by Hamilton E. Davis
Among the remarkable epiphanies wrought in American life by the Covid virus is a new appreciation for reliable information on important issues. The modern world has been starved of that by the rise of the Web and the concomitant collapse of the American newspaper. Information in this new dystopia has been politicized, degraded, weaponized.
Arising from this rubble, however, has been a new kind of player on the public stage. He or she might be a bureaucrat, a scientist, a politician, or somebody who just wandered into the frame. What they have in common is that they clearly know what they are talking about, they speak plainly, they don’t lie, they don’t talk down to people. Those characteristics shouldn’t be rare in public life, but in this deracinated environment they certainly are, so that our new players feed not only the mind but the soul: people trust them, and public trust is very hard won these days.
An outstanding national example is Dr. Anthony Fauci, the chief federal government spokesman on the Covid-19 virus. No person in the United States has as much credibility on the pandemic as Fauci. And he has achieved that working for Donald Trump, the highest of bars. Another is Michael Osterholm, a brilliant professor at the University Minnesota, who was well known in the scientific community, but who is now teaching the whole world how to navigate a pandemic like Covid. In New York, Governor Andrew Cuomo metamorphosed a thuggish political persona into statesmanship simply by talking sense to his constituents as the wave engulfed his state.
Vermont is a tiny player in the pandemic world, but we have our own version of this new player. He is Dr. Mark Levine, Vermont’s Commissioner of Health. Levine was appointed Vermont’s Commissioner of Health by Governor Phil Scott in 2017 after a long career in the UVM system. Health Commissioner has never been a particularly high profile role in Vermont state government, but that changed earlier this spring when the Covid virus appeared. The Vermont response team was led by Scott along with Levine; Mike Smith, the Secretary of the Agency of Human Services; and Mike Pieciak, Commissioner of the Department of Financial Regulation. Beginning in March, the Vermont team held three open press conferences a week, and Levine played an outsize role there because he was the medical guy and the core of the crisis was the medical dimensions of the virus. Over the tenure of the pandemic, Levine was involved in something like 50 press conferences; I believe that was more public exposure for a health commissioner than all of Levine’s predecessors combined.
The whole Vermont team performed well in the face of the virus, but it wasn’t perfect, which I’ll get into later. But through the dark days, in the view of A Vermont Journal, Levine was rock solid. Like many of my colleagues in the ink-stained space, I have become a Covid web rat, surfing constantly for insight, facts that rang true, wisdom even—anything to keep the boat on an even keel in the roughest seas I have ever seen.
During that time, I found Levine as valuable as the Faucis and Osterholms and occasional eminences from the University of Washington at Seattle or John’s Hopkins or University College London. Levine was never uninformed, flustered, anything but measured, steady. If I could have asked for anything more, it would have been that he come down harder on the blundering of some of the players.
And, in my own fantasy, I have wondered whether Levine might be willing to expand his portfolio to pronounce on the insanely contentious issues surrounding the much broader issue of health care reform in Vermont. If he would do that, it would be a service to the state that would resonate for decades. We need truth-telling on reform as desperately as we need a vaccine for the Covid beast.
Talking to Fauci (Levine)
The other day I got the chance to talk on the phone at some length with Doctor Levine. Since the virus debuted in early March, the Scott administration has communicated with the public by holding first thrice-weekly, now bi-weekly press conferences, with Scott and his top lieutenants making a variety of presentations, and then taking questions from 25 or 30 members of the media. For a functioning journalist that availability is better than no availability, but it is nothing like the pre-virus days when you could talk to pretty much anybody at whatever length you needed; you could ask follow up questions, resolve ambiguities, explore interesting lines of inquiry. So, it was a breakthrough for me to have Levine take my call. Our conversation reinforced the impressions of Levine I had formed since March.
My first questions involved two performances by the medical system that seemed problematic to me, and which I think embody the gnarly issues that form the current environment. The first was the decision by Copley Hospital in Morrisville to use antibody testing on their own employees; the second was the generation of a fake news outbreak of Covid in Manchester that turned out not to exist. The Copley situation was problematic, but not clear-cut, while the Manchester mess was just bad medicine and bad public policy. My question to Levine: if he had come down harder on the Copley situation, could that have headed off the obvious blunders in Manchester?
As is his wont, Levine laid the whole case out carefully, while characterizing the Copley initiative in as favorable terms as he could. “To their credit,” he said, “they tried to study it as opposed to just doing it.” And they did pick up a marginal piece of useful information; namely, that using a finger stick to get a blood reading is not good enough; you have to get a regular blood drawing. Beyond that, the whole Copley caper falls apart. First, as he does regularly, Levine went to the science.
The gold standard for testing, he said, is the PCR version--the one where they stick the swab way up your nose. It’s not totally foolproof, it can give you a false negative if there is just a trace of virus in your system. It also takes time to process. But PCR detects the presence of the actual Covid genome, and hence is the most reliable test to see whether a person has the virus. There are two other types of tests; one is a serology or blood version shows whether you have antibodies to the virus in your bloodstream. In other words, whether you have had the virus in the past. The second is an antigen test, a shortcut version of the PCR test that detects fragments of the virus in the system at the time of testing.
The Copley initiative involved testing their employees for antibodies, and Levine explained first how limited that process is. There are two kinds of antibodies, those that the body produces on contact with the virus, which tend to fade fairly quickly; the body produces a second type of antibody which can last for a very long time—real immunity.
“What they learned at Copley,” he said, “is that it isn’t very useful to screen for (the short-lived) antibodies because they couldn’t correlate it with any PCR (the gold standard) data and the sample size was so small they couldn’t really conclude anything—it wasn’t very useful, it’s a small place and it’s a small number, and we didn’t have a very high level of disease in the state.”
The test could be valuable, he added, if it was done with a large enough sample to inform state policy makers about managing the virus in the future.
“What I have been saying in my press conferences is that this is not a test we should really do to inform an individual about anything—whether they should donate their plasma, whether they should go back to work, should they get a vaccine,” Levine said. “It’s not going to be helpful for individual decision making.”
Okay, got it. I’ll explore later whether the Copley experience was just the kind of blind alley that is common in medicine, an error of execution, a publicity stunt, or something else. We also need to know if it was a waste of money, and if so, how much. What is clear right now, however, is that nobody in Vermont should follow the Copley example. How do we know? Because Mark Levine, MD., says so. He’s our gold standard. Can he be wrong? Of course, but someone in Vermont who wants to plow new ground on pandemic medical issues should be ready to get over a very high bar. The Copley caper didn’t come close.
The Manchester Debacle
The Copley testing was ill-advised, but it didn’t appear to cause any serious damage. The same cannot be said of the testing mess in Manchester. A pair of local doctors there ran antigen tests in the late spring and early summer; recall that the antigen test is a quick and dirty look at whether the person has the Covid virus at the time of testing. The Manchester Massacre was a perfect storm of errors and egregiously bad behavior that rippled out in all directions and illuminated just how difficult it is to manage the pandemic. That narrative is still unfolding, and I will address it in a future post. This is a profile of Doctor Levine, so I’ll just sketch Manchester here to enough to make the necessary points.
On July 16, a Thursday, Vermont Digger published an article saying that, “A Manchester health clinic reports 59 Covid cases in a growing outbreak.” That was possibly the most striking headline Vermonters had seen, beyond the reporting of the presence of the virus. Fifty-nine cases outside of a nursing home or prison dwarfed anything Vermont had seen since the virus appeared in early March. The headline and the top of the story was enough to cause panic in the Manchester area, and deep concern in the rest of the state.
But then the first red flag appeared. “But seemingly contradictory reports between town and state officials about the surge of cases have sparked confusion among residents and a backlash against the state on social media.” Finally, the Digger piece gets to the real news:
“At a press conference on Thursday afternoon, Health Commissioner Mark Levine said his department had confirmed just two of those (59) positive cases and didn’t have enough information to label the incident an “outbreak.” The story added that Levine said he took the information seriously, but that “We need to let the data and information come out.” Levine is bending over backward here not to trash the locals because in fact the data is out, and the story the data tells is that the whole thing is giant botch. I mean, two out of 59 cases confirmed. Really?
The final count was 65 positives from the antigen testing, and just four could be confirmed. That is actually a national story because the consensus of the Web tribe was that the antigen tests had very few, if any, false positives.
By the next day, the facts were pretty much clear. A small primary care group called the Manchester Medical Clinic with just two doctors mounted a testing program to find people with the Covid-19 virus. The test was only cleared for use in mid spring, so it was unproven in operation, and it and its basic design limited its use to people who had Covid symptoms; no responsible person ever thought it would displace the PCR test that was standard all over the world. In July the clinic reported that it had found 59 cases of Covid in the area of Manchester, a town of just over 4,000 in Bennington, County, and Londonderry, a town of 1700, about 17 miles to the east. That’s a huge outbreak for such a small area, and it caused an uproar.
In substantive terms, however, the “story” was over in not much more than 24 hours. Mark Levine said on July 17 that standard PCR testing of the 59 cases showed that just two actually had the disease. That’s a 97 percent false positive rate, which is simply preposterous. It was obvious to anyone thinking clearly that there was something wrong either with the test itself or the way it was used.
An obvious inference, however, couldn’t keep the story from spinning out of control. The Manchester Town Manager, John O’Keefe put up the erroneous data on Facebook page, and he said later that it would have been unethical not to have done so. The direct result was several downtown businesses closed down and a retail market program was aborted.
The lead doctor at the Manchester Clinic, Janel Kittredge-Sterling, denounced Levine for bringing up the testing issue. She was quoted by Digger as saying Levine was creating a “false sense of security that may lead ultimately to increased spread of the virus.
“Please don’t make the blanket statement that these are false positives and that people can go about their business, because that is dangerous,” Kittredge-Sterling said. “I’m concerned that these folks don’t go out and with this false sense of ‘Ok, my second test was negative. I can go out.’”
Meanwhile, the Digger stories noted that there was talk on social media about the “deep state”, and criticism of the state for “undermining the (clinic’s) positive results.” There was talk of conspiracy theories. Ryan Ferris, who operates an ambulance company in Chittenden Country, said his firm had carried out antigen tests on some 800 workers, only one of whom had tested positive. Yet, he blistered the state officials for “jumping to conclusions,” and suggested to Digger that the standard PCR might be inaccurate.
“For the Department of Health to jump from ‘Oh, they tested negative to PCR’ to ‘Oh, that test must be bad,’ that doesn’t bear out nationally, and it doesn’t bear out over the results of the several hundred we’ve tested…” He added he had offered to help the state solve its testing problem, but that they hadn’t taken up his offer.
Mark Levine barely held his own against this tsunami of medical ignorance, financial self-interest, political irresponsibility, bad press performance—all in all, a goat rodeo. After a six day run, the whole issue went away, when hundreds of real tests showed only a handful of actual infections. Its long term effect, however, remains: Vermont has a desperate need for reliable information about issues like the Covid virus. Levine isn’t the only one who understands the issue, but he is the only one people will trust to lay it out for them. Here is what the public needs to know about antigen tests.
Levine: If you use an antigen test within the first five days of infection in an area that has a “reasonable prevalence of the virus” and the person being tested has some symptoms, then it can give you a jump on getting the person tested, isolated and treated. That’s not what happened in Manchester, Levine said.
“Many of the people they were seeing we didn’t think satisfied the definition for Covid in terms of the victims they presented,” he said. “And on top of that they had a bunch of people we regarded as having no symptoms, and that’s not where the test should be used. And so, there were a lot of problems in execution…
“The problem,” he continued, is that this test is now being used at work sites. People are marketing it and using it at a work site to reassure the employer that the employees are free of disease and to reassure the public facing those businesses that the employees are free of disease. And the reality is (the test) is not meant to be given to people who feel well and don’t have Covid. “
Being Mark Levine
It may have seemed tedious, even to my tiny corps of brilliant readers, to follow the meanderings of the Copley and Manchester adventures, but I believe it is necessary to understand the environment in which Levine works, and the difficulties he faces. A hospital goes off into an ill-advised medical adventure, a couple of emergency room docs blunder into the weeds on Covid testing—and blame Levine for introducing sanity into a public health crisis; and a business guy markets a marginal Covid test on employers in Chittenden, and trashes “state health officials” when his product is described as basically useless. And every piece of half-baked junk gets amplified by the dodgy health care reporting of VTDigger. (Example: Digger had the last word on the Manchester mess: “Testing company says Manchester tests were accurate”)
There is nothing easier in Vermont today for people who have no serious credentials to say, in effect, ”Hey, it’s just Levine. What does he know?”
So, my question to the Health Commissioner was, do you need to get tougher? Do you need to come down harder on the actual performance of the various players? Do you have a plan to bypass the garbage flying around so that the Vermont public gets a clear view of the issues involved? Levine said he intends to do just that.
“That will probably happen,” he said. “I am being somewhat respectful of the process, and I want the full report by the FDA (on testing) to come out, no matter what it shows, to help guide us and explain what went wrong in Manchester, not in a shaming way, but as an example, and then be able to reiterate what I said before about who the appropriate audience for this test is, where it should be used, where it shouldn’t be used.
“I have maintained all along that we will use these tests in Vermont…but it will be done under the right terms and the right conditions.”
Okay, Mark, but do you have a plan to articulate those terms and conditions at the front end and thereby foreclose poor performance by the various players?
“I absolutely do have a plan; that’s why I want to have the support of the investigation by the FDA, because I will not say anything different than I am going to say anyway. But having that investigation will reinforce the point I want to make. That’s key.”
Levine sounded determined to me, and his getting more forceful would be an important advantage as Vermont navigates the white water that lies between where we are now and either a vaccine or herd immunity. Enhanced oversight by Levine and the rest of the Covid team will be both difficult and important. Difficult because so many of the players are driven by ignorance, self-interest and political forces. Important because the state is already badly stressed by demographic and financial forces. The underlying issue is that Levine’s basic decency and understated style can work against him, as we saw in the Manchester case. My own view is that we can count on Levine—he is one of the vanishingly small number of national class players on the field.
That conclusion gave rise to my personal fantasy: that Levine might move beyond his immediate concerns with the virus to the broader issues that stand in the way of driving health care reform to full maturity, and a delivery system that is sustainable into the 21st century. That question is nowhere near as immediate and visible as the Covid battle, but it is much more difficult financially, socially, politically and culturally. So, if Levine could extend, or be asked or directed to extend, his portfolio to commentary on reform issues it would an important asset going forward. Those issues abound—what services should the small Vermont hospitals deliver; should Northwest Vermont Medical Center in St. Albans build a new Intensive Care Unit with Burlington’s Medical Center nearby; should 25-bed hospitals do hip replacements, or vascular surgeries? And dozens more. Vermont seems to me to be an information desert and a reliable medical authority would be a huge help.
Would Levine be interested in that?
He said he would, and that he believes that the Covid emergency could drive a new emphasis on public health by governments. In the U.S., he said, governments normally spend two to three percent of their budgets on public health, while the figure in Europe is in the teens. “The pandemic should make people so much more aware of the shortsightedness of that approach,” Levine said.
And those nasty questions attendant on reform: Should Vermont have someone who can provide medically credible advice there?
“Absolutely,” he said. “We know we can’t spend money on everything under the sun,” he continued. “The pandemic will help drive reform based on value over volume…”
Failure by Vermont to wring the best out of Levine’s skill and knowledge and the public trust he has engendered would be to waste one of the state’s most valuable assets. Vermont can’t afford to do that. Not even close.