Covid-19 policies haven’t helped the people most affected by the virus — except in Vermont.
In the middle of March, while many Americans were panic-buying milk and toilet paper, Michael Redmond had other things on his mind: how to safely house the dozens of people who rely on his organization for a bed to sleep in every night.
The executive director of the Upper Valley Haven social service agency in White River Junction, Vermont, had read the reports that the new coronavirus could easily circulate among people living in close proximity — retirement homes, prisons, or homeless shelters like his.
So he contacted the state to ask for advice. “‘Don’t worry,’” he recalls an official telling him. ‘“We’ve entered into contracts with local motels. If you feel you can’t operate your shelter, everyone can be given a room in a motel.’”
Within days, Remond was able to cut the number of beds in his shelter to reduce crowding and divert additional clientele to state-subsidized motel rooms. His nonprofit also organized outdoor dining and meal deliveries to further support social distancing.
Eight months into the pandemic, Redmond has seen no Covid-19 cases among his patrons. Overall, there have been fewer than six cases among Vermont’s homeless population, according to the state health department. That’s less than a 1 percent infection rate — a stark contrast with the 25 percent infection rate among the homeless across the US.
Vermont has also remained an island of low coronavirus spread generally. Even with a recent surge — from fewer than 10 cases per day in September to 57 on November 18 — it’s consistently had one of the lowest infection rates in the continental US: 14.6 cases per 100,000 in the last seven days compared to 27 in New York, 74 in Georgia, 84 in Colorado, and 185 in North Dakota. Anthony Fauci, the nation’s top infectious disease doctor, has called Vermont “a model for the country.”
Researchers studying Covid-19 policy say Vermont’s successes are inextricably linked to its approach to helping at-risk groups avoid the virus. “Vermont’s prioritization of its vulnerable populations has helped both to protect those [people] from the worst outcomes we’ve seen in other settings but also contributed to the much lower transmission rates in the state,” said Anne Sosin, the program director of Dartmouth University’s Center for Global Health Equity.
“If we look globally,” Sosin continued, “the countries that have done better [with Covid-19] prioritized their vulnerable populations.”
Vermont’s health leaders recognized this very early in the pandemic. And instead of relying only on stay-at-home orders or curfews — which tend to benefit people who can work from home or fully isolate if they test positive — the government designed a response with the needs of high-risk groups in mind.
The package of measures now includes state-supported housing for the homeless, hazard pay, meal deliveries, and pop-up testing in at-risk communities. The state’s Republican governor, Phil Scott, is even proposing $1,000 stipends for people who’ve been asked to self-isolate.
Most states have “been using really blunt public health and policy measures to respond to the pandemic,” Sosin said. Vermont highlights a different way. When governments “tailor responses to the needs of our most vulnerable populations,” Sosin added, “we can stop the virus and save lives.”
Covid-19 is not an equal-opportunity disease. Covid-19 policies haven’t reflected that.
There’s a fatal flaw embedded in the basic Covid-19 test, trace, and isolate trifecta used around the world: It doesn’t account for the fact that the coronavirus is not an equal-opportunity pathogen. The people who are most likely to be tested, and to have the easiest time quarantining or isolating, are also the least likely to get sick and die from the virus.
From the United Kingdom to Sweden to Canada, we have evidence that the virus preys on people employed in “essential service” jobs (bus drivers, nurses, factory workers), which don’t allow for telecommuting or paid sick leave; people in low-income neighborhoods; and people in “congregate housing” like shelters, prisons, and retirement homes.
People of color tend to be overrepresented in these groups — but there’s no biological reason they’re more likely to get sick and die from the virus. Simply put: They tend to work jobs that bring them outside the home and into close contact with other people, live in crowded environments ideal for coronavirus contagion, or both.
“My guess is that the only globally consistent finding about Covid-19,” Stefan Baral, an associate professor at the Johns Hopkins Bloomberg School of Public Health, said, “will be an inverse relationship between Covid-19 incidence and the square feet per person per household.”
This means that, even when social distancing orders are in place, because of an individual’s work or living circumstances, they may be less able to physically distance. If they test positive, they may not be able to isolate.
The Green Mountain State has features that might have helped in this regard: It’s more rural and less dense than many other areas in America.
But focusing on Vermont’s size or rurality misses important lessons in what the state did right during the pandemic, said Sosin, who has studied the state’s Covid-19 response. Vermont also has attributes that put people there at higher risk. The state borders New York, home to America’s deadliest outbreak, and ranks fourth in the nation for the largest percentage of people age 65 and older, and last when it comes to ICU beds per capita. Other even smaller states, like Wyoming, or more rural places, like the Dakotas or Nebraska, are grappling with some of the worst outbreaks in America.
So what’s the key to Vermont’s success? It’s pretty simple, Sosin said. Instead of just talking about how “social distancing is a privilege,” leaders in the state thought about how to make sure health policies actually addressed barriers to social distancing.
How Vermont kept its coronavirus rate low
Vermont’s governor was quick to issue stay-at-home orders when the virus began surging in neighboring New York, shutting down schools in mid-March and issuing a stay-at-home order a week later. But the approach to helping people keep their distance and then reopen was much more nuanced — and involved everyone from the state and municipal governments to nonprofit workers and volunteer community groups.
In early March, there was the decision by the state to subsidize motel rooms to alleviate crowding in homeless shelters, said Sarah Phillips, director of the Office of Economic Opportunity and the leader of Vermont’s Covid-19 homelessness response team. While the program built on an existing motel voucher system the state had in place, “what we’re doing now is far beyond what we’d normally provide for emergency housing and is entirely due to the need to provide non-congregate shelters” in the pandemic, she said.
There are currently 1,400 households in motels around the state — above the usual 300 at this time of year. The state also gave personal protective equipment and cleaning supplies to shelter workers, and made funding available to take other actions, like improving ventilation.
To support the motel program, social services organizations organized food and health services. Redmond’s Upper Valley Haven agency, for example, stood up a mobile food pantry at the motels where people were staying, and partnered with a health clinic organized by students at Dartmouth University’s medical school to connect the motel residents with primary care, and addiction and mental health support.
Communities across the state also formed mutual aid societies, Sosin found, mapping out their towns, and going “door to door or house to house, to identify vulnerable residents and organize services to support them so they could stay home.”
Vermont tests a lot: It has consistently had high per capita test rates and among the lowest test positivity rates in the country. But the testing has always been tailored, said Vermont’s health commissioner Mark Levine. Since the beginning of the outbreak, the state health department organized pop-up testing in neighborhoods, housing facilities, or workplaces where the virus had begun to spread, or there was a risk of an outbreak. Instead of waiting for people who needed testing to find it, Levine said, they brought free testing to the people.
Nursing homes and prisons were other priority areas. After two outbreaks in retirement homes at the start of the pandemic, the health department put restrictive visitation policies in place, and tested and quarantined new residents moving in. “We have not had an outbreak since that time until this most recent surge. And that’s because of our protecting the most vulnerable steps we took,” said Levine, who described a similar approach — and success — in state prisons.
In May, Vermont expanded hazard pay to support essential workers making less than $25 per hour. More than 35,000 front-line workers will benefit from the program. The governor has also asked lawmakers for $700,000 to offer $1,000 stipends for people who need to quarantine or isolate but may be worried about missed income from work.
When the case count dropped close to zero in May, the state took a gradual approach to reopening, lifting restrictions on different sectors one at a time, every two weeks — the coronavirus incubation period — to understand what, if any, impact reopening had on viral spread.
Even though cases are now climbing in Vermont — with 57 on November 18 — Levine says, “We’re very optimistic.”
That’s because, just like last spring, Vermont is responding in a fast and targeted manner. Since new cases tend to be connected to travel and household gatherings, officials have tightened the borders and outlawed multi-household gatherings, even ahead of Thanksgiving. Shops, schools, and restaurants — which haven’t so far been identified as major sources of contagion — remain open.
“That’s pretty strict,” Levine said. “We’re hoping, if everyone listens to us, we will not see any further surge.” But it remains to be seen if Vermont’s targeted approach can keep working, with lax measures contributing to rising cases in other parts of the country.
What the rest of America can learn from Vermont
There’s a simple adage in public health: “Never do a test without offering something in exchange,” said Johns Hopkins’s Stefan Baral. So when a patient gets tested for HIV, for example, they’re offered treatment, support, or contact tracing. “We’re not just doing the testing to get information but also providing a clear service,” Baral added, and potentially preventing that person from spreading the virus any further. “This is basic public health.”
“If we are asking people to stay home and not work, we have to make sure society is supporting them,” Baral said. “An equitable program would support people to do the right thing.” And doing the right thing involves taking the types of approaches Vermont has.
“President-elect Biden’s plans for Covid-19 must ensure that the social goods of effective quarantine and isolation are supported by society,” Baral wrote in an op-ed with Yale University’s Gregg Gonsalves, “including the provision of paid leave and temporary housing support, especially for those in multigenerational households, and alleviating barriers to testing and health care.”
The Biden administration may be constrained by Congress but still could change the course of the pandemic with a stronger focus on equity. The president-elect has appointed a health equity researcher — Yale University’s Marcella Nuñez-Smith — to co-chair his transition team’s coronavirus task force. She’ll be focused on addressing the disparities the pandemic has once again revealed, she told Politico, moving “from policies to the blueprint on day one.”
But there’s no need to wait for the new administration to take these actions, Sosin said, noting that Vermont’s governor is a Republican. “These are not Democratic policies,” she added. “It’s good leadership and policy.”