by Hamilton E. Davis
As we transition from the winter of our discontent to our spring of who-the-hell-knows, A Vermont Journal thinks that we are at an inflection point in the arc of Covid-19’s passage through our Green Mountain home. We have been hunkered down for a couple of weeks now with the expectation that the “surge” will be upon right about now. And that’s what it looks like. In fact, the surge may be over.
The trace of both total cases and new cases per day are flattening, and I will argue below that for the general population, as opposed to potential hot spots like prisons and nursing homes and aircraft carriers, we may well already be on the backside, the downhill side, of the epidemiological curve. Of course, even if that supposition is reasonable it does not support a letup in our defensive posture; I believe that Governor Phil Scott did the right thing in extending the shutdown for another full month. Still the numbers are the numbers and they look very encouraging to me.
In any event, it seems like a good time to assess the performance of the Scott administration’s Covid team over the period of the epidemic in Vermont. That process will get my tiny corps of brilliant readers to the dissonance part.
On the front end, I believe that the Scotties have done very well to date. The team is led by the Governor himself, who has done a terrific job. He has assembled a strong team, and led it well: he has been calm but firm in outlining his strategy and candid about the difficulties ahead. An important piece of evidence for that is the response of Vermonters themselves, whose voluntary acceptance of the Scott regimen has not just moderated the growth of the virus, but has driven it well below the ‘most likely” track generated by the epi model. By my rough calculation, the “reality” track moved half the distance down to the “best case scenario,” which is defined basically by the performance of South Korea. South Korea has established itself as the gold standard for democratic countries in the Covid management biz.
The day-to-day management of the Vermont response has been led by a troika made up of Mike Smith, the Secretary of the Agency of Human Services; Mike Pieciak, the Commissioner of the Department of Financial Regulation; and Dr. Mark Levine, the Commissioner of the Department of Health. The Commissioner of Public Safety, Michael Schirling, weighs in when needed.
The Scott team holds a press conference every couple of days. Smith plays a dual role in these efforts. In general terms, he speaks for the Governor and the whole administration; he tends to elaborate on and pound home the Governor’s message about the need for vigilance—social distancing, closing down all but essential activities. He also speaks specifically to any problem in the prison system, of which there have been many. Corrections is a part of the AHS portfolio. He also plays a role in the regulation of nursing homes. And Smith acts as quarterback, handing off some questions to Levine or Pieciak.
Mike Pieciak, the DFR commissioner, pretty much owns the whole technical side—the state’s modeling of the virus effects—as well as the data that moves every day, the total number of cases, the number of new cases, etc. Pieciak, not as well known to the public, speaks quietly, but radiates a steady sense of competence. His agility with the numbers comports with his day job, which includes regulating the insurance industry. That process involves the efforts of actuaries, who forecast the movement of the kind of numbers that lie at the center of the virus models.
Mark Levine, MD, the health commissioner, actually also works for Smith as AHS boss, but he has an outsized role by virtue of the fact that he is a doctor. All the other players, including the Governor himself, tend to defer to Levin for that reason. My conversations with a variety of policy players over the last month or so reflect a consensus that Levine has played well; he has developed a valuable amount of political capital in the process.
Sounds Good, Where’s the Dissonance?
A preliminary note:
The work the Scott team is doing is really, really hard. Nobody on the Scott team, and nobody off it for that matter, has done anything quite like this before. The team members have to juggle three balls at once. They have to decide, in the face of great uncertainty, just what to do next. Then, they have to communicate it by providing the public with adequate, credible information. And they have to avoid scaring the bejesus out of the public in the process.
If my tiny corps will forgive a sports metaphor, you can watch 10,000 basketball, football or hockey games and not have the faintest notion what it’s like to actually play in one of those games. In the game underway now, anybody not actually playing is a member of the peanut gallery. And modesty, humility and empathy become peanuts…still, the peanuts have their role. Hence:
The Scotties have played well, but I think they can play somewhat better; and, moreover, I think they need to because there is a second wave coming. The second wave is already guaranteed and it’s huge—not the virus, the cost of the virus. More about that later. First, playing better:
The most difficult challenge once we are able to keep people alive is how to restart our economy. Scott has talked about that several times, but in generalities. It won’t be all at once, he says. “We’ll turn on the spigot slowly, a quarter turn at a time.” We can do different industries and different regions at different times…
That all sounds good, but actually doing it will be really tricky, and will require a very sensitive reading of the epidemical curve. The Scotties may have such a reading, but they are not sharing it with the folks anywhere clearly enough. Most of the data they are pumping out stops each day. The only data is actual data. But the whole reason to have an epi curve in the first place is to get the best possible fix on where the system is going. It costs serious money to build the epi model and then refine it as the data flows in. Not many people will care enough about the track and fewer will be able to assess it; but that number is not zero.
The peanut gallery needs humility, but so does the Scott team. As a practical matter, there are people in Vermont, a not insignificant number among them members of my tiny corps of brilliant readers, who know more about epidemiology than Mike Pieciak, more about medicine and biology than Mark Levine, and more about how to run a state than Mike Smith. It would be very smart of Phil Scott to make sure that his team guards against exuding a sense of—don’t worry your little heads about these technical complexities, we’re the experts, you can trust us. If you want to see an example of a guy doing it right, check out New York Governor Andrew Cuomo’s performance. It’s really good.
So, I believe, and some people who understand these issues better than I do believe, that we are already on the backside of the curve. Are we wrong? Possibly. But let’s see the full run-out of the model.
A further modification to the model that seems obviously necessary to me is to split the rate of new cases into two categories, the first from obvious hot spots like prisons and nursing homes, and the second from the general population. A particular marker came about a week ago, on April 10. The new cases for that day showed an increase of 33 in Franklin County. The other 13 counties showed no new cases at all. I believe that all or most of those 33 came from a state prison in St. Albans.
It seems obvious that the management of nursing home residents and prisoners is very different from managing the virus that lives in the general population. Prisoners and nursing home residents don’t generally have to go to work, shop for food, go out to the movies, or drive to Boston to see the grandkids.
Managing the virus inside prisons and nursing homes is obviously difficult, but the job is perfectly within the capability of Mike Smith and his AHS team, and we ought to leave it to them. The central issue to reopening the economy is the general population, and Mike Pieciak ought to let us all see what the runout curve looks like when the confined populations have been stripped out.
Virtually every action taken, and every word spoken on health care over the last month has been tightly focused on defense against the virus. No attention has been paid over that time to the health care reform project that has occupied a major swath of state government since 2011, and which was entering its critical stage when the virus intruded.
That issue needs to move back to center stage now, for a very good reason: the finances of Vermont’s hospitals, as well as much of the broader health care delivery system, have collapsed. The federal government is providing an infusion of money to help. Some of that money is in the form of loans to hospitals, the remainder is in the form of outright grants. It isn’t clear the extent to which Vermont state government has any voice in how the money is split up among the various facilities.
The importance of that issue lies in the way the onset of the virus coincided with the final phase of the state’s health care reform project. The core of the reform project—the last big step needed for full maturation of the project—lies in the recasting of the state’s small community hospitals. That effort has been manifested in the Green Mountain Care Board’s orders to a half dozen smaller hospitals to produce a “sustainability” plan in conjunction with their FY 2021 budget submissions. The common problems they faced—pre-virus—included falling patient traffic, expenses rising faster than revenues, and negative bottom lines, year after year.
Just shoveling money into that system with no clue whether the recipient hospital’s business model makes sense medically or financially will be to just waste it. And by next fall, when the virus is reasonably under control, the financial tsunami will be devastating not just for the hospital system, but Vermont state government itself. Every taxpayer dollar, state or federal, needs to be spent as wisely as possible because the surest thing in the current situation is that there won’t be enough of them. The Scotties need to be thinking about that now. And they need to begin preparing the public to think about those issues also, because the public’s money is what they are playing with. A suggestion to Mike Pieciak: we will need to see a day-to-day listing of the Covid patient loads not just by county, but by hospital. Trust me, that data will be crucial when we hit the Class 6 white water that lies just downstream. Thanks.
I think that Mark Levine could bring his game up a bit. He’s obviously fully professional and the whole state is riding on his judgments, but I’m uneasy about some of them. In a direct answer to my question a couple of press conferences ago, Levine said that the Scotties were going to begin contact tracing, which is actually now a term of art rather than a general posture. The issue is whom you test for Covid-19, and when. I wrote about this in an earlier post; I called it tracking then, because I hadn’t heard the new term. The idea is that whenever you test somebody and find them infected, you isolate and treat them; but you also talk them and find out who they have had contact with. Then you find and test those people—even if they don’t have symptoms. That is the way you get beyond obvious hot spots like nursing homes, prisons or aircraft carriers; the hard nut to crack is the penetration of the virus into the general population.
That is how South Korea knocked the virus flat in two months. Their extensive contact tracing took them right into the body of their general population looking for every version of the Covid beast. Their ability to do that depended not just on an aggressive strategy, but on the availability of all the testing reagent they needed. We don’t begin to have that. Real contact tracing in Vermont would require turning half of Shelburne Bay into testing material, which I believe my tiny corps would agree is not likely. When discussing the management of nursing homes and prisons, Mike Smith occasionally uses the term contact tracing to refer to a decision to test everybody in a nursing home if some residents already have the virus. Given the hairball Smith has to deal with every day, I don’t care what he calls it. But the Scotties need people to understand that our defensive toolbox does not include contact tracing. And the guy that ought to explain that clearly is Levine.
A more serious complaint:
A short time ago, VTDigger published a report that Joe Woodin, the president of Copley Hospital in Morrisville, had taken a breakthrough step by utilizing a test to determine whether his staff members were carrying antibodies that would render them immune from the Covid virus. The Digger story on this piece was a typically overwrought piece of sloppy journalism, which I’ve dealt with before (see my posts from Oct. 22, Jan. 7, and Feb. 18), and I would have just written it off as such. What jumped out at me, however, were the Digger quotes from Dr. Mark Levine.
Digger paraphrased Levine as saying he was supportive of the Copley effort, but advised caution in adopting the test more widely.
“This is an important strategy, and there will be a point during this unprecedented public health event when we will want to [know] if people interacted with the virus – whether they were aware of it or not,” he said in an email. “This would probably be in the deceleration phase of the virus in Vermont (which we have not yet reached).”
Levine said the state doesn’t yet have the testing materials to roll out serology testing for the population at large, nor does he have confidence in the accuracy of the tests. With serology tests, “there is a risk of false positives and false negatives which can lead to false reassurance or false alarming,” he argued.
I stopped there. If Levine didn’t have confidence in the tests and he understood that the risks of false positives and negatives, then why was he supportive? If Woodin tests one of his staff members and he gets a false positive (the person appears to have antibodies to Covid) that amounts to a get-out-of-jail-free card and the worker is free to go anywhere in the hospital…if the test is wrong, then that worker could turn a hospital into a nursing home: Joe Woodin could spawn his own personal Typhoid Mary. It would be difficult to get more irresponsible than that. There were more typical Digger machinations in the rest of the story. But I couldn’t get by the Levine quotes.
So, in a subsequent press conference I asked Levine about it—what did he think of the Woodin caper? Lo and behold, he was still supportive. I didn’t tape his answer, but I understood him to say he didn’t have a problem with the Copley move, it involved small numbers and we might learn something from it. OMG!
I then did what I usually do when confronted with something like this: I called around to some of the industrial strength docs that I have known for years, and they were amazed at Levine’s posture on Copley. “Bad idea” was the consensus. Those conversations were private, so I won’t name them here. But if my tiny corps is concerned that my view is not that of a doctor, which they should be, I offer this recent interview in the Washington Post with Eric Topol, a cardiologist and geneticist at the Scripps Translational Institute at LaJolla, Calif.
“The antibody test is challenging because there is (considerable) cross-reactivity between Covid-19 and four other coronaviruses, some of which cause common colds. Moreover, antibodies may or may not protect a person from spreading the virus or getting a second infection, and we have no idea how long they last.” Sounds like Topol and Levine read the prospects for the serology tests the same way.
It sounds to me as though Levine agrees on the science with Topol, and many others whose views flood the web. Which makes the Health Commissioner’s imprimatur questionable at best.
Phil Scott and his quarterback might think about that.