Citing lower case counts and less strain on hospitals, Gov. Greg Gianforte said last week the state will move to managing COVID-19 as an endemic disease like the flu and wind down some of the state operations Montanans have come to know over the last two years.
“As we enter our third year of responding to COVID-19 … we’re shifting our approach from a pandemic response to an endemic response,” Gianforte said in an interview. “That means the virus is going to stick around, but with lower lower frequency, and it’s going to be much more like seasonal flu.”
The change comes as hospitals in Montana breathe a sigh of relief with a dramatic decrease in cases and hospitalizations, but still nurse the deep damage done to their employees since March 2020.
Communities and schools are also welcoming a decline from the sharp omicron surge, with many easing measures like face-mask requirements.
Public health officials, who saw their authority curtailed by legislative action in 2021, struggled through two surges of the virus last year without access to many of the previous tools in their toolbox. But now they’re cautiously informing their communities about the lowest transmission rates in months.
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Two years after the state marked its first case of the virus that would go on to kill at least 3,223 Montanans, some people are testing the waters, returning to restaurants, movie theaters and other venues.
Others spent much of the last year living as if COVID-19 was already a relic. Gianforte ended the statewide mask mandate in early 2021 and eliminated many of the restrictions on businesses and events that limited hours and capacity. A person attending a basketball game in plenty of parts of the state this year wouldn’t have seen much difference between the pre- and post-COVID versions.
As case counts reach lows unseen since last July before the delta surge, it feels like Montana and the U.S. broadly are emerging from a dark winter toward a spring of optimism. But those with health conditions putting them at high risk for severe outcomes from COVID infections feel left behind.
The state’s new approach
In shifting Montana’s management to an endemic approach, Gianforte said a main driver was looking at the strain on hospitals.
“From Day 1, we’ve been concerned about health care capacity, particularly occupied beds. … As we’ve been in touch with our hospitals, we’ve seen the utilization come down dramatically and the trends are in the right direction,” Gianforte said.
Intensive care unit nurse Paul Lee dresses in personal protective equipment before entering a COVID-19 positive patient’s intensive care unit room in September 2021 inside St. Peter’s Health in Helena.
Data compiled by the state health department showed COVID-19 hospitalizations dropped 37% last week from the week prior, with an average of 102 patients hospitalized from the virus around the state on any given day. For comparison, in the week ending Feb. 19 the state saw an average of 230 people hospitalized for COVID-19 daily.
Gianforte said another reason for the change was the decline in cases combined with the state not seeing “any new variants on the horizon.”
Average new COVID cases on Friday dropped below 100 per day in Montana for the first time since last July, before the delta variant took hold and sent the state’s caseloads skyward.
The rapid decline in new cases is a fresh development, however. Just six weeks ago, the state’s 7-day average was 2,400 new COVID cases each day, far surpassing previous surges of the virus. Hospitalizations and deaths were likewise elevated.
One way the state’s management might change, Gianforte spokesperson Brooke Stroyke said in an email, is possibly following a recommendation from the administration’s public health team to report new infections on a weekly basis, rather than the every-weekday updates Montanans have seen for the last two years.
People line up at the Lewis and Clark County Fairgrounds in January 2022 to receive a COVID-19 test from the county’s testing site in Helena.
Stroyke said the state will still monitor infections and test for variants on a daily basis, as well as keep a close eye on high-risk settings like long-term care facilities.
But it’s far from clear whether the emergence of new COVID variants could propel future surges in cases, hospitalizations and deaths in the months ahead, said Dr. Neil Ku, an infectious disease specialist at Billings Clinic. If Montanans along with the world have learned anything during COVID-19, it’s that it’s impossible to predict what might come next.
“As long as this disease can continue to circulate, there is always the opportunity for new variants to evolve. … The more people who are infected, the more opportunity for the virus to evolve, to become a variant of concern,” Ku said in an interview last week.
The state will stay “nimble to pivot if we need to,” Gianforte said, meaning the framework will stay in place to respond if cases again surge. “But this also means we’re winding down some of the measures that we have in place and shifting our strategy towards COVID-19.”
‘A marathon of pain’
Scott Ellner, the CEO of Billings Clinic, said while the state’s largest health care system is happy to see the decrease in very sick COVID-19 patients, the last two years have caused damage that will take a long time to recover from.
“I would say now that we’re seeing some light, seeing some hope,” Ellner said. “The focus is really on going through a process of healing and helping people move forward.”
St. Vincent Healthcare doctor Adam Zelka undergoes a pulmonary function test from respiratory therapist Kayla Nelson as he recovers from COVID-19.
He described COVID-19 as both an “unrelenting marathon” and a “marathon of pain,” shared by doctors, nurses and other hospital employees along with the families of patients sickened by the virus.
“You start to see the amount of deaths from patients who had long hospital stays – it was really impacting the well-being of our workforce,” Ellner said. “I think we started off really feeling like ‘We got this, we can handle the challenge’ and people rose to the occasion and did some very special things. And then at some point it really started to become such a grind, to where we started to see that people were becoming scarred emotionally.”
That’s led to an exodus of workers and serious challenges for those who have remained.
“The reality is that a large number of people have probably retired or resigned from health care prematurely and so it has created a shortage in the workforce,” Ellner said, adding the problem is not unique to Montana. “What we have to do is really focus on creating the job and meaning and purpose of the health-care workforce so that they come back and they stay.”
Given the uncertainty and potential for future surges and stress the health-care system, trying to rebuild the workforce is critical to be prepared, Ellner said. That includes helping employees with mental health services, debriefing following difficult cases and deaths and listening to what employees say they need to recover.
“We’re still not sure what’s going to happen in the future,” Ellner said. “We may be going into an endemic. We may see a surge again. So going through a process of healing is important.”
Like other hospitals in the state, Billings Clinic also saw a shift from strong support for health-care workers early in the pandemic to later outright hostility to employees in some cases.
Adriane Beck, director of the Missoula Office of Emergency Management, piles at-home COVID-19 tests for distribution at the Missoula County Elections Center in Feb. 2022.
“It’s better, but I wouldn’t say we’ve gotten to a point where people are feeling good,” Ellner said of how things have gone recently. He predicts if case trends continue to improve, policies around visitors and masking could ease, something he expects to help heal strained relationships between communities and their hospitals even more.
But as Gianforte said the state needs to remain nimble, Ellner said so do hospitals.
“What I do know is that if there is another surge, we’re going to have to fall back on the guidelines that we follow through our unified health command and (Centers for Disease Control and Prevention) to protect our staff and protect patients,” Ellner said.
‘Very few tools’
Under the endemic approach to COVID-19, Gianforte said the state intends to “mainstream” vaccine operations to look more like the process for flu shots and other vaccinations. That means people would be more likely to get a COVID-19 vaccine from their doctor during a wellness visit or at the local pharmacy and not a mass vaccination events.
Roughly a quarter of the state’s population has tested positive for COVID-19 at some point during the last two years, which Ku said can impart some level of immunity.
But vaccination rates in Montana have remained stubbornly low compared to other parts of the country. Just 57% of the overall population is fully immunized, according to data from Johns Hopkins University, versus the national rate of 66%.
Braden Gibson, the kitchen manager at the Butte Rescue Mission, looks on as Sarah Borduin, a registered nurse with the FUSE program at Southwest Montana Community Health Center, prepares to give Gibson the Johnson & Johnson COVID-19 vaccine in March 2021 at the Sycamore House.
Health experts have for the past year said vaccinations remain one of the best ways to protect the population as a whole. Ku noted that as long as COVID-19 continues to circulate, there are opportunities for new variants to emerge and pose the risk of future case surges.
But when vaccines first emerged, Ku said he cringed any time they were sold as a sort of miracle to end the pandemic.
While vaccines have been incredibly successful in preventing severe illness and death from the disease, the vaccine is still a “work in progress, and the vaccine is not the be-all/end-all, the magic silver bullet (to end the pandemic) that we had hoped,” Ku said.
In Montana, data from the state health department shows from April 1, 2021 to March 4, 2022, unvaccinated Montanans accounted for 80% of hospitalizations and 77% of deaths from COVID-19.
Vaccines became available as the pandemic entered its second year, and Gianforte adjusted the distribution plan left by the outgoing administration to focus more on the elderly and medically vulnerable. While he’s encouraged Montanans to talk with their health care providers, he’s also staunchly opposed mandating vaccinations.
The governor’s actions in lifting the statewide mask requirement and ending the state of emergency, combined with those of the GOP-majority Legislature, dramatically changed how Montana responded to COVID-19 in the second year of the pandemic.
Sgt. Jacob Hamberg delivers prepared doses of the Pfizer-BioNTech COVID-19 vaccine to nurses at the vaccination clinic at MetraPark in Billings.
“What we learned was that really top-down government mandates don’t work, are impractical, and are inefficient,” Gianforte said. “And honestly, the vast majority of states have moved away from them … We shifted to a strategy of personal responsibility. And the truth was the prior response had created an economic pandemic. … It’s a different approach that relies more on personal responsibility, communication and education and less on mandates.”
Nearly a year ago, a bill was introduced during the 2021 legislative session that would have an outsized impact on Montana’s approach to COVID vaccines.
The Republican-backed legislation sought to prevent what many on the right feared would be discriminatory policies against those who opted against being vaccinated. Montana became the first in the country to extend that prohibition to the private sector when Gianforte signed it into law in May, along with several other measures that reduced the authority of public health officers.
In Lewis and Clark County, Public Health Officer Drenda Niemann said the county shifted to an “education-based approach” because of the legislative changes, with a frustrating outcome.
“During this time, we experienced two significant surges in cases (delta and omicron) that resulted in more deaths and strain to the health care system,” Niemann wrote last week. “St. Peter’s Health had to move into ‘crisis care’ because they did not have the resources/capacity to serve all individuals who needed care when they were overwhelmed by individuals who were very sick with COVID.”
In Butte, Karen Maloughney, a registered nurse who is the health officer for the county, described the 2021 legislative session as extremely disheartening.
Ellie Nuño, a Missoula musician, receives her COVID-19 vaccination in February 2021 from retired doctor Kathleen Rogers.
“The tried and true public health protection measures that have kept our communities safe and healthy were attacked,” Maloughney said. “We are left with very few tools in our toolbox, which puts our communities at a greater risk of outbreaks and other threats of public health significance.”
Maloughney said health department staff has been beset by a variety of emotions now as the virus appears to be loosening its grip on Montana.
Ongoing legal challenges have put on hold multiple federal vaccine mandates except for at hospitals and other health care facilities. The legal landscape surrounding COVID vaccine requirements likely won’t be decided for some time. Multiple challenges to various vaccine rules of the Biden administration — including those for federal contractors, armed services personnel and Head Start employees — are slowly playing out in the courts. There are also ongoing challenges to Montana’s vaccine law, which is still in place as the courtroom battles advance.
Asked how he would answer criticism about how he’s navigated the pandemic and if the state could have had fewer cases and deaths under a different approach, Gianforte said he would respond first with empathy to the lives lost.
“We’ve lost too many lives, too many Montanans have gotten the virus and are not with us anymore,” Gianforte said. “However, that being said, in America, we lost more lives in 2021 than we did in 2020. … On our watch, we really empowered Montanans with the tools, from vaccinations to treatments to prioritizing the most vulnerable and encourage them to make informed decisions.”
‘Learning how to integrate it’
As of Wednesday last week, the Butte-Silver Bow County health department had recorded 129 deaths attributed to COVID-19 since the pandemic began. Residents of the city and county mourned the loss of loved ones, friends and neighbors and grieved for forsaken annual community traditions such as the St. Patrick’s Day Parade and the Montana Folk Festival.
But both are scheduled to resume this year, though the road to their comeback has been strewn with thistles and thorns.
“For now, I think a lot of us are cautiously optimistic. Then there are some days when we are waiting for the other shoe to fall,” Maloughney said. “We are coming up on the two-year anniversary of the first case in Butte. Since that day, we have lost 129 people to this horrible virus — which is what it is — a horrible, awful virus.”
But COVID is anything but gone, Maloughney said: “In some ways for us, it is here to stay. It’s learning how to integrate it into your everyday routine.”
Meanwhile, the school superintendent and school board for Butte School District No. 1 weathered a withering campaign waged by some parents and residents to overturn the district’s mask mandate.
But School Superintendent Judy Jonart said in January that she was determined to keep students learning in the schools as long as possible. The omicron variant’s spread was worrisome for a time and the mask mandate continued.
“Our goal is to keep the doors open,” Jonart said then. “We’re doing everything possible not to go remote. And we appreciate the cooperation of parents and the community.”
On Feb. 22, the school board lifted the mask mandate as COVID cases declined in the community.
Second grade students study mathematics at Kessler Elementary school in Sept. 2021.
Even as case growth slows, those who still remain at high risk of severe outcomes if they become ill feel left behind by shifting public health measures.
Asked about the frustrations from people at high risk for severe outcomes, Gianforte again turned to “personal responsibility.”
“That’s what personal responsibility is, for folks that are more susceptible to COVID-19,” he said. “The obvious one is the elderly. That’s why I’m really pleased that about 85% of Montana seniors are vaccinated. That was a good decision.”
For those with underlying health conditions, the governor said “they should work with their medical professional and they need to take appropriate precautions.”
“What this really means is that the virus is still going to stick around, but at a lower frequency. It’s going to be more like the flu. And if you’re sick, don’t go out. If you have extenuating circumstances, you may want to wear a mask or not be in large groups. These are still good procedures to protect yourself and your family,” Gianforte said.
Ku said while those in the medical field hope to see case growth continue to decline, there’s no real defining clear line of when when COVID-19 will become more like the seasonal flu.
“We hope it will become endemic, but there’s a lot of hurdles to get to that point. And so I think that we’re doing better now than what we did before, but it’s still fairly murky what will happen in the next few years,” Ku said.
Charlie Cejka, 8, receives a COVID-19 vaccine in November 2021 during a public vaccination clinic for kids age 5-11 at East Helena High School.
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