 Next to the last session, next week we have Susan Abbott who is coming with photos and sketches of her walk on the treatment of the Santiago. And then after that, Rick Winston has picked out three films at the Savoy based on Harry James novels. So, hope to see you there. And this week, we plan this because some of you might remember. The early frightening stages of COVID-19, you remember that? Washing our groceries. And in all my years in ethics, I don't think there ever was a time when all the news was about, was discussing ethical dilemmas. There was individual responsibility versus individual rights. There was individual versus community well-being. I wrote a lot of them down. Protection of the vulnerable versus freedom of choice. The health importance of economic stability and the economic stability of health. Risks and consequences, resource allocation, challenges of important consent what people didn't believe and know which were the facts and what the predictions were. And every week, this guy showed up. Seven times a week. Seven times a week. So, he was appointed to picture health in 2017 and he knew just exactly what we were getting into, right? And he came to that role with a background as associate dean and professor at UVM College of Medicine. And he also has internal medicine practice that focuses, among other things, on health promotion and disease prevention and, I quote, solving complex diagnostic dilemmas. He was well-prepared. I think he served on numerous boards, work groups, public education, professional education. And so he has a lot of, you could tell, has a lot of big picture and hands-on experience. Scott said about him, Governor Scott, said, in addition to expertise and talents, Dr. Levine helped us navigate this once-in-a-hundred-year crisis with an even-keeled style and an ability to explain and offer solutions that we could understand. Yeah. Yeah. See, there you go. And Vermont Business Magazine said he is the right man in the right place at the right time. We're very grateful for that until you came here today. Thank you. Thanks a lot, Michelle. Am I coming through okay on this? I don't think it's on. Did I turn it off? Oh, did you turn it off? Oh, see, I'm sabotaging. No, it looks like it's on. You might just have to get close to it. It's on. Maybe I'll just... I'll just hold it. So, thanks for inviting me today. And this is what I was asked to talk about. But it's going to take us a few steps to get there. So I don't think this audience talks about public health every moment of every day. So we're going to give you a little 101 public health lesson in the beginning on our way to really understanding what this pandemic meant in light of what we traditionally do every day. We're going to learn a little bit about how I explain to people why over two and a half years, we didn't always say the same thing over and over again, things changed. Because I really review that five epidemics, over two and a half years, different phases. And then we'll get to the title of the talk and some of those challenging decisions and how we sort of understood priorities, understood ethics, understood really how to get Vermont through this. Not without some controversy. So, generally, in my experience, people focus on health because that's an important thing, but they always use health and healthcare in the same breath. And if we use the World Health Organization's 70- to 80-year-old definition of health, it really doesn't look at disease. It looks at minus disease. So, physical, social, mental, well-being, not just not having a disease. And so that's really the focus of what public health does as well. Now, when you ask for a definition of public health, everyone knows we kind of manage infectious disease, outbreaks, and epidemics. And that we understand that the environment can be pretty toxic and we have to protect people from environmental hazards. And that health promotion disease prevention point that was just made because chronic disease is what drives all of our healthcare costs in this country. 80-plus percent of every dollar is going to chronic disease. All the usual players, high blood pressure, diabetes, obesity, cardiovascular, menabin, cancer. So that's the traditional definition of public health. But the more modern definition builds on those building blocks but then talks about sort of what we as a society collectively do to assure the conditions in which everyone can be healthy. And public health can't do that alone. This is done through intersectoral partnerships across every aspect of society. And we are often in the informing business, not the doing business, but we also do a lot, we catalyze a lot, and we really provide the public health lens for all those people that we work with because it really takes a health in all policies approach to achieve the goals of public health. And you can't just have a health department that all of a sudden does all the heavy lifting. It just doesn't happen that way. So we're always forming important collaborations. Now, the percentages on this slide will change depending on what resource you use. But the one that's constant is that, to most people's surprise, healthcare only accounts for 10% in terms of a factor that determines health. Everything else is the lifestyle behaviors we choose to use on our own, how our nutrition, our activity, our use of substances goes, and the socioeconomic and environmental environments that we find ourselves in. Those are the determinants of how healthy people are. Building on that, this is called the health impact pyramid. Things at the top having the lowest impact, things at the bottom the largest. As a practicing physician for several decades, most of my time was from this line up. So I think everyone understands, you go to a doctor, if they don't tell you, you've got to lose weight, or stop smoking, well, they don't do their job. And so counseling and education is always very much first, but probably the lowest impact. It doesn't mean it doesn't have an impact, but it could take two decades for my patient to quit smoking. That's a success, but it took two decades and constant discussion and helping them try to acquire the skills and confidence to do that. Clinical interventions is really all the management of chronic disease that we do as doctors. The long lasting protective interventions are all the health maintenance kind of things. Screening for various conditions, screen for cholesterol, diabetes, heart disease, screen for cancer, provide immunizations. All of that is really what is embodied in that part. Now, in public health, my entire world is in these two categories. So changing the context to make individuals the fault decisions healthy. If you don't smoke, you can't get lung cancer from going into places where smokers have been because they're not allowed to smoke in those places anymore. So you won't get the second hand smoke. If you do smoke, we don't take your right to smoke away, but we can make it really expensive for the successive years of increasing cancers and discourage you from wanting to continue that habit. If you like to eat crackers, you used to have very little choice. Most of the crackers you would buy would have trans fat in them, which is one of the worst fats of all for cardiovascular disease risk. Now it's pretty much like shaving processed. You won't find a box that says they have trans fat in them because they can't sell it. And it's been recognized as a hazard. A little more controversial subject if you live in a community that offers fluoridated water, your teeth are going to do better. And if you don't, you're going to have to find another way to make sure your kids' teeth develop in a way that you want them to so that they don't lose them all by the time they're teenagers. That's called changing the context, making it a fall decision in the healthy world. And then the heaviest lift is at the bottom of the pyramid, which is dealing with all of those determinants of health that take a whole society to focus and prioritize on. So getting people out of poverty, making sure that people have adequate housing, food security, et cetera. So in terms of population health principles, we talk about focusing on the broad population and health outcomes, focusing on wellness and prevention, as opposed to disease. And then what we call going upstream, trying to change risk factors that would adversely impact people's outlook in life and their health and foster protective factors that would be of benefit to them. And most importantly, linked to what are called the social determinants of health and the environmental factors. And the social determinants are quite simply the circumstances in which people are born into, live their lives in, learn in, worship in, grow up in, work in, and eventually age in. And those are always determined by forces that are usually more political, social, and economical. So when we talk about the social determinants, basics like employment, allowing you to actually pay your bills and not be in debt and have a healthy income. The neighborhood and physical or built environment that's called having housing, having adequate transportation and being able to get to places where you can improve your health by walking and exercising, having access to education, having food security, all of the things that we take for granted often in life, but that for much of our population can't be taken for granted. Looking at how we work with these, everybody knows there's a certain rate of asthma in any age group and in any community. Well, in public health we're always digging deeper, drilling down, trying to find out what associations exist that require important policies or focus. So in this slide you can see that if you have less than a high school education or you fall at the lowest levels of the federal poverty level, there's a markedly increased rate of asthma compared to those who are in a different strata on the slide. We try to apply an equity lens in which means that we're basically looking at health inequities across all aspects of public health. We're trying to reframe the questions to look more at the systems and less on the person. So for instance, why are different populations impacted more than others? What are the systemic root causes contributing? What's public health's role? Here's a great example going back to the asthma. If you basically look at people's poverty level, going from a gradation of low to medium to high levels of poverty, and you just look at where they live and the rate of going to emergency departments for exacerbations of asthma, you find that the worst the poverty gets, the more likely there are cockroaches and other varmin that there are molds and that there's secondhand smoke exposure. So a group like the Camden, New Jersey Coalition came together and essentially were so alarmed with the rates of people's asthma and especially kids going to emergency rooms that they chose to do home visits for their entire community and many of the high-rises in that community. And markedly impacted all of this bad stuff by doing that rather than telling kids, oh, you just don't know how to use your inhaler or you haven't been keeping up with what your doctor tells you to do because those weren't the problems, the problem were in the environment. So that's a very nice example of how we really have to drill down to help people in our societies. Which brings me to health equity. Health equity means the fairer and just opportunity to be healthy. It sounds so simple, but basically those who have experienced some kind of historical injustice like racism or socioeconomic disadvantage are often not able to have that fair and just opportunity. And it's defined along all the usual criteria you might imagine, race, gender identification, social position, socioeconomic status, sexual orientation, disability. If you're a visual learner, basically this tries to differentiate equality from equity. Here's an example of three kids wanting to see the game. One of them can't possibly see the game. The other one now can barely, but they've all been treated equally. They all have a support there to try to help them see the game. To get through equity, you need to change the supports. So all of a sudden you have a wonderful situation here. And to have what some people call liberation, you take away the barrier as in the last slide. So that's why we look at equity. Very important. This became a real big issue during the COVID pandemic, as you're all aware, especially with our BIPOC population. So every few years we do a state health assessment. We bring together lots of stakeholders and lots of data analysts from our department, and we figure out what the health of our models is like. And then we use that information to create a state health improvement plan, which runs about five years. The most recent one is running for another two years, but it was, I guess, severely interrupted by this pandemic. But we basically do this improvement plan to figure out what we're going to do about the health of our models, and how do we improve the outcomes. So the plan we're on now basically looks at these five priority conditions, development of children at various stages in their development, chronic disease prevention, improving mental health, optimizing oral health, and reducing substance use disorder. But in the context of the things we talked about, the social determinants, knowing that these have such an impact on all of these. And the populations in focus we just discussed, all the ones that you might expect, except for the additional one I put on of rurality, because it turns out we live in a rural state, and the more rural you are, it's actually associated often with more adverse health outcomes. It might be, for instance, harder to go get some of the screening tests you need because they're not available in your region. If you're on chemotherapy for breast cancer, we found out that your drive time is negatively correlated with how well you might do with your breast cancer because of your need to get to a center for chemotherapy. So, our vision is that over the five years that all people in Vermont have a fair and just opportunity to be healthy and live in healthy communities, and that we will have impacted these abundant social determinants factors that we've been discussing. This is the sort of tied-all-together slide. In public health, we talk about downstream, midstream, upstream. So, downstream is basically the healthcare system. So, basically treating and managing diseases and counseling and educating about risky behaviors. We in public health move towards the midstream, which used to be upstream, but now it's midstream, which is address all of those social determinants in the physical and social environment and in the economic environment. Most powerful now is to go the furthest upstream, which is dealing with these inequities at both institutional and social levels. Why are some people unable to accumulate wealth and live in poverty? Why are others unable to have what they need to have? It's usually because of historical injustices, often racism or defined by gender or socioeconomic class. So, that's the sort of foundational teaching for today that's going to let us move now into the pandemic. And what did we learn over these couple of years before we get into the dicier stuff? So, early in the pandemic, you start to hear about what we call mitigation strategies and NPIs, non-pharmaceutical interventions. What that means is this list, essentially. No matter what you're dealing with for an infectious disease, especially for a respiratory virus infectious disease, there are only so many things you can do that are non-pharmaceutical. And as you know, when you have a new infectious disease, you have no pharmaceutical to deal with it. You try to use some of the things you used for other viruses, but you're starting with a blank slate. So, these are things everybody's familiar with. Personal hygiene, respiratory etiquette, meaning wash your hands all the time and cough into your elbow. Avoid crowd and indoor settings and sometimes distancing yourselves from one another. Most important thing that we've learned, stay home if sick. And we hope we've had a culture change at the level of adults, at the level of parents of kids and at the level of the kids themselves who need to go to school. Masking, indoors, high quality masks being the later addition. I see a lot of high quality masks out there today. I do want to say that if you're still wedded to a cloth mask, it should only be for show on top of a higher quality mask. And of course, if you're going to have masking, do you mandate it or do you strongly recommend it? We'll get into that. Testing, if you have symptoms, understanding if you're a close contact and if you've put yourself into a risky position and might benefit from testing so you don't harm somebody else who's more vulnerable. Then when it comes along, obviously the whole spectrum of vaccine going from terms that we try to not use to terms we still use, like up to date. Again, do you mandate vaccination? Do you have people at businesses or other establishments say you can't get a ticket or you can't come in if you don't have a mask? How does one do that? You can't have your job if you don't have a mask. There's a whole spectrum of what happens on vaccination. And then stay home, stay safe, which is the Vermont friendly term for lockdown. That's the toolkit. So keep that in mind as we move along. So obviously phase one was we just going back to now March of 2020 when the virus showed up on our shores. Lots of relevant themes. I'm not going to dwell on too many. Everyone should remember, hopefully without PTSD. This graph, this is called Protecting Our Healthcare Systems Capacity. If you don't put any of the mitigation measures in place that we just talked about, you end up in the red and you exceed the capacity of the healthcare system. People with COVID die because they can't get into the ICU. People who have a heart attack die because they can't get into the hospital. If you use the protective measures, you have a more gentle curve. The virus stays around longer, but less people are going to be impacted at any point in time. And the healthcare system can handle all of them and everyone does fine and dandy. That's the whole principle. So, what did we learn initially? We learned this virus is a little different than many other respiratory viruses because it does have asymptomatic spread. Perhaps as much as 40% or 50% of the time. Containment. Containment means you've gone through a cycle of tests for the virus. If you find it, isolate the person. If you isolate the person, do all the contact tracing around that person so you know who they were in contact with and could have infected and quarantine the people who were positively identified through that process. That requires, of course, things we didn't have at the very beginning, like a test to figure out who had the virus. And eventually it occurred that we needed to actually do surveillance testing once we had adequate so we could figure out how high-risk populations were doing. How to protect the most vulnerable was another important concept, mostly for people who live in what we call congregate settings. That includes college students, but of course we learned they weren't highly impacted in a negative way from the virus, most of them. But certainly people living in long-term care facilities of all sorts, whether it's a skilled nursing facility or assisted facility or an independent high-rise where people live independently who are retired but still have access to more services or whether you're in the ultimate congregate setting, a correctional facility. All of those require different levels of attention and all of those people are more vulnerable because of the circumstances they're in. And we learned that morality is not totally protective. The other items on here I'll discuss a little later. It's really important, and one of the reasons we were so successful in Vermont is the decision early on to be very abundant and consistent with clear communication and transparent. So here's the secret sauce. This is Public Health Communication Principles 101. Be first, be right, be credible. If you're nothing else, you've got to adhere to that. Be a bit empathetic, it doesn't hurt, and show some respect for those that you're talking to. Under promise and over-deliver, never the opposite. Be very, very humble. Disability is important, especially when you're coming to the table with a virus that nobody knew anything about five minutes ago. You don't suddenly know everything you need to know about it and don't act like you do. Let people know what you're confident about and why you're doing this and that because you know what you're not talking about. But also let them know what you're guessing at or where best practice is right now based on no evidence at all and no basis by smart people. So you've got to really be honest with your population. And countering myths and rumors in real time is so critical. It's part of 101, but little did we know we were entering this misinformation era where that would become one of the core priorities of what we had to do every day. So just by drilling into people what we believe is in a way countering a lot of the misinformation. So that's how that worked. So we got through the first days, as you know, and now most of 2020, and then we're getting into the turn of that year and we have the UK variant, B117. So that began to unleash the era of variant strengths. And so no matter what the variant, it's the same questions. It's a variant that's on your radar because it's more transmissible by definition. So how much more transmissible is it? Is it more variant? Will it cause people to get sicker, cause more people to die? You need to know that. And if you actually have treatments or vaccines, is it actually going to be responsive or is it going to evade the immune system in new and unique ways? So, and this evolution happens so fast it's Darwinian natural selection evolution, but real time. It's not like the apes going to primates apes in kind. It's like overnight, here's the next variant at the virus level, the glacial level, very, very interesting. So what we learned from this is of course if it's a really transmissible strain, it becomes a dominant strain and it outcompetes everything else and all the other things disappear and you have to contend with this. It has these receptors and spike proteins that you don't probably need to go there today. Most of the time it doesn't cause more severe disease. It just basically infects more people. But if you have something that is even milder but it infects more people, you still may overwhelm the capacity of your healthcare system because more people have got it. So even if only a small percentage get really sick, it's a smaller percentage of a much larger number. So we always have to be worried about that. And obviously it can at least early on but it did spur people on to get vaccinated and to really adhere to a lot of the strategies that we talked about. So how do we contend then? The first time we basically sequentially shut things down, as you'll recall, over a very, very narrow timeframe of one or two weeks and then we gradually reopened them using good public health principles under a very phased way. And as Governor Scott used to refer to the spigot and the opening and closing the spigot, turning the spigot a quarter turn, a half turn, foreshadowing that in a few weeks we'd be turning another time. That's the strategy we used and people got used to it and were happy. When we got to this next B117, we actually used our public health data and we learned that if we just focused on travel quarantines and if we just focused on restricting the size of modest household gatherings, those were where most of our cases were coming from. We did not need to close down all of retail. We did not need to close down the one-to-one contact businesses like hairdressers, dentists, doctors. We actually could just reinforce the telework message because that was working well for the people who were privileged enough to be able to telework. And we could tell people to go outdoors and stay healthy and do all the things you want to do outdoors because we know it's safe out there. And you can go indoors in more modest settings with well-fitting masks and all of the usual mitigation strategies. Restaurants weren't looking as safe, so we were a little more cautious. Hours were restricted and bars were completely a no-no and they stayed closed. So we used actually real data to come to these conclusions. And we got through it. And then we had a really great summer for about a month in 2021 and the summer of fun ended when Delta came along. And then all of a sudden people were kind of shocked. Like, I got vaccinated, what's going on here? And Delta was a very different creature. Then again, being more transmissible is why it took over. And there were other factors at play though. Turns out, we'll take all the credit for this. We were so successful in Vermont until that point in time that very few people had gotten infected. And so nobody had natural immunity. People who had got vaccinated by the time Delta came here we didn't know that the vaccine immunity would wane so quickly but it had waned. So people were more susceptible at that point in time prior to getting boosters. This was a very, very different kind of thought process we had to go through. And when people refer to the pandemic of the unvaccinated it was true, most of the country. People were more mobile and people had gotten used to that fun month and were sort of a little more lax on some of their restrictive behaviors. So what did we do then? Vaccination was the primary strategy and we learned that boosting was important and boosting could be very successful. And if you wanted to be protected that's what you needed to do. However, it was a time when you still needed to think about doing all the other traditional things that we asked people to do but there was a little reluctance to make all of the mandates because people were fed up with the pandemic fed up with mandates. And we'll get into that at the end of the talk here too. And we also had therapeutics. Monoclonal antibodies had come on the scene. So not only vaccine but monoclonal antibodies. And there's all these issues I've listed which we're going to save for a few minutes. Then we had the fourth phase which began in this year which was Omicron which is actually still here as you know. We have no more variants that have been on the horizon or happened since the beginning of this calendar year. Every virus that we've encountered has been a sub variant of Omicron all in the same family. People wondered if that was the pathway to endemicity and it turns out it is so transmissible that many, many people have gotten it. Everybody you talk to tells you that they know five people who recently had COVID even if they were vaccinated. But most of them have done better than the previous variants because they've had less severity of illness if you will. Doesn't mean nobody has but many have. And that's been the experience worldwide. So we know there's some element of vaccine evasion but be that as it may. Even if it's a less severe virus it has undeniable impacts on our workforce and on our healthcare system so we can't forget that. And being absent from school and work is still a disruption to people's lives. So the mitigation for this most recent phase which you've seen not just in Vermont but nationwide is all of the basics of course but then this element of personal choice, personal responsibility, personal assessment of your own risk merged in with all of that. And people were surprised to see contact tracing go out the window. Well it turns out it's ineffective for the virus this transmissible that when everybody knows everybody who's got COVID and they're all over the place it's like well what would contact tracing have done to prevent the spread from that to that? It's happening no matter what you would have done. So even the CDC said based on Vermont data actually we're going to throw out contact tracing for this virus at this time. Contact tracing is a poor public health tool that will never be thrown away. The question is when not if. That was a Dr. Fauci statement which people have learned has come true pretty much. And we had a real imperative to maintain in-person learning during this period of time and we'll get into that in a second too. Still talk about gathering size. Doesn't mean everybody should go to an indoor basketball game or to a rock concert. But again, personal choice. People get away with it. And then we still are pretty unrelenting and telling people it's you should vaccinate, you should boost, you should get the latest five elements. All of that. Travel restrictions make no sense. People are actually traveling fine but I'm getting sick because they've traveled. I recommend you still wear a mask on the plane. That's me. And I think we're on the way to endemicity. We're not quite there. The true definition of endemicity means you don't see surges anymore and nobody's confident we're not going to see another surge of COVID with yet a newer subvariant of Omicron. So that's not really endemicity yet. We'll see for almost there. We're much closer than we have been. And so the rest of this year from the summer on has been subvariance, as I said, and we've told people to do this personal risk assessment and risk tolerance and all the things listed on this slide that you've been hearing over and over again, although you're not hearing it so much in public anymore, people have moved on, it seems. So, now we're in the final phase of what I prepared you for. Evidence-based clinical practice versus evidence-based public health practice. When you go to your doctor, if you want to know your risk of something based on your behaviors and your family history or just being a human being, doctors using epidemiologic studies, using what we call cohort studies where you follow a population who doesn't have that condition over time and see who gets it, who doesn't get it, what they were exposed to, what they weren't exposed to, and you figure out how to talk to patients about risk. If your doctor is treating you for a disease and puts you on a treatment, you want to know that treatment has gone through a randomized, controlled clinical trial, an experiment where there were people who got the drug, people who got the SIBO, and we know the drug is what worked. Public health is a lot messier than that. Public health is often natural experiments, multiple interventions, hard to track which one made the difference, and it's often in communities that aren't very homogeneous that have many diverse groups. So it's always challenging to translate things in a way that clinical medicine could translate them. This is a nice definition, the process of integrating science-based interventions with community preferences to improve the health of populations. Ideally, evidence-based public health graduates will be data-driven, have a peer-reviewed evidence base of public health science, use information systems systematically, have a strong evaluation component, and have interventions that are acceptable to the population and embraced by them. Now think about it, no word politics appears in there, though public health is often criticized. But if you think about how politics fit in, water fluoridation. Well, you know, public health-wise it's a no-brainer, fluoridated water supply, and we've seen the outcomes of that, but you're all good. Yet, it's a highly controversial thing in many communities. Harvard does some strategies for opioids, like using a syringe service program, or needle exchange, to prevent HIV and other viruses, and to keep people safe in their drug-using hands. There are those who believe we're fostering drug use, so they are against that. Yet, all of the public health data for syringe service programs is positive in terms of the outcomes. As I said earlier, we don't tell people you can't smoke and we ban it like prohibition era for alcohol in this country, but we can tax the heck out of tobacco and vaping products. But many people feel like, well, that's discriminating against a certain segment of society. In Vermont, we have no trouble passing all of these laws. Other states, much more challenging. The issue comes up in a public health crisis with an emerging infection. Who's the expert authority? And that's caused a lot of issues in this country. So, you know, is it the CDC? They've really suffered in terms of their PR image. Is it the World Health Organization? Some people said it took them way too long to call this an epidemic or a pandemic. Is it Dr. Fauci? Is it other members of the coronavirus team from the White House? Are there local, national, international leaders in infectious disease? State health officials. We have an organization, Astell, the Association of State and Territory Health Officials. It's only like 59 of us. We lean on each other throughout this pandemic. None of us were the authority. But we put together our practices, we put together our policies and our data, and at least thought we were coming up with reasonable recommendations. And then, of course, the ethics community. There were many things we've done that we've reimbined the ethics committee because we just needed to actually get their input and make sure we weren't missing anything in our thoughts. So, of course, the answer to the question is, who knows? And it's everybody. But it's a very challenging thing. There are so many other things we do that there is a true authority. So, competing priorities. There are governors like Governor Scott and a number of others who said, my first two tasks as a governor are to protect the public's safety and their public's health. There are other governors who said this virus is a figment of your imagination, and we need to keep ourselves on an economically stable base and the hell with public health. They didn't quite say it that way, but that's how it turned out. Now, I'm going to pick on South Dakota not because I have anything against them or their Christie, their governor, but at the same time, the media helped me because they came out with articles comparing and contrasting Vermont and South Dakota. So what did we learn? The approach in Vermont, we had a fifth of the number of cases at the peak that South Dakota had. Look at the deaths. We had one sixth or flipping it around, six times the number of deaths in South Dakota. Most people who are immune in South Dakota got the virus. Most people who are immune in Vermont got the vaccine. And in fact, data I just got today from the CDC, Vermont is still the lowest state with the level of antibodies showing infection-related immunity. We're 28%. The highest state actually turned out to be South Dakota, 70-plus percent. So I mean, that's like incredible. And then look at the economic indicators. No difference in the unemployment rate as we, this is now as we came out of 2021. And recovery to baseline GDP from 2019 quarter four to 2021 quarter two, slight increase in South Dakotas, kudos to them, Vermont back to baseline. I look at that as essentially no difference. So again, public health and economic health don't exist. So that's a principle I think we did well with. So many competing priorities. Thinking about individual health, I still, I take it personally, but I still get attacked or taxed to struggle to work, criticized by many people who think that we've thrown the individual's health out the window. So I'm thinking of a mother of a kid who's in school or who wants to be in school, but they're in a vulnerable health care setting. They're vulnerable because of their health care attributes. And they are afraid to send them to school because the school doesn't have bass anymore in century of distance to kids, blah, blah, blah. I'm thinking about individuals who feel their own health is being compromised and they can't coexist in society where everyone else is doing what the heck they want to do. And they're very concerned because they have reasons to be concerned. So we try to balance those very valid concerns with keeping the community well and if you will, the public's health in the plural. Knowing that for an individual any illness is disruptive to their health, to their work, to their education. Anyone can get possibly long COVID. We don't understand why some do and some don't. And many, many can. That's not enough what we want. And the vulnerable groups are just raised. So people can again assess their own risk and decide if they're going to do what you're doing here today. Most of you are masking or if you're not. And that's where society is right now. There's health equity issues galore. I mentioned the BIPOC population. So in our new American population early in the pandemic in Chippin County major outbreak what the causes are it's multi-generational households, some congregate living with multi-generations public facing jobs needing to take public facing transportation to those jobs. Again, the social determinants. Migrant workers in a slave quarry in southern Vermont you may remember the apple orchard in Shorham where the community turned out in a wonderful way and brought them food and all kinds of stuff to support them. These are individuals living in congregate living, sending money back home to their country of origin trying to just earn a living here to help them but because of where they're living they are more susceptible to the virus. We had another in Chittin County that was more sociocultural network of households and we've had numerous outbreaks in our correctional facilities none of which came to the level of one firm honors who were imprisoned in Mississippi not to deal with where the entire facility basically got infected. So let's talk about some of these competing priorities if you will because it turns out that we can accept criticism and the governor, his team, myself will accept all the criticism in the world but people have to understand some of the decision-making. And this is where I use the term applied public health or pragmatic public health because here you would need to understand that yes every individual deserves the right to stay as healthy as they possibly can and have that opportunity to be healthy but when do the mitigation strategies become too much and balance with some of these forces. So mental health you can't pick up the newspaper any day without realizing we're all in a mental health crisis whether we live in Utah or Vermont whether we're an adult or a kid doesn't matter. Mental health issues are galore they're causing people to be living in emergency rooms because they can't get to the next level of care they need to get because they don't have access to that and our suicide rates went up substance use everybody's read about the opioid overdose death rates more now than ever before even though on the way into the pandemic we had actually started to have a decrease pandemic reversed all of that for a whole host of reasons one of which is social isolation in public health talk social isolation is the root of all the disaster it leads to all the adverse behaviors that end up hurting people not just the streams of the opioid overdose death and the suicide but basically any ill that you can think of we have a huge component of our society that is socially isolated and then you add a pandemic to it and the social isolation increases to a new sentence of society look at the data on our kids and their fifth grade performance in various subject areas like math decrements that were worse than people anticipated they would be so again sure we could try to focus everybody on masking 100% of the time mandate masking vaccination all of the other mitigation strategies these things were overwhelming and what we felt honestly was we could balance these things with what was going on with the pandemic and I think we've kind of proven that this fall because in the fall kids aren't being sent home from school for COVID most of the time they're getting a lot of other respiratory viruses which are terrible but that's because they haven't been exposed to them for two years but COVID is actually not shutting classrooms down shutting schools down disrupting the educational environment and we felt that in-person education was the prime directive if you will and I think we have good reason to still support that as well as those other conditions we've talked about lastly as an internist health debt is really important to me it's defined as the accumulated impact of changes in health behaviors that will have long-term negative impacts on health basically that means more chronic disease that's going to go on for ages so any inroads we were making in that arena are clearly also being severely impacted at this point in time finally let's talk about some of those ethical and other considerations because they really are important I think equity I've hammered home already so I'll move on to allocation of scarce resources because early on we had who got tested who didn't get tested now we have access to at-home testing but it was a whole different ball game early on and then vaccines well everybody probably remembers most of you were first aligned looking at the age in the room but if you weren't how would you have thought about that well this is where we get into the notion of priority groups so if you looked at what the CDC said initially when vaccine came out it's like people who were highest vulnerability meaning living in long-term care or working in healthcare people who were chronically ill for whatever disease they might have people who worked an essential function in society which could be a grocery store worker who was 23 years old could be somebody who worked in preserving our electricity or water plant infrastructure or what have you and by the way BIPOC as well because the data was really ugly showing increases in cases hospitalizations and deaths so how do you give this much vaccine to 85% of the population which is what it would turn out to be so we used our data and our data showed that the people who were dying were the people who were oldest and age stratification and try to preserve life as our prime directors early on in the vaccine effort till we have enough to give it to everybody and that's how that worked but again very important thought process same thing happened with treatments and then the intersection of local, national and international health countries like ours and Europe are still being criticized because Africa has to wait way too long to get vaccine you may recall that most of these new variants have come from South Africa keep that in mind but African nations are still playing catch up to get to a respectable vaccination rate in their population which I would call respectable better than even the worst before in the US state and many of them have not gotten there navigating trade-offs is sort of what I mentioned I think earlier with economics versus public health and do you close schools at the start of the pandemic to reduce transmission that's going to hurt the kids a lot and kids don't suffer as much with COVID we learn we stand by what we did early on but then later on you've got to open the schools because the harms of not having them open is worse than closing them for reducing transmission and then the issue of recommendations versus mandates when do you say we strongly recommend you wear a mask if you're indoors versus you can't go indoors without wearing a mask or when do we say you can't get into this event without being vaccinated even places like New York City that held that line for a while have abandoned that at this point of the pandemic so again you need to look at the pandemic in faces and understand when certain strategies are going to be more productive and when they are going to be less productive or counter-productive you also need to look in terms of ethics at the sort of four basic medical ethics principles we always use one is beneficence meaning you want to do the most good second is maleficence meaning do no harm that's probably the prime directive for a doctor third one is justice and justice is more like trying to achieve this equity that we have and be fair and then the third one is autonomy so maintain a person's right to choose or not choose so weighing all of that in all of this is very critical it happens at every juncture and then realizing that it does take time you know we don't know everything about the virus on day one we learn more and more as time goes on so we have to respect the fact that we're getting data in an evolving fashion and if we change course or change policy it's because we've learned something new that we didn't know about before and then finally is the public it's quite clear that over various recent times many in the public have said the pandemic is over and I don't even think about it anymore others are like I'll never forget about it and every day of my life I'm going to think about it and then others are sort of in a midway phase yeah if I have to do this or that because you told me so I will because I'm really sick and tired of hearing about the pandemic and don't tell me about the boosters because I'm sick and tired of hearing about vaccine so you have to be understanding about that and be pragmatic and that's again part of this what I call pragmatic public health is balancing all of these things together because you have to I'll close by just saying there's something called something called the nanny state and the savvy state so the nanny state is basically everything that's good for public health we shut down your throat and that's the way it goes so you can't buy trans fat anymore because we've all met you and we're not going to encourage smoking because we're going to price it out of your range and blah blah blah and then you have which is kind of like we're going to tell you what's right but you decide what to do because we don't think government should be coming down on people so aggressively and of course most things aren't on the extreme one end or the other they're kind of in between but just imagine one thing that hasn't passed in Vermont yet it's passed in a few regions of the country like Berkeley, California in a few countries like I believe in Mexico even taxes on sugary beverages so you know we have an epidemic of obesity in this country we have an epidemic of diabetes in this country most of which is related to obesity about a hundred percent and diabetes leads to cardiovascular disease, kidney failure and blindness all the all the things you've heard of should we be just asking the heck out of sugary beverages so people can only mind sugary beverages and how would you feel about that versus we just sort of tell people probably sweet beverages aren't that great for you find an alternative so that summarizes the dilemmas of public health in one sort of example and hopefully builds on what we've talked about thanks for your attention if there's I'm here for a few minutes if there's questions I'm happy to take you're referring to the ethics community I'm just curious to know who or what that is and also we've done self-testing with these common things for a long time to be continuing that or what so there's something called the Vermont Ethics Network which is an ethics community so we utilize personnel from there who are ethicists and UVM Medical Center has an entire ethics what we call division they have ethicists department that sounds good so we also use them so those are the answer to your first question the Vermont Ethics Network you may know from something you get in the mail about advanced directors because your advanced director is still good you want to change it that's a product of having the ethics community involved in what goes on in the state with regard to testing you shouldn't continue to have your little stockpile of tests at home as we get into different futures who knows what the future scenario is I think it's still really important that people become symptomatic they actually figure out what they have and do the testing according to the hard protocol which is first negative do it again 48 hours later if you have been exposed to someone you have to sort of think about that one but it is still a valid reason for testing and I do think so many people are concerned when they know they're going to visit somebody who's more vulnerable than they may be that they do a quick test so I still find that it's useful, lots of people are still doing them and even though people are feeling like they're getting false negatives if you do it by the protocol every 48 hours if you really are positive you will turn positive two questions for you, the first is when you are without a mask in front of all of us I know what are the factors that go in for you and should go in for the public in terms of deciding what is a safe level of risk and the second question is during the pandemic the briefings that you held with your governor were very useful and very important and you had and I do miss in both senses of the word an incredible level of solidarity and unity what went on behind the scenes and give a specific specific example of a push and pull between various factors within the administration about we should do this and we should do that and I think you can be specific I really appreciate that is the media here is the media here so the first thing that I am asking so at this point in my life I don't think I had COVID but who knows if they had COVID I mean it is such a funny virus unless you had a real kind of flu like illness that really knocked you out you could have had sniffles you could have had no symptoms so it is really unclear until we get a valid antibody test to use over the population it is going to be challenging to figure that out but obviously not just to be a role model but I am conscientious about the vaccination vaccination I got the 5-0 booster at the appropriate time and I still look at different settings that I am going into to look at the level of risk I will definitely always do this on an airplane now which I have started to use again on airplanes I will definitely use it if I were going into a very high density sporting or concert type setting here everyone else has got a mask on I am feeling like you arrived with a mask I arrived with a mask in respect to the fact that I knew this would be an older community and people who were actually very interested in me being asked there is two way of asking and one way of asking both are actually beneficial obviously two ways more beneficial than one way for me it is a lot easier to speak up here with a mask on and I feel very protected I have kind of been everybody out there it is out there, not on top of me I am not sure about the ventilation of the room I usually think about that too but there is ventilation in the room but I am not sure it is possible and that is how I make my decision now in terms of controversial stuff so no I think there is one that is very clear it is not like I am divulging it is super top secret obviously the governor is the man on top and he does have the ultimate decision about most things he has never stood in the way of public health telling people what is good for them and what is not good for them and we have a team that obviously public health helps inform that all sectors of government bring us input as well as we bring back our opinions on how to make things more safe so the education sector the commerce and development the housing sector the agriculture sector who named them everybody is there the biggest area where I think some people may have different with what we did is sometimes later in Delta when we very strongly recommended asking but did not mandate and it is a tough argument to make because I was looking at the only six states that still had mandates and the data was very mixed it was not like their state health official was 100% convinced having the mandate did anything to their numbers but it seemed like good public health guidance at a time where we had this Delta thing just taken off, I'm crazy so again harder for the data and science to support it but the kind of recommendation from public health that most people would have said we understand why they're doing that even though it was hard to really make a strong case the case that was made by many was where is it of course having trouble finding the slide now but was this bullet point right there issues of mental health suicide, substance use isolation, education setbacks recovery health damage Mandating masking was viewed as perhaps getting people's attention in the wrong place on all of those things persistence in having people mask might cull on the problems that all those things were having so in the end there was a more pragmatic approach to strongly recommend the heck out of it but we're not going to go back to a mandate people that kind of moved beyond mandates people being not just a governor's team but a public government and we did hear from people who obviously had it moved felt like that would be really important I still in my heart of hearts don't think a mandate would have changed our experience in Delta because I'm looking at all the states that had mandates and just not impressed with what resulted from that but having said that Vermont continues to have the best data in the country and that's you can't beat us and so we didn't hurt those but of course in the heat of the moment those are the challenges there's a couple of communication with Carmen in question the question is what do you see changing your strategy in a world that is in the tribalism sort of a rational world the second is the comment the first amendment issue you can't tell the media to stop doing this but it's somebody who's afraid of needles to see photograph after photograph an idea going on that's going to fix that and I've heard that so many times I heard that so many times and I got sick of seeing needles and I don't talk I thought that was counterproductive I really do but the first post-rational world question I'm taking notes I'm trying to remember how you phrased the question tribalism but that's more of a comment what was the question how do you address how do you address okay yeah so I mean what we just decided to do is literally assault everyone with maximum information and be consistent with it until it was proven wrong or whatever or updated and then be consistent with updating it and showing why we had an exchange of course but what you're really asking is how do you deal like if you're Dr. Birx and President Trump is standing there telling people to put an IV in with this infection how do you deal with that on national television I didn't have that problem I had the most rational governor of the country and popular who was basically delivering the message that we all wanted him to deliver so that was not my problem but you do speak to how do you address misinformation which the Surgeon General of the United States has labeled his primary problem to deal with during his tenure and it's like some of those who we used to call anti-vaxxers in the anti-vaccine community where if you only go to a certain part of the web for your information and you're so narrowly focused there and you've lost the total visibility to see any other source of information you can't be you can't enter a conversation because there's nothing else to confront the person with because there's no other source of information than the one that they have that's what we're up against now with anti-vaxxers and everything else is just not willing to be a little more expensive and hear other inputs I've never dealt with this ever before I don't think it's a society we've dealt with this ever before but here we are in the same way that we have people who denies January 66 I'm not here to get into a political discussion but the reality is there's a conversation out there that shows that January 6 did exist and things did happen as you see them on television but again you can't convince a portion of the population of that basic fact forgetting about people's intentions and who orchestrated what what happened so that's where we're at and should we get another booster so everybody here should have gotten the new i-valent unless you were infected with COVID within the last three months you should wait three months from your infection to get it or unless you happen to get a monovalent boosters very recently and two months haven't gone by yet but most of those people are now pretty much ready to get their i-valent we hope you don't need another vaccine for a year but we don't know because number one we have to learn about the duration durability of your immunity from this i-valent so just like has been studied with the previous versions of the vaccine we'll see how long it lasts and that's number one number two there's more science involved so everyone has been measuring neutralizing antibodies in the blood do you need another booster or not but they're not measuring what we call cell mediated immunity T cell function things that are in your lymph nodes in the lymphatic system that actually you'll define if you got infected even if you're neutralizing antibodies of that we need to measure those better so we can measure the people better and understand when they need their next shot and then the third thing which is the wildcard we're going down the pipe with the virus if it's more of a sub-variance of Omicron we're probably going to be fine for quite a while but if it's some other new variant strain that's a very different story I think the likelihood of that is getting lower and lower because Omicron is so established we would just see sub-variance but one of these sub-variance could be a marriage of one sub-variant with another sub-variant that we do have to get concerned develop a new vaccine and give it to people we'll just see if that plays out but you will let us know hopefully long before I let you know from the national scene you'll hear thank you so much for this talk I just have a very specific question I sing in a choir and we have the test because of the singing and I got some tests from SASH from my SASH coordinator that said they were they were expired back in March but they'd been extended and I want to know how why does that happen and is it a problem? yeah so every time they get extended it's because again we've learned that they last longer than we thought not saying that we the companies who make them and then the FDA who allows them to extend so it's just getting new data and you should accept the fact that if it can be extended it can because again these tests were never ever used before and now they're being used on a wide basis and we're learning about how long they can actually last okay we'll take a couple more okay and then over here maybe slightly technical but you mentioned deaths so your previous answer who gets to decide that the cause of death was COVID and how public is that to do and how much effort is associated with it? yeah so it's generally a medical examiner decision because all of the death certificates come to the medical examiner to review and if somebody had an autopsy obviously the medical examiner would make that decision we're very liberal in the definition so none of the people who has written death certificates but death certificates say what was the cause of death in the usual line and then the next line is as the result of and then the next line is contributory causes so if the word COVID appears anywhere in those three lines it is considered part of the reason for death but there are abundant deaths even in our low death rate in Vermont that have COVID as the contributory cause and it was quite clear that the traffic accident the stroke the diabetic kidney disease and section were the cause of death COVID may have tipped the balance a little but it probably wasn't the cause of death because it was people most of the people have been extraordinarily ill people of the dance age who have a lot of strikes against them but we're very liberal so we could never be criticized as sort of stacking the cards in one way if COVID's mentioned it's gonna be a potential cause and there's times now in the fall of 2022 where people are admitted to the hospital for all kinds of reasons and COVID's not why they're admitted but when they get into the hospital they get tested and they turn it positive so if they have something life threatening and eventually succumb to COVID's gonna be on there as they cause death that's just the circumstances we're in last question was right here so cloth masks not good not good alone by itself I can barely wear one blue ones from doctor's offices are they good yeah so those are surgical masks they're better and then the most the most better is the KN95 which is this and then if you happen to work in a healthcare facility you may have actually been fit tested for an N95 which would be the top of the line but you wouldn't need a KN95 that's been approved would be fine you know supermarkets are not a high risk environment if you think about it you know this is usually most of the time you're not next to people for prolonged periods you know and if you're really going in there and doing your business so business is like I need this I need that you know you're on the move so not a high risk environment you could do a surgical or a KN95 thank you