 Hello, I'm Dr. Louis Myers, Vermont physician, and this is the first episode of a new series called Health Care Today, in which we're going to explore various medical health policy and research issues that affect Vermonters in the healthcare field. I hope that this will be interesting for a general audience, as well as other physicians and researchers, and that we'll get some feedback as we go along. I am so honored today to have as our first guest on this show, Dr. Mark Levine. Dr. Levine, as many of you know, has been our Health Commissioner in Vermont for the past six years, and has been with us through the COVID epidemic and through so many other important health issues. Briefly, Dr. Levine grew up in Massachusetts. He went to medical school in Connecticut, at the University of Connecticut. He did his residency in internal medicine at the University of Vermont Medical Center, and has been in Vermont since, along with some other training that he has undergone. He was the head of graduate medical education at the University of Vermont's medical school, and approximately six years ago, Governor Scott tapped him to be our Health Commissioner. Dr. Levine, welcome. It's great to be on to kick off your show, Louis, and I do have to make one correction. Yes. The University of Rochester. Oh, Rochester. Excuse me. I'm sorry. But I think most Vermonters recognize you as one of the people that they turn to during the, particularly during the first couple of years of COVID, when you and the governor stood side by side, often three times a week in your press conferences. I think it was appreciated that you presented the information clearly and calmly, and helped us through a very difficult time. What are your memories of that first year? You know, I have to say, there were many correlations with internship. Internship and your training. In my training. Basically, it was night and day living this experience. But it moves so fast, and there were so many unknowns, just like internship, where you're learning how to be a doctor and a whole host of conditions. Well, we knew nothing about COVID. So the amount of learning that I was doing at that time, along with everyone else, and then trying to convey that information as rapidly, as credibly, and efficiently to people as possible, because everyone was anxious, everyone was scared, and they really didn't know what to expect. Where were you getting most of your information from? Well, we have a great Department of Health with an epidemiology section, so we had a lot of very local data. We were looking to major organizations like World Health Organization, CDC, to get as much information as they could provide as well. It was really a community of learning, if I can say that. I don't want people to get the impression that nobody was competent in the beginning, because we have so much experience with epidemiology, so much experience with respiratory, viral, infectious diseases, that we could draw on all of that. There was a pandemic preparedness plan made for the flu virus from about 2017 to draw on, even though we couldn't use every piece of it. So we had a lot of building blocks in place. But again, this was truly called at the beginning a novel coronavirus, and it was just that, so we had to learn as much as we could as quickly as possible as it traveled from one country to another and tried to apply strong public health principles in our ability to have people stay safe. Well, we have learned a lot about the COVID virus. Where are we now? We hear that the numbers are down in Vermont. And yet I guess one question I would have is now we also know that the current iteration of the virus is symptoms tend to be less severe. So certainly there are probably people who are getting COVID and may not even be testing themselves, just stay home for a couple of days. There are others who take home tests, may be positive, but they're not reporting that. So how do we know that the numbers are as low as projected right now? Yeah, we actually don't, to be completely honest. However, we have a pretty good handle on things. We look at things like syndromic surveillance, which means checking with emergency departments and urgent care centers to see how many people are presenting to them with symptoms of things like COVID or flu or whatever illness we're interested in. And those are at fairly low levels for this time of year. As you kind of pointed out, we have this Omicron version of the coronavirus that's been with us since January a year ago. And it is a very different part of the virus compared to where we all began. The virus itself seems a little more transmissible, but less virulent, meaning not causing as much disease, severe disease. But in addition to the virus being a little less virulent, we're finding that there are people who are more protected than they ever were because they've had the virus before or they've had some version of the vaccine or number of vaccine boosters. And that makes them a little different than we all were back in the beginning in 2020 when nobody had any immunity to this at all. So we look at syndromic surveillance. We're looking at hospitalizations which really aren't very high at this point when it comes to COVID. There are plenty of people in the hospital, unfortunately, but COVID fortunately is not the driving force. And we're looking at the number of deaths and it's markedly reduced. But this is not to say COVID has gone away. And in fact, even though the White House's office for COVID preparedness is now starting to vanish into the background, that's really still in the setting of perhaps hundreds of people still dying a day in the U.S. from this virus. Let me ask you this. From what we know now, and of course we know more now than we did then, as you've said. There is a debate now as we look at what's happened in, for example, the school system. Particularly the public school system and particularly school systems that serve kids who are in economically challenged neighborhoods, that the test scores are down. This is nationwide, not just in Vermont in math and reading. There's been increased in anxiety and depression in young people. There's been an increase in crime among young people, some of which may be related to the schools having been closed for so long. Question, did we close the schools for too long? Well, I'm glad you're addressing this topic because I think a big mistake that most people have when they think about, in medicine we call it, looking through the retrospectoscope. You know, looking at the last couple of years and saying, you know, what did we do well? What did not we do well? Big mistake is treating this as one virus, one pandemic. I look at it as five viruses, five pandemics, and we learn something new every time. We started with the original coronavirus, none of us having immunity or anything. We moved on to the UK variant. We moved on to the Delta variant. We have the Omicron variant. You know, you keep moving along and the population is different each time because we've had the benefit of vaccines, of treatments, etc., because we've had exposure to the virus or not, and the virus itself is different. So early on, school closing was one of those major things that happened that was appropriate in an effort to try to prevent the transmissibility of the virus from person to person. And we didn't know enough about how it did or didn't impact kids at that time. And it was part of a broad portfolio of public health measures that, in Vermont, were called Stay Home, Stay Safe, in which most people agree was very beneficial at that point in time. The we part is, you know, there's we in Vermont, there's we in the US, there's we in the world, and it's all different levels. But I'd like to say that we in Vermont tried to transition as quickly as possible from remote to a hybrid kind of learning environment and then eventually get the kids back to school quite soon compared to some other settings. There's no question that what we're dealing with now is big problem with academic performance, and we see that in the test scores. Big problem in emotional and social development. Big problem in the way that society is functioning in the mental health of all of us, whether you're a youth or whether you're an adolescent or an adult. So did we close the schools too long? I think the schools were closed for an appropriate reason and an appropriate amount of time. I think that over time we tried to do that transition back to a healthier state for our students and then eventually got them back to school quite brusquely with, by the way, a fair amount of resistance from some parties thinking we were going too fast. The teachers were at too high a risk. Individual teachers worked their tails off trying to get students through this online. Teachers unions, not just in Vermont but across the country and many big cities across the countries we know were very resistant to reopening schools. How did you as a public health official and the head of the public health department interact with the teachers union to try and share this information? I can't tell you how many Zoom meetings we had with the NEA, which is their union, with superintendents. Our department, the Vermont Department of Health, works very closely with the Vermont Agency of Education, which is the state sector that deals with our whole educational environment. We also, by the way, had regular meetings with all of the leaders and the leaders of student health clinics in our college system across Vermont. So we were very engaged at all levels of education in trying to do the right things and, believe it or not, problem solving every step of the way. So we were actually partners as opposed to dictating one policy or another. We were actually partners in trying to make sure that what we were doing seemed right and was going to benefit the students and staff in all of these settings. You know, nationally, I believe it's 20 states thereabouts. All of them with somewhat conservative legislatures have now passed bills which will mandate or prevent the use of mandates, such as you've had. Now I know you're in contact with your colleagues who are the other commissioners around the country. How will they deal with this in the future if there's a legislated bill that says what they can and cannot do? You know, that has happened, as you point out, in a number of states. Thank goodness not in Vermont. And I've talked with these colleagues. They are very concerned because though I don't want to be a fear monger, we are not going to wait a century for the next pandemic. And even if it's not a pandemic, we're seeing a great heightening of more public health emergencies in their frequency of occurrence. So they see this as tying their hands tremendously and trying to do the right thing for the right occurrence and see it as, you know, very politically motivated and not really with a strong public health conscience to it. So we as an organization, the Association for State and Territorial Health Officers have actually come out with some position statements about this because we really do think that in the zeal to prevent mandates for masking or a vaccine or what have you, people are losing sight of the fact that there are going to be circumstances in the future which really demand rapid public health reaction and rapid public health mitigation procedures, which might be limited in these states that have forcefully limited it legislatively. Speaking of public health, I think it has been an under financed part of our health care system. And this certainly came to the fore during COVID and it's being discussed now, but what do you see happening in terms of the funding of her public health at this point? Yeah. So right now we're in a time of plenty. There have been a number of grants that public health departments have received from the federal government, congressional appropriations which go through CDC and end up with us. They funded a stronger workforce in epidemiology and laboratory science, a stronger workforce in emergency preparedness and a stronger workforce in immunization and in that field of health equity, making sure everybody, no matter what their skin color, their gender orientation, their socioeconomic status, has equal access and opportunity to good health. Do you think the money will continue or is this? Well, that's the problem. So the money is there and we're already starting to make plans for what will happen when the money runs out because by the end of 2024, we really are concerned that if there's no further appropriations made, these positions will disappear, which will bring us back to that historic time that you were speaking of, Lou, where the reality was decades of underinvestment in public health and in attrition of the workforce because it was viewed as something that didn't need to be supported, actually needed to be cut. So we don't want to get back to that point. We did pretty well during the pandemic in spite of the fact that we started with a lower workforce, but it was really all hands on deck. And we don't want to see that situation. And I think it should be emphasized that your agency handles much more than simply COVID. Tremendous amount. Just talk very briefly about some of the different departments that you have to discuss them. So COVID is part of infectious disease epidemiology and laboratory medicine, which is basically all infectious diseases, not just one. We have environmental health. And people have seen that in the news recently with this EPA's discussions of the PFAS class of compounds in water. The forever chemicals. The forever chemicals and the testing we're doing in schools across Vermont for PCBs, polychlorobiphenyls. And there's a whole host of climate change associated with environmental health. We also have a very strong maternal and child health section dealing with all things family and child development related. We have health promotion, disease prevention, because chronic diseases are the number one driving cost in our health care system. And we want to improve people's health and reduce the likelihood that you get chronic diseases. And of course, with the pandemic, people got a glimpse of emergency preparedness and injury prevention, which spreads, you know, to infectious pandemics like the one we had, but also natural disasters like hurricanes and things of that sort. So we have a lot of different departments. How many employees are at the public? We're in a 600 range, which is more than we've ever had, needless to say, but still probably could use more, to be quite honest. Let's talk about opioids, which is also... And that's our other division, substance use programs. And it's an important one. We know that we're in the midst of another epidemic, which is opioid use, opioid deaths. And unfortunately, directly or indirectly related to COVID again, with various service shutdowns and disruption in society, that opioid use and opioid deaths have skyrocketed again after making some progress. Vermont, I think, led the nation in certain ways. And I know you testified in Capitol Hill about the work that was being done in Vermont, particularly with the spoken hub manner of treatment. But now, the last couple of years, we've seen the death soar. Tell us where we are and what we're trying to do to stop this. Absolutely. So you're right. Back in the year, pre-pandemic, 2019, we had seen a significant drop-off in the opioid overdose death rate, which was completely overturned by the pandemic. And now, 2022 is the greatest number of overdose deaths we've ever seen in the course of a year. Tragically so. What fed into that? Some of that had to do with the pandemic, obviously. People were staying home, stay safe, meaning they were isolating. Isolation is a core problem in public health in general. And if you're a user of opioids by the injection route, the last thing you want to do is be injecting a loan. No one there to rescue you should something happen. So we saw that. We saw people's supply chains disturbed. People weren't always sure of what they were getting. Concomitant with all that, fentanyl has become the biggest kid on the block. And it is really potent. It is really lethal. Over 90% of our overdoses involve fentanyl. As if that wasn't bad enough. Lately, we've seen a drug called xylazine, which is not a narcotic. It's an anesthetic agent, often used in the animal world, which also, of course, sedates people and can depress the respirations and lead to an overdose death. And most recently, the newest breaking news is a class of drugs that also can sedate called gabapentin, which is often used as an anti-convulsant, often used for neuropathic pain syndromes. And now we're trying to figure out how much that's playing a role, because that's being cut with all of the other things that are in these powders. So a lot has happened to lead to the problem, but what has actually happened is we have now access to a lot more money than we ever did because all of the drug companies and the distributors that contributed to this widespread opioid crisis are now being taken to court. How do you want to use that money? And so we have an opioid settlement advisory committee that's essentially debated that recently and come up with a number of initiatives for spending the first seven and a half million dollars of that. We feel that primary prevention, meaning preventing kids and even adults and young adults from getting involved in this in the first place should be our number one charge. But fortunately, we have money going to that now from the state and the federal government. So we're delaying use of these monies for that because we have a crisis and death now and we want to spend the money on harm reduction and on providing greater access to treatment for people who may not have ever wanted treatment before. Which would include suboxone. So the harm reduction part includes a whole new suite of ways to get naloxone which is the reversal drug to as many people as possible through very novel ways. By the way, I think the FDA just today authorized over the counter Narcan. They did. Hopefully that's priced appropriately so people will access it. There's also a harm reduction for people to test what they are injecting. So fentanyl test strips and now xylazine test strips are available. We're investing in those. We're also trying as I said to get more people involved in treatment which is suboxone or methadone. Suboxone being the brand name for buprenorphine. So we have a hub and spoke system that is really unparalleled around the country. But the reality is there are still people who won't attend that. 75% of our overdose deaths involve people who never had contract with the treatment system. And well over 50% of those died at home alone. So we need to find them and make treatment attractive enough to them because we're not putting up any barriers to their access. Well, let me bring up this matter. And I know that's one that Governor Scott has already weighed in on, but I'll ask you. And that is safe injection sites which are being, this is places where people who use can come under supervision, clean needles, someone there to revive them should they overdose. Certain cities in Philadelphia, I believe in particular are experimenting with this. How does Governor Scott feel about this? Yeah, well, let me tell you how I feel about it first. I don't want to speak to the governor. I don't want to put you in hot water, but please either one of you. So I mentioned getting people involved in treatment. So I just want to broaden that one second. Creating geographically more equity. So if it's too far to travel to a hub, creating a setting where there's less travel. Finding through the use of outreach workers places where we can actually access individuals who haven't wanted to get treated before and find them and educate them more. Safe injection sites, also called overdose prevention sites, have appeared around the world, mostly in places like Vancouver and Sydney, Australia where the data is coming from. We have two in the United States right now in New York City. They've been running for one year and we're waiting to get more scientific research data from them, which they will be producing soon. Other cities have not done this yet. Philadelphia, you mentioned, Seattle, San Francisco. There've been a lot of barriers to why they couldn't do it yet. Number one being it's not legal for the federal government and there's no liability protection for those who would engage in helping individuals who come to them. But for your listeners to understand, these are sites where people aren't provided with drugs. They bring the drugs into the site and then are observed in terms of the injection. The site also provides a whole host of support services whether it be the lock zone and other harm reduction, might be a shower, might be a meal, might be counseling, might be access to treatment. The literature up until the last couple of years basically told us if you were within the walls of the site, you were not gonna die of an overdose. Thank goodness, so they were effective. The thing we've wanted to see for some time is if you're in the neighborhood, will you still see a lower overdose death rate? Not necessarily, but sometimes. And if you're in the region, will you see a lower overdose death rate? Because you can imagine these are not geographically located everywhere. They're in select neighborhoods and places. So in a place like Vermont, we have to think where would we position these? We're a very rural state and the opioid crisis respects no boundaries, so it's geographically everywhere. How would we integrate that into the state? And do these facilities actually provide more access to treatment, et cetera? So I am actually involved with members of our substance use program department in working on the literature analysis and I am warming up to the idea that these may be effective, though still unclear how they would work in Vermont. There's actually a place in Canada that does mobile safe injection. We'd have to learn a lot more about that. So what we're doing in terms of moving forward is in this committee I mentioned, we are taking testimony. We're gonna have the people from New York, the researchers from Brown, and others from Canada come and provide us with firsthand information so we can make an educated decision about dedicating future funds from the settlements to this overdose prevention concept. What I'm hearing is in the field of public health, there are no immediate decisions that occasionally there are, for example, in the initial thing with COVID you had to make a rapid decision, but otherwise you are looking at the data, you're talking to your colleagues around the country, people who have tried these things and trying to put all this information together, and then you have to interact with the political aspects, you and the governor, because obviously there are a lot of people in Vermont who would oppose this, and as you say that federal government still, there would be legal issues. And of course, even in the state, there would be legal issues. So the legislature had a bill pending that was going to examine relaxation of any liability concerns so that one of these could be opened, because we couldn't even dedicate money to this if there was no legal apparatus to support it. In the last couple of minutes we have, let me ask you this, what keeps you awake at night in terms of your job? Of what are some of the things you have that keep you awake and that you worry about? The thing that keeps you awake the most is what's happened to all of us as a result of the pandemic? You know, mental health is not something where we can just point, oh, it's affecting that person or that person. It's on a very broad stage in affecting youth, adolescents, and adults very profoundly. The substance use crisis has only worsened and it's part and parcel of that. The way... The staffing and the hospitals and the clinics has been hit. The whole healthcare system is very fragile, mostly because of workforce issues, whether it's public health, whether it's healthcare, it doesn't matter. But the reality is everyone's looking for someone to do a job and most of these jobs are really beneficial to all of us in society, yet we don't have enough people to do them. So those are very, very significant concerns that are on my mind. The rate of chronic disease and the adverse health behaviors that many people in society adopted is also of concern to me because that will lead to future crises and chronic disease. But on a general foundation, I'm overall concerned about how we in society interact with one another, the levels of misinformation that people are talking about all the time. We need to have a much more civil discourse and respectful discourse. Well, I thank you for being here today. You are always civil and have been a great leader for Vermont and we appreciate it. If you have comments or questions, please get in touch with us here at the station at 802-862-3966. And I look forward to seeing you with our next guest. Thank you so much.