should all be proud of that We're in the top five every year depending on who's doing the analysis whether it's the United Health Consortium whether it's Commonwealth fund there's a whole bunch that do this analysis but I've just illustrated it depends who you are So the average remuner puts us into that group of top five states of being healthy but When you start focusing in on people by race By their gender and sexual orientation by their disability status or by their socioeconomic status or even if they're more rural in a pretty rural state You start to see all of the disparities in health So unless you focus in in that way you delude yourself into thinking we are a healthy state and everybody enjoys good health And has the same access and opportunity to good health We do a state health assessment and a state health improvement plan every five years and The last time around these are the things we chose to focus on the broad area of child development The high cost and impact area of chronic disease and then very obvious things mental health and substance use disorder This is even before the pandemic and we added in oral health because there were such disparities and oral health for our children in the state We knew we couldn't look only at that We had to look at the social conditions as well that we discussed already during the talk In aggregate to really get a good picture and our aspiration was if we had worked over five years and weren't Interrupted by the pandemic And we're working towards Achieving health equity we would have accomplished that people have a fair and just opportunity to be healthy And it would have looked at the core values of equity Affordability and access and then everything on the right side of the slide are all those social determinants Whether it's your ability to exercise have healthy food have quality housing you name it have a great job It's all in there because again the recognition is public health is not just fix the disease It's prevent a disease by providing the most opportunity to everybody who lives here and So when we talk about how do we reduce health inequities? The traditional what we call downstream approach is our health care system. It's managing disease and Trying to counsel and educate people about risky behaviors and lifestyle choices Not enough to accomplish this task The now called midstream approach is addressed the social determinants in our physical and social and economic environments the most enlightened and current upstream approach is work on these inequities acquisition of power and wealth Racism Discrimination on the grounds of disability status gender you name it Obviously public health can't do that work in a vacuum They need every partner they can have and it has to be a whole of government and a whole of society approach So let's talk about a little bit How do we actually do evidence-based public health practice? so you know during the pandemic people saw this in action all the time and Discerning people began to come out on one side or another of policy decisions that get made but really Public health practice that's evidence-based is trying to integrate science-based interventions with community preferences to improve the health of the population Not everyone's going to agree on everything. We know that We try to be data-driven. We try to use the engagement of communities We have evaluation components and we look at the acceptability of something because you can tell people do this Something like wear a mask Who would have thought that might not be acceptable in some way for preventing a respiratory disease from being spread? Other things you might ask people to do they might go well, I'm not going that far So you have to understand just like if I tell you You need to have a colonoscopy starting at age 45 and you laugh at me and go there's no way in hell I'm doing that well that was an unrealistic thing for me to counsel you about But the reality is I could prove to you that that would actually be a life-saving potentially life-saving intervention for you to have and Political considerations and I don't consider my job political but lots of people do consider it that way But you can't ignore them. So we talked about fluoridating water. Well, how many communities have had major you know upheavals and Controversies and have not chosen to fluoridate their water because they believe there are adverse impacts of that that outweigh the public health benefit We have an opioid use crisis And we do things like tell people to go to needle exchanges and get clean needles. So you don't transmit hepatitis or HIV well There's a little bit of stigma that goes in that makes some people say you got to be kidding me And now we're talking about overdose prevention centers And there's a lot of stigma that goes into people saying you've got to be kidding me yet on the other hand if you can prove that These are harm reduction strategies that save lives and people might eventually get to treatment and have a successful productive life You've got to balance it with that and then We try to get people to stop smoking one thing to sort of you know Tell kids in school. It's bad for you tell adults here take take some gum or take a patch and see what happens but There's also like we can tax the hell out of it and make it so expensive that people will stop buying it and We could do that with vaping which we just did a few years ago So every public health decision even if it sounds really important and good for us all It's going to be met with some element of political controversy This is just the toolkit for what we used in COVID Less people think we were such geniuses. I mean, there's only so many things you can do to prevent a respiratory virus So of course stay home when sick is like number one on the list but it's also, you know social distancing and coughing in your shoulder and Washing your hands all the time etc. But then there's things like Masking indoors with a high-quality mask. Do you just recommend that? Do you mandate that? Get testing See if you have a close contact that person should be quarantined. That's a huge thing for disrupting somebody's life Don't go to a large gathering because you're more likely to get it there than you are if you stay away from large Get vaccinated get revaccinated get boosted Stay up to date Require a vaccine passport to get into somewhere and then stay home stay safe Which is of course the lockdown kind of thing. So all those kinds of things people think, you know Well, they don't think we were cavalier about any of it But the reality is we didn't have a pandemic we had five Because if you really look at the different parts of the pandemic Different decisions were made from the beginning whether we had nothing to fight the virus To when we got to Delta to when we got to Omicron, etc It was a different virus. It was a different population and their level of immunity There were very different tools at different times. So every decision had to be reanalyzed because we were in a different place and Not only were we in a different place But when it came to the decision-making we had a lot of work to do Not only did we know that someone getting sick has a big disruption to their life and the lives of those around them But they also have a significant risk of getting long COVID Fortunately that risk is decreased over time, but it's still present And we know that there are some groups of us that are more vulnerable And I see a number of masks here and I see the age of the people here And it's like people understand that they're more vulnerable and some of you may actually have illnesses too that make you feel more vulnerable So we have to balance Everyone who feels they're vulnerable with can society function if we enforce certain rules on everybody in society And that changed with time during the pandemic too and then We learned Collectively as a society and as public health across the country about health equity Because the statistics for the BIPOC population were absolutely much worse than for the general population And then in Vermont we found we had outbreaks related to multi-generational housing Which not everybody has but certainly our refugee populations That was a frequent occurrence the very youngest and the Very oldest all in the same household. We had migrant workers in our apple orchards and elsewhere We had cultural groups that were networking through what we call sociocultural networks Which increased their risk based on the activities they did in common And then even in our correctional facilities we had no deaths in corrections We had plenty of outbreaks, but we had plenty of policies to protect those in the correctional facilities We also had a subset of our incarcerated in Mississippi and Mississippi had essentially no policies And had much larger outbreaks than we had here And it was really challenging to try to manage one population. That's in two states and one state We had little control over People wondered about why didn't we mandate a mask when Delta came versus we mandated it earlier And I've alluded to the fact that there were different aspects of the pandemic that you had to look at all the data at each time But think about what we were facing as we were getting into that phase of the pandemic We had multiple issues in our society. There was mental health for sure Suicide as part of that increase in substance use The isolation social isolation is really the thing in public health that leads to all the bad outcomes Well, that was certainly part of the pandemic We had the impact on our kids whether you measure that by academics or by their social or emotional development And then this concept of health debt Which essentially refers to the fact that we might have had good lifestyle choices in terms of physical activity nutrition and avoiding bad things Prior to the pandemic, but then a lot of those habits got worse during the stress of the pandemic and Made chronic disease higher in prevalence Exacerbated people's underlying chronic disease and leads to long-term negative health impacts Which means the chronic diseases we were already having trouble with are getting worse and when you read in the summertime and all this year about our emergency rooms being full and Hospitals actually being challenged in terms of having enough beds. It's not because of COVID patients being admitted It's because a chronic disease And then of course there's navigating trade-offs every governor wants their state's economic status to be as healthy as it was without a pandemic during a pandemic Really challenging for that to happen needless to say However, you compare us to a state like South Dakota for instance similar size Republican governor rural state We have the same economic Outcomes that they had in terms of getting back to the GDP we were before the pandemic and our workforce employment and all of that yet We had like the best experience in terms of lowest deaths in the country And cases and hospitalizations and South Dakota was on the other end of the spectrum because their governor said I only care about the economy School closures, of course were a litmus test for everybody's patience and perseverance And evolve during the course of the pandemic. Do you recommend something? Do you mandate something? Do you have what I call a nanny state versus a savvy state? So a nanny state would mean Sugar sugary beverages are bad for you and they're going to give you obesity and diabetes So we're going to tax the heck out of them and we're going to make them hard to be accessible versus a savvy state that's sort of like well, we're going to try to do all that but Educate you more and not really Impinge upon your lifestyle choices as much These are really challenging decisions as you might imagine that public health officials governors legislatures all go through The key to success by the way, if you didn't know it already is frequent communication and transparency So we're going to focus a little bit on environmental health now at this phase Because it's all around us, you know, we've activated what we call our health operations center That's like our emergency response arm in public health four times in the last couple years first covid then Mpox Then that winter storm that was such a high wind thing and a disastrous thing with power outages and all of that That was a very short activation And then the flood of course And everything that we're seeing to this day so we have an environmental health component in addition to an emergency preparedness component That traditionally looks at things like lead and you may recall we passed some laws about lead in school drinking water To protect our kids brains cyanobacteria, which is the blue-green algae food and water safety and climate and health We only have like a One and a quarter FTE doing that work Because we rely on CDC for a lot of money and there is no money for that yet But If you ask the World Health Organization They say what's in the title that climate change is the greatest public health bread in the 21st century If you ask all the major health organizations, they call it a public health emergency and if you Read a Editorial from journal editors in 2021 of all the major medical journals They basically say if our global temperature goes to that degree, which it already has it's the greatest threat to global public health so We have analyzed our situation in Vermont and we think these are the six key health impacts First of all heat related illness. We're talking heat exhaustion heat stroke things that you try to prevent every day with air conditioning and Sometimes they're challenging to prevent because we have three days of 90 plus degrees in September. That's a heat wave And if that keeps going on, that's not good Storms and floods like we just went through our biggest emphasis was on molds on debris and Hazards in the water ways that people wanted to recreate on and Water quality issues because of the tremendous influx of bacteria as well as chemicals Vector-borne diseases We all know Vermont has a lot of ticks and has Lyme disease But there are many other vector-borne diseases that ticks provide called the BC osis and a plasmosis and now mosquitoes West Nile virus and there's going to be a press release in minutes You're getting to know at first talking about a horse who just died of Eastern equine encephalitis triple E No human has had that this year. No human has had that in Vermont in 10 years But we found mosquitoes in it this year that that have it in their testing for the first time since 2015 so we're putting out a little special alert now because Humans who live in the areas of concern which are in grand aisle and Franklin counties Need to be cautious and probably not Going to football practice in the evening when the mosquitoes are out biting Cyanobacteria blooms the more erosion and Flooding you have the more phosphorus goes into the waterways. Let's say all bacteria love that And beaches were closed during these heat waves here in Burlington Water and foodborne diseases go without saying and then air quality impacts By that we're talking about wildfires From Canada, which are not rare anymore Respiratory allergens like pollens that are increased in frequency with the longer seasons because of the Climate change that's occurred We now have an air quality index that you can go on our website and find out if what the air quality is that day and What zone it's in in terms of what behavior you should do or not do and Then we have the confounding Confluence of things where we have people in Montpelier finally able to go outside and Cart out all the furniture that they have to throw away All the drywall that they have to throw away and we want them to be outside and away from the mold But it's a day that the air quality is in the red zone And it's like you shouldn't be doing exertional work outside that day This is this is what has happened now not to make you lose hope or anything, but But this is what we're facing And Back to health equity if you're in a marginalized population that impacts you more so who lost their housing It wasn't most of Montpelier That they lost a lot of businesses and that's very tragic but the people who were living along the rivers and Lost their housing and their mobile homes were actually people in the lowest socioeconomic class in the state And so it's almost a form of rural red lining if you will we're in cities You know there are neighborhoods that nobody would want to live in but people are living in and it's been orchestrated by society Why they're living in those neighborhoods and they have the worst air debris they have the asphalt jungles no greenery etc And here we are in a rural area like Vermont and if you're more socioeconomically challenged You ended up having a bigger hit from these natural disasters and of course We can exacerbate that further if our solution is to drive electric cars and give subsidies to those who buy them Well, that helps the wealthy, but it doesn't help the people on the lower end of the economic ladder Multiple other impacts in terms of mental health in terms of Especially in our farmer population and their crops have been really ruined. Thank God Agriculture has come in with some economic relief for them Exercise we're telling people to be healthy and exercise But if it's riskier for you to be outside because it's too hot or because you like to hike But don't hike because there's too many ticks or whatever. How do we give those messages and achieve an equilibrium there? chronic illnesses all Physicians know do much worse in heat and then soil and crop damage leads to nutritional issues So what else does public health do? You may not have known we do this in public health So we have a very active and I'm being selective here We have a very active maternal and child health section. We now call it family and child health to try to be more Equity-minded if you will but the fact of the matter is they do things throughout pregnancy throughout early childhood years through adolescents focusing on getting people to breastfeed school health issues adolescent health issues prevention of substance use and other things like that and we have a WIC program women infants and children to really help the nutritional status of those who are below a certain level of the federal poverty level I Like to think of the work. I've done with my department in that capacity as preserving kids brains So I talked about lead in school drinking water the biggest source of lead of courses and houses that were painted before the 1980s where lead-based paint was used and We still have problems in that area, but we've really taken care of a lot but now we found lead in the drinking water in schools and Fortunately an easy way to mitigate that but that was a success story We have a trio of laws to combat vaping that were passed a few years ago One was to increase the age of using any products to 21 The second was to put the same excise taxes on these products as on combustible traditional cigarettes And the third was really internet protections because kids could go on and say what they they were whatever age They wanted to say and buy these products, which is not the intent We focus a lot on building resilience across state government preventing what's called toxic stress Which leads to what are termed adverse childhood experiences that? Really set a kid up very poorly for a successful life We have a substance misuse prevention council emphasis on the prevention and then the whole issue of recovery from COVID Has been focused essentially on kids and mental health and all of that stuff that we talked about earlier, so There's an actual section called health promotion and disease prevention, which is where my heart is and I wish I could do more Because as an internal medicine physician I want nothing more than to prevent all the chronic diseases So we don't have to manage them all the time anymore and keep society healthier but the reality is they get the less federal at least federal money of anybody and It's not that people don't understand it But there's so many other pressing things I think that it's hard to just sprinkle the money equitably everywhere But our tobacco control program is housed there oral health Which we're making some progress in Vermont on is housed there still have a lot of work to do with lower socioeconomic class individuals and preserving kids teeth at those ages We have self-management programs for diseases like asthma and diabetes And now a whole new focus with our partners in the Department of Aging and Independent Living is Healthy aging because the reality is we are one of the three oldest states along with New Hampshire and Maine And not only do we have to worry about that demographic We also have to realize that anything you do to make aging healthy is helping everybody at every age So it's helping the family that's just arriving in Vermont to grow up in a good healthy place It's helping the person who's going to take a new job and come to Vermont to live The the rising tide raises all boats essentially as the concept I did mention earlier emergency preparedness and injury prevention That is really what happens when there is a major disaster that arm of our operation goes into play We run the EMS around the state We do all the Disaster response and then in prevention we do things like falls prevention and older people we do Suicide prevention no matter what your age things that actually take a high toll in society Injury prevention would also be considered to include opioid overdoses and things of that sort But we have a whole other division to deal with those But are we prepared for the next public health emergency? Well to be prepared these are the ingredients you need a workforce number one the health care workforce struggled during the Pandemic and lost a lot of its membership due to burnout Same thing has happened in public health But it's happened in multiple sectors of society and if you listen to Governor Scott Every sector is challenged in Vermont with workforce. We don't have enough people moving into the state to help us with that Data modernization the CDC has admitted a true confession to the country that you know they're antiquated when it comes to the what what they operate on for data and Congress gave them a lot of money. They sprinkled that money to states We're benefiting it from some of it, but there's a lot of work to do and it doesn't happen overnight Infrastructure sort of involved in that as well laboratory capacity Lots of public health emergencies require a public health lab because not everybody does test for things like anthrax and Rison and and other biohazards never mind the amount of testing that needs to be done early on with something like COVID before you have Healthcare system capacity Congressional memory, I wish I could be optimistic there You know lots of pandemic money came during COVID most of it runs out 2024 and 2025 and listening to the rhetoric there won't be any more coming but the whole thesis that we present is the country was not ready for pandemic when it when it hit us and not only was the country not ready the The the bottom line is we had a 50 state strategy. We didn't have like a national strategy And leadership to help craft that so I don't see I see the leadership having evolved, which is great But the congressional memory is like they got too many other fish to fry and they're not going to be giving us a lot more money And we'll be in the same situation with workforce and infrastructure that we were in pre-COVID and CDC funding is totally reliant on congressional appropriations and state health departments like mine are Really highly not totally highly reliant on CDC sending us money so I think you know we proved we were pretty prepared in Vermont, but it's not optimal and We'll be as prepared for the next one But we're challenged by everything on this slide And then some overarching themes. I'm just gonna Focus in on this one with actually I'm going to ignore this one because these are very COVID related But I did want to talk about this the word zoonosis means it's an infection That's usually in the aminal animal world and then goes to the human well This is our future. We saw it with COVID. We saw it with M pox and We'll see it even more Climate change is doing a lot of that The mobility of populations obviously things travel through the world very quickly We are encroaching on animal environments and on the eco zones There are concentrations of humans in cities and there are concentrations of animals and markets like Wuhan Everything on this slide allows a zoonosis to sort of take hold and perhaps spread so It's the expectations in the infectious disease in public health world that this is going to happen more frequently So it will not be a hundred years before this happens And then the last topic is going to be just to give you up-to-date information on opioids We have a substance use programs division that deals with everything that's on this slide and it's all critical stuff Currently in 2023 95 overdose deaths through May Three-year average 78 that tells you we're not going the right way yet And to reinforce that this is data through 2022 the blue line shows the rate the others to show the numbers obviously tragic occurrence going on with deaths from opioid overdose in our society Keep in mind. I am still subscribing to the fact that it's not because we're not doing anything It's because the drug supply is so toxic at this point in time and people succumb very quickly We have a whole bunch of things going on Fortunately, we're starting to see millions of dollars come into the state for opioid Settlements, and we have a whole committee that I'm in charge of that works to get The right the right money to the right place, which I'll show you in a second We pioneered decriminalization of buprenorphine, which is the major drug besides methadone used in medications for opioid use disorder and Decriminalizing had no adverse impacts. I wish it had more beneficial, but it didn't Decriminalization of other substances and overdose prevention sites are hot topics now, and I won't give you opinions But just say that they are under discussion, and they are having presentations to our committees We have a mental health integration council because mental health is so poorly integrated into general health care Our hub and spoke system, which is really nation-leading for in the country For treatment of opioid use disorder is going to broaden more so that it manages all substances and so that it manages co-occurring mental health disorders and then dovetailing into this is a public safety initiative with the governor's Point plan because there's been more violence in our communities Some of which is related to this epidemic And Here's where our moneys went in the last year. This is eight plus million dollars. We focused purely on harm reduction more naloxone in all kinds of places fentanyl and xylazine test strips Wound care because xylazine causes horrific wounds, and that's a way to get people involved in your system Stimulant use disorder we have more than I can imagine people dying Thought they were using cocaine and methamphetamine, but it wasn't it was powder that had Fentanyl mixed in with it and because they didn't have tolerance to fentanyl. They succumbed to an overdose So there's an actual evidence-based Incentivization program that's used to treat stimulant use disorder that we're going all out on and then drug checking services with people Without liability you can get their powders checked and understand what it is they're injecting and Then enhancing access to the treatment system because so many of the overdose death people were not connected to all the treatment So trying to increase our hubs and make them more geographically accessible Outreach workers whether they be on the streets and homeless shelters in hotels Finding people where where they are essentially and then hopefully One of our principles invest in youth prevention We will return this year to also some monies going specifically to youth prevention amidst this need for great harm reduction so that's sort of going to wrap up my presentation I've taken you on a whirlwind tour of public health and I thought I'd leave 15 minutes for questions. It turns out to be 11 but I Can stay a few minutes after for those who don't get it their fair shake great. Can you hear me? Yes One quick announcement those of you who are expecting the Harborview bus. That's coming at 15 minutes after three You don't have to rush out Great. Do we have any? Questions on zoom just one. Well, let's start with that. What about firearms and public health? Yeah What about firearms and public health? So that's a big one for me Early early during my time as commissioner. We had that Fair Haven event Which got from vpr It got jolted was the name of the thing because the governor was jolted by what he saw Which was a plan for a former student to go back to the school and shoot up the school So some important gun laws went into effect then which had to do with extreme risk protection orders mental health state Background checks, you know some fundamental things that one never would have thought would have happened in Vermont So public health was in the background. We weren't certainly leading but we were providing the evidence basis and all of that Which I think was important But the other thing is more recently As you know suicide occurs most successfully with a firearm So there was a law that was just passed that the governor did allow to go into law That was basically focused on a waiting period so people don't have the opportunity to make a rash impulsive decision but can actually Have to have to wait several days where perhaps they would have thought things through a little differently or access some other help There's also been an expansion of some of those background checks and the safe storage aspect of firearms Which is probably the number one public health thing kind of got into law this past Congressional set legislative session. So a lot has gone on That's good for public health and good for everybody Without necessarily as it goes taking away guns from people And interfering with their second amendment rights of doing common sense public health interventions So that's a big role for public health. The CDC now has a very small component of its operation devoted to that Dr. Levine, I don't have a question. I have an observation. I think I'd like to thank you The effect efficient way Orderly way Intreating vaccinations for COVID Thank you for that and I would just comment again Communication and transparency were everything we we told the state. Here's our data Not everyone is dying from COVID But there are people who are dying at a much higher rate than everybody else and it was really a very nice relationship Graphically to show that the older you were the more risk you had So why wouldn't it make sense to put you first in line and not a 20 year old who works in a supermarket and feels That they're exposed, but they might die Mark over here Thank you for that wonderful presentation. It was very clear and Gave us a lot to think about and to understand as well. My question is is their research that supports getting vaccines Let's say a month apart So if we're talking about COVID's newest variant The flu and RSV What research is there that says that spacing might be more effective than having them collectively given Yeah, glad you asked that question. I Could just turf it and say come to the press conference next Wednesday because We got to talk about it, but the reality is you'll get it first Flu and COVID the research is fine at this point getting them together does not reduce the effectiveness of one or the other And really doesn't enhance your getting bad effects or anything of that sort and if it does nothing else it Acts as a memory for you so that you're not going to forget one or the other because you got them at the same time The RSV is a new vaccine just out this year just so people know it's for over age 60 It's not one of these mRNA vaccines like the COVID one. It's a traditional protein-based vaccine and If you're over 60 and especially if you're over 60 and have significant lung or heart disease That vaccine is for you. It's being billed as recommended With shared decision-making shared decision-making is codeword for talk to your doctor But it's also codeword for the committee wasn't ready to say 100% just get it And don't ask questions because there were a And I don't want to overblow this a slight amount of neurologic adverse effects in a small number of people That were in the trials. So we call that a signal. It wasn't a statistically significant outcome It's the kind of thing you want to watch closely post marketing once it's out there in the population to see is that real or was that just An artifact of the study population So that's the caution in it But the other caution is we have no studies that show whether getting it with or without another vaccine Makes it as effective as it is billed to be and it's quite effective by the way in reducing RSV hospitalizations in older people with these diseases, so I Tell people I wouldn't get it with another vaccine But there's nothing out there that says you can't do that, but there's just no data you mentioned in passing the large settlement opioid settlement and I may be confused about this so if you can help me my understanding is that the case is going to the US Supreme Court Because Purdue pharma and the Sacklers were able In all of those negotiations to say that this was really a bankruptcy and so that put some limits on both the amount and the timing of that of the payoff and So do you know is it at the Supreme Court now or is the state actually getting What they're supposed to get over that agreement you're talking about the Sackler I'm talking about I'm talking about but isn't that what the opioid money to the state is coming? We have seven different funds. Oh, okay. So Sackler is the one that's still tied up in the courts Even though it was probably the first one It's supposed to be for us three million dollars a year for 18 years So 54 million dollars, but we do have a number of other manufacturers as well as distributors That we're getting money from right now so Over the 18 year period we'll have an excess of a hundred million dollars Sounds like a lot, but you've got to realize programs you institute today if you need to keep them alive They need to be subsidized each year So reduces the amount you have for something new the next year But it's really good because it combines with our state money which is three million dollars a year for prevention for kids and Now federal money which we've been getting for many years that is more substantial Mark my question is tangentially related which is that how does the availability of specialists in the hospitals and the inability to get timely appointments in fact Yeah, good question So the question is Let me turn this the question is We have a problem in our hospitals and in our healthcare system with Access to specialty care and long wait times. How does that affect public health at large in the state? So, you know the flip side of that is we actually have really good access to primary care and Even though you may need to wait for your appointment We are like one of the best states in the country. If not the best for the number of people in our Population that have a primary care clinician So that's good because primary care is capable of managing a real lot But I do agree that there are things that have to be elevated to specialty care We did some you know when Secretary Smith was still here we did some studies with UVM of what is going on there and I think the bottom line ended up being a Problem with hiring people Often because Vermont didn't pay the kinds of salaries that other states pay Etc. And so it was very hard to solve the wait time if you couldn't increase the number of people in the practice We don't have a good measure to say how that's impacting public health in general Most of the measures in public health rely on access to health care and that's a very broad category So it doesn't isolate out access to primary care access to specialty care And so by that parameter, that's one of the reasons we rank so high all the times on these health surveys Is because we have access to health care. I'd like to think in an emergent situation We also have access to everything that you would need in terms of specialty care But I can't give you a firm answer about how it's impacting public health in general Just because we don't really have that measure Mike my question is in the relationship with public health and mental health systems and I Was pleased to see that the priorities of dental and mental went up on the list But it has traditionally, you know gotten short shrift both have under insurance systems and other ways And so I is my impression I wasn't living in the state Over the last 40 years, but it many states did devote more money I believe in attention to an organized mental health care system that worked well And I have the impression that Vermont retrenched on that score. I certainly from specialized care And but in any event coming up to the present I'm interested in your your overall I have a particular question. Is the Department of Mental Health and the Department of Health Well-integrated how well they work together. That's a broad probe kind of question and yeah Where do you see most of the action I saw a number of signs that suicides getting attention and violence to some extent and opioid but Mental health. How does how do you see it in in relation to that as particularly picking up on the specialized care part? Yeah, good. So mental health integration Council, which I mentioned I Co-chair that with the deputy commissioner from the Department of Mental Health. So we're very tightly aligned We have our last meeting after a year and a half of meetings next week Actually, and we're going to come out by the end of the year with a whole set of recommendations about how better to integrate mental health And to overall health care There'll be things like the whole health model, which just by the sound of it sounds like we should all want it But but it is a real evidence-based program. There are things like Integrating or embedding Mental health expertise in primary care settings, which is already happening in some parts of the UVM Medical Center and elsewhere There's a whole host of things that actually can improve that integrative piece not to mention the way we pay for things and the way we incentivize care because Health care reform has got to be a core piece of this Just as you alluded things don't always get paid for the way they should and they certainly don't get incentivized the way They should because there's a lot of services to be delivered Not only traditional health care and physical health, but the mental health component the substance use component, etc so Can't solve it all overnight, but we are very integrated at the state level and recognizing the problem Calling it out and it was one of the major reasons We took masking from a mandate to a strongly recommend later in the pandemic Because we really needed to have people able to focus on these emerging problems that were so severe at the time and still Thank you I was very pleased to see your emphasis on oral health, but my understanding was you're talking about it primarily in terms of Oral health programs for children But it's my understanding that oral health Has an impact on many other aspects of systemic health throughout the lifespan Yes, and he made any many ways becomes more acute in the elderly Could you talk a little bit more about? What you're actually doing for oral health and children and whether their plans to expand expand that extend this to Good, you know throughout the lifespan, so the big part of that starting with the adult is Especially with periodontal disease These in the gums and inflammation There's correlations with cardiac disease and other severe outcomes in adults again The adult who's a general average Vermont retiree Probably has access to all the care they're going to need on that part of the spectrum But if you look at those in Medicaid We don't have enough dentists Dentists can't survive economically in the state if they take a hundred percent Medicaid and that population Was only getting reimbursed at 50% of the rate So the law went into effect in the last Session that raised that to 75% and we have good news from the dental community that that was a positive thing for them They would actually increase the amount of Medicaid that they saw so helping the adults But the real problem is pediatric dentistry and having enough people to see kids Especially kids who are socioeconomically low on the ladder or have other reasons in the health disparities list to not get the care There are so many novel interventions varnishing of the teeth Substance called silver diamine fluoride which not only identifies cavities, but manages them and Just general preventive dentistry that many of these kids have no exposure to so the goal is to Find a touch point Touchpoint may be a school nurse Maybe a pediatrics office. You don't think a pediatricians is doing dentistry But it's very easy to paint the varnish on kids teeth The touch point may be somebody coming to the school as a dental hygienist who Works for the health department We have numerous places to try to put that but that system needs vast expansion and more financial support But that's the key to the future because there are kids at age three who have been waiting a year I hate to say it to have their teeth pulled Kids at age seven or eight that have been waiting over a year to have their teeth pulled because they're no longer Disavagable, but they can't even get in to get that done in a timely way So we have a lot of work to do That's why oral health was prominently in our state health improvement plan and we'll remain so but it's Evolving in the right direction, but it's Thank you