It has been over a week since I have been able to write a post. It turns out, my work has been much more complex and challenging in many ways during this re-opening phase than the closing down and ramping up for the pandemic a few weeks ago.

Since the beginning of this pandemic, I have been monitoring its spread in neighboring states and provinces as well as in Maine. Just as a raging forest fire can send a spark across the border to a neighboring state or country, this virus likewise does not recognize our borders, and can ignite a fire most anywhere there is travel. Given my job at MaineHealth, it has made sense for me to regularly monitor the pandemic in nearby areas as well as their responses to it, since these can easily impact us. More recently, I have been monitoring the re-openings in our neighboring states and provinces so as to share any lessons learned with my colleagues. I thought I’d share some of these gleanings with you.

First, it’s easiest to review what is in common. In places that neighbor us, as well as in Maine and the rest of North America, people living in long term care facilities, people 60 and older, and those with underlying conditions have been hit the hardest. However, most of the underlying conditions are very common, e.g. obesity, high blood pressure, diabetes, asthma, chronic obstructive pulmonary disease, and even being immunocompromised. For instance:

  • • 42% of Americans are obese
  • • 9% have severe obesity (BMI>40, which is most highly associated with severe COVID-19)
  • • 33% have hypertension
  • • 11% have diabetes
  • • 8% have asthma (about 2/3 of them have persistently severe asthma, which is more highly associated with severe COVID-19)
  • • 6% have COPD
  • • 3% are immunocompromised

I mention these data since it seems common that people suggest one approach to this pandemic is for us to return to life as it was in January, and simply ask older people and those with high-risk conditions to self-isolate at home. Given how common these and a few other high-risk conditions are, there would not be enough eligible for the in-person workforce. And, we are still learning about who is at risk for severe disease from this novel virus.

Additionally, it is not uncommon that some younger or otherwise healthy people are hospitalized and/or have died from the virus. As a tragic example, Maine lost a 42-year-old firefighter several days ago to this disease.

Schools and nonessential businesses and services all closed in mid-March across this northeast area. Schools remain closed. The lifelines of most of these economies the last few weeks have been through a combination of transferring services to the internet, through finding creative ways to deliver services (e.g. curbside and no-contact home delivery), and through governmental assistance such as unemployment benefits.

Even with these lifelines, many economic engines have been disabled, especially those that rely on people traveling or congregating, such as tourism and restaurants. Where the virus has set ablaze the biggest fires (e.g. Massachusetts and New Hampshire), the economies seem hardest hit and reopening may be more complicated.

While there is much in common with how these neighboring states and provinces have closed, the impact of the pandemic and approaches to reopening have also varied a great deal. Here are some summaries by state and province.

MAINE

Maine seems to be flattening the curve, with overall downward trends and dramatic increases in doubling times of cases (from two to thirty-four days), a recent flattening and even decline in hospitalizations (from a high of 55 in mid-April to 33 as of Sunday), and with relatively low death ratios. However, evidence of community transmission exists in four counties, and ongoing outbreaks are occurring, including in long term care settings across much of the state and at a large food processing plant in Portland with yet-to-be-determined community impact.

Maine started re-opening May 1, with the ability for health care to open up, prioritizing time-sensitive care, and for hair salons, pet grooming, drive-in theaters, golf courses, some state parks, auto dealerships, and car washes to open – all with social distancing and hygiene-related restrictions. Gatherings of 10 or more are still prohibited. People traveling to Maine must be quarantined for 14 days. As of May 1, people need to wear cloth face coverings in public settings where physical distancing is difficult to maintain. Additional business sectors will be able to open up in the coming days and weeks, as long as the pandemic maintains the criteria set by the White House.

NEW HAMPSHIRE

Although New Hampshire has approximately the same number of people as Maine (1.3 million people), their case numbers, hospitalizations, and deaths are much higher than Maine’s. For instance, as of Sunday, they have twice as many cases (2,518 vs 1,185); three times as many who are currently hospitalized (103 vs 33); and one and a half times as many deaths (86 vs 57). Most of this illness and death have occurred in the last three weeks, though the increases have generally slowed.

The vast majority — 80% – 91% of the cases, hospitalizations, and deaths — is occurring in the southern counties of Hillsborough, Rockingham and Strafford, that border Maine or are wedged between Maine and Massachusetts. This hot area is likely in part an extension of the Massachusetts pandemic fire, given the amount of commuter traffic between these counties and Greater Boston.

New Hampshire is just starting to open up. Their stay-at-home order was renewed starting Monday in a modified way to May 31. Groups cannot congregate with more than 10 people. Leaving home is only allowed for essential services or visiting a parent, spouse, or child. Time-sensitive surgeries and procedures will be allowed starting Monday the 4th. Hair salons, golf courses, and drive-in theaters may open with modifications and requirements starting May 11th. Restaurants may serve outdoor dining starting May 18, again with a number of requirements. No indoor dining will yet be allowed. All hotels and lodging are closed until May 31 except for emergency purposes for essential workers and vulnerable populations due to the pandemic. New Hampshire has been the hardest hit New England state when it comes to unemployment claims filed due to the pandemic. Further plans for re-opening are expected to be unveiled in the next couple of weeks.

VERMONT

Pandemic activity in Vermont has been quite similar to Maine’s. They have flattened the curve quite well with early and strong social distancing mandates, which for the most part are still in place. Although they have had 897 cases, 10 are currently hospitalized, and 52 have died (all lower numbers than Maine), their case rate and death rates are higher. This is because Vermont’s overall population is less than half (46%) of Maine’s. They too have had a concentration of impact from the pandemic in their urban areas, especially Burlington.

Like Maine and New Hampshire, Vermont is also implementing a phased approach to reopening. Their stay at home order was renewed on May 1-15. Starting Monday, some limited construction businesses will be allowed to open, in which no more than 10 are gathered and the work is primarily outdoors. Vermont requires out of state visitors to quarantine for 14 days. The public must wear face coverings when on public transportation, and are strongly encouraged to elsewhere. Restaurants and non-essential retailers are closed except for take-out, curbside pick-up, and delivery services. Hair salons and gyms remain closed. Future opening dates of these other business sectors have not been set.

MASSACHUSETTS

Massachusetts, Connecticut and Rhode Island have all been hit harder by COVID-19 than the northern three New England states. Massachusetts especially has been surging the last several weeks, and is considered one of the hardest hit areas of the U.S. It has seen over 68,000 confirmed cases. Almost 4,000 were hospitalized a few days ago, and although this number has decreased, over 3,600 are currently hospitalized. Tragically, over 4,000 have also died from this disease in Massachusetts.

Just to put these numbers into perspective, Massachusetts has five times the population of Maine, so if these numbers were in Maine, we would have approximately:

  • • 13,200 cases (we have 1,185)
  • • 720 – 800 hospitalized (we have 33)
  • • 800 deaths (we have 57).

Massachusetts hospitals have been full beyond their normal capacity. As a result, several alternate care sites were set up in convention centers in urban areas such as Boston and Worcester, and they have been used for COVID-19 patients, especially those who are homeless or are in prisons. With numbers of cases and hospitalizations down these last several days — both early indicators — it appears their surge may have peaked. But only four days ago, they recorded their one-day largest death toll — 252.

Like most other states, Massachusetts has been in a declared state of emergency since early-mid March. From March 23 and until at least May 18, gatherings of 10 or more are prohibited; non-essential businesses are closed, including restaurants; there is a stay at home advisory. Although face masks or coverings have been encouraged since early April, as of Wednesday, May 6, they are required in public situations when social distancing may not be possible to maintain.

One in four workers in the state have filed for unemployment benefits, making it and New Hampshire the hardest hit in New England in this regard. Although state government is starting to formulate reopening plans, many, including prominent business leaders, recommend a slow reopening. The Massachusetts High Technology Council – comprised of leading business CEOs and health experts, just released their recommendations, linked to below. The Governor has convened a reopening advisory board, which is supposed to provide recommendations by May 18th.

RHODE ISLAND

Rhode Island, which has a population of just over one million and less than Maine’s, has seen about 9,300 cases, 300 deaths, and currently has 333 hospitalized — all 5-10 times Maine’s counts. They continue with a stay at home order, and all nonessential businesses are closed, including restaurants (except for take-out and delivery). The famed Newport Jazz Festival as well as other festivals, parades, fairs, and carnivals are cancelled for the summer. On April 27th, a set of four phases for reopening was announced, with timelines to be determined. On May 1, the governor announced state parks would start to reopen in phases through May, with restrictions on parking and social distancing.

CONNECTICUT

With close to 2,500 deaths so far, Connecticut has the 3rd highest death rate in the country, just after New York and New Jersey. It appears some of the reasons for this have to do with its proximity to New York as well as an older population (6th oldest state in the nation) and its population density (fourth most densely populated state).

Since April 17, people in Connecticut are mandated to wear a face covering when out in public when social distancing is not assured. Executive orders are in place until at least May 20 for people to stay at home, for food establishments to be closed except for take-out and delivery, and for all non-essential businesses to be closed, including gyms, movie theaters, and hair and nail salons.

CANADA

Although Maine’s border with Quebec and New Brunswick has been closed since the U.S. — Canada border closed March 21, and is expected to remain closed until at least mid-late May, there is some essential travel between the two countries. Interestingly, non-essential travel within Canada has been restricted, including between provinces such as between Quebec and New Brunswick as well as between some regions within provinces. This has been enforced by checkpoints. (This is not an option that is felt to be allowed in the U.S. under these circumstances, which is why no state has done it.) These travel restrictions may explain some of the factors contributing to lower impact of COVID-19 in Canada.

There is also a 14-day quarantine mandate for those who must enter a province, and the Canadian government’s website specifically states this quarantine also applies to snowbirds arriving home for the summer. Non-residential cottage owners are not allowed to travel to their seasonal homes in Quebec and the Maritime provinces (New Brunswick, Nova Scotia, and Prince Edward Island). Schools and non-essential businesses have been closed, and those without pay across Canada have been given $2,000 per month income by the government.

QUEBEC

Quebec Province has seen about 30,000 cases and over 2,100 deaths, with about half of each of these in Montreal. The regions bordering Maine (Estrie, Chaudiere-Appalaches, and Bas-Saint-Laurent) have seen in aggregate about 1,300 cases and 34 deaths.

Quebec announced a stepwise reopening of their economy, which begins May 4 with the gradual lifting of inter-regional travel throughout May. Some businesses (with social distancing restrictions) will open Monday, including some retail stores (but not malls) with some additional businesses such as construction to be opened May 11. These business sectors in Montreal are scheduled to open a week later. Tourist sites, festivals, campgrounds, and non-essential lodging remain closed, with timeline and strategies awaiting a more comprehensive plan for reopening the province’s economy.

NEW BRUNSWICK

New Brunswick has seen a total of 118 cases, all of whom are recovered, and therefore not contagious. They have seen no deaths due to COVID-19. As of May 2, they have been two weeks with no new cases. As a result, members of one household can gather with members of one other household. Churches can now hold outdoor services so long as congregants stay in their cars.

The premier also announced that the reopening of New Brunswick would be done in four phases, with timelines for the phases beyond this first one to be determined at later dates, depending on disease progression. Currently, elective healthcare, daycares, restaurants, campgrounds, and offices are all closed.

The Premier also recently announced that he feels this is the time to re-tool several sectors, including assuring the province can produce its own food supply with its own workforce to the extent possible, and that health care can be delivered digitally on an ongoing basis.

Borders with other provinces are to remain closed for the foreseeable future, except the one with Prince Edward Island, which might open up in July, if the pandemic situation remains the same.

PRINCE EDWARD ISLAND

PEI has only seen 27 cases, no deaths, and only one new case in the last two weeks. PEI announced their four-phase re-opening plan on Friday. After being in a state of lockdown for several weeks, they will now allow some outdoor activities such as walking, hiking, golfing, and fishing, with a number of restrictions, including no more than five people being able to gather. Some non-urgent but time-sensitive health services will be allowed. Daycares will open, but only for essential workers. Restaurants and some limited lodging (B&Bs) are not allowed to open until mid-June, and then, only to PEI residents.

NOVA SCOTIA

Nova Scotia has seen 963 cases and 31 deaths. One-third of the cases and 25 of the deaths have been in one long term care facility in Halifax. On Friday, Nova Scotia’s premier announced the lockdown would continue at least through May 17, but that people could go outside for gardening, to some parks, and to golf ranges. Beaches and golf courses continue to be closed.

PUBLIC HEALTH AND POLITICS

Listening to the news, it sometimes seems that public health and economic decisions have been mixing a great deal with political divisiveness, with some from the Right calling for quicker reopenings, and some from the Left asking for a slower pace. But reviewing these neighboring states and provinces, there seems to be much more unity than divisiveness among those making the policy decisions.

For instance, a quick examination of these six states and neighboring Canadian provinces does not reveal a strong association of political affiliation and these decisions. New Hampshire, Vermont, and Massachusetts are all led by Republican governors, whose policies on reopening seem to vary little from the Democratic governors of Connecticut, Rhode Island, and Maine. Some of the strongest statements about the need for a slow pace for reopenings have come from the Republican governors of Massachusetts, Vermont and New Hampshire as well as from some prominent business leaders.

Additionally, the bipartisan set of northern New England governors have discussed publicly how they are coordinating some of their reopening efforts, are collaborating in the sharing of information, and are communicating regularly.

Even within Canada, the premier of Quebec, who is a centrist, is promoting a much quicker reopening than his colleague in New Brunswick, who is a conservative. Nova Scotia’s premier is a member of the Nova Scotia Liberal Party, and the PEI premier is a conservative. All three maritime premiers publicly are promoting a very gradual stepwise re-opening. Like the three bipartisan governors of northern New England, they also seem to be collaborating, communicating, and coordinating their efforts.

CONCLUSION

We are living with a great deal of uncertainty, especially with a pandemic with a novel virus. The last pandemic this severe raged the earth 102 years ago. The virus does not see our state and countries’ borders. We have to recognize that areas such as southern New Hampshire and Massachusetts, a few minutes’ drive from our border, are still confronting massive outbreaks. And even southern New England and the Mid-Atlantic, where the pandemic is still raging, are only a few hours’ drive away.

While the pandemic seems to be smoldering in Maine, it only takes one spark to ignite its fire. This is something that seems to be well recognized across the area’s policymakers, including those with the Canadian Maritime provinces, which continue to have closed economies and closed borders between them.

Clearly, there is no playbook as to how to reopen. But one thing is very clear. No matter how open or closed our states and provinces are, each of us as individuals needs to take responsibility to do our part to continue social distancing and not ignite any fires. While Maine and each of these neighboring states and provinces are under various emergency orders, they are only as effective as we the people are at implementing them.

What can we do? We can each become familiar with the new social distancing requirements for businesses and lend them a helping hand in complying. Most importantly, we can make sure we as individuals, our household members, and co-workers are practicing good social distancing: wearing a mask when appropriate in public; maintaining six feet distance; washing hands often; and not gathering inappropriately with others. These measures — to one degree or another — are likely a way of life until there is herd immunity achieved with a vaccine. They are also the most effective tools we have to fight this virus — to protect us who are carrying out these strategies and importantly, to protect those around us.

This pandemic is likely to threaten us for months if not several years. It is a bigger force than any one of us. However, I know that together, we can stamp out its fire.

Dr. Dora Anne Mills is the chief health improvement officer for MaineHealth and former head of the Maine Center for Disease Control and Prevention.

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