Levine on COVID Response, Disparities Among BIPOC

During the 2020 Annual Meeting of the Vermont Association of Hospitals and Health Systems, “Achieving Health Equity: A VAHHS Virtual Meeting,” VAHHS was proud to welcome Dr. Mark Levine, whom VAHHS CEO Jeff Tieman introduced as Vermont’s Dr. Fauci. Levine, Commissioner of the Vermont Department of Health, discussed the state’s response to COVID and the effect it had on several populations.

He began with a familiar graphic—one most of us remembered from the earliest days after the COVID patient in Vermont—the “flattening the curve” slide.

“This was really about VAHHS,” he noted, pointing out that a surge like the one shown if the curve was not flattened could have overwhelmed the health care system.

“The last thing we wanted for Vermont was for it to look like China, where hospitals were overwhelmed. We were looking at the anxious faces of Italian citizens and doctors. And we would soon see in New York City families devastated by losses and not allowed to see their loved ones as they lay dying. Inpatient care was being delivered in hallways; there was a debilitating lack of personal protective equipment; and refrigeration trucks were compensating for overfilled morgues,” he said.

“Thanks goodness, we—VDH, and you—collaborated and creatively financed our response so that the surge was an outcome that never came to be,” he exclaimed.

He enumerated the hardships hospitals had to endure to create that eventuality, listing sacrifices such as empty hospital beds awaiting COVID patients, teaching hospitals that had to reimagine medical school, rigorous testing protocols and the fear that many health care professionals faced.

“You wondered what would happen to all the other medical problems that weren’t being taken care of because of people choosing to ignore them or consciously delaying seeking attention for them,” he added. “And when re-opening would occur, what if no one came?” he remembered.

“Fortunately, that was a false prophecy,” he noted.

“And thought it wasn’t terrible, the health care workforce did suffer out of proportion to the rest of the population, leading to abundant concerns about staffing,” he stated.

“Collaboration with the health care sector, public health and the state, I am glad to say, continues to this day,” he said, explaining that hospitals and other health care workers have provided assistance with targeted pop-up testing efforts at the early signs of outbreaks, bailing out nursing homes with staff coverage when these facilities were at desperation’s doorstep, helping to craft the new rulebook for re-opening the health care sector and partnering with the health department to have a diverse and comprehensive testing protocol statewide.

“Setting the table” for keynote speaker Dr. Mercedes Avila and the meeting’s theme, Levine stressed that health care providers are not the only Vermonters to be disproportionately affected by COVID.

“Like the US being only 4 percent of the world’s population, but a far more significant portion of deaths from COVID, the rate of infection is four times higher for our black, indigenous and people of color (BIPOC) than white Vermonters,” he said, adding that the disparity appears not only in the case rate, but in higher hospitalization rates as well.

One in four Vermonters with COVID are BIPOC. Levine explained that while we are unsure how most white Vermonters are infected with the virus, we are more likely to be able to trace how BIPOC individuals got it.

“BIPOC are more likely to be part of an outbreak, more likely to have come into contact with someone else who has COVID and more likely to have had household contact with a case, as we saw during our largest outbreak in Winooski,” he said.

BIPOC Vermonters are also more likely to have underlying conditions that can make COVID more serious, which Levine attributed to the circumstances people are living in.

“People might say the predisposition to underlying conditions is just genetic—that may explain a small part of this,” he allowed.

“But I look at that as a genotype,” he argued. “The phenotype is really the interaction of the environment with that genotype and the fact that, even if you have one of these underlying conditions, the circumstances you’re living are what is predisposing you for the worse outcome with COVID—not necessarily your genetic background. And if you happen to be in a community that’s predisposed to it, it may be that you’re working in a much more public job—you can’t do telework—and to get to that job, you may be using public transportation. You may live in a multi-generational household where people are very close together. And you may have had less access to some of the things we use to protect ourselves,” he added.

Levine ended by asking, “How do we impact those social determinants through working together in our society—not as a health department or another sector of government, but how do we work together as a society to impact some of the structural or systemic racism and other issues that are really causative in this entire endeavor?”

Tieman commented that he and Levine have been considering using the VAHHS Discharge Data Set to try to inform this work on an ongoing basis and understand what’s going on with disparities with COVID and how Vermont can manage them.