Some frank talk between Hawaii’s doctors and its state government is long overdue. Back in February, when the epidemic first slipped beyond China, I did what a lot of other doctors did. I looked for guidance from our state Department of Health (DOH).
What I found, unfortunately, was a lot of BS about how “the risk is low,” delivered in the sedating drawl of official news conferences. Not convinced by this, I began to chart cases outside China. It became clear quickly that the risk was not, in fact, low. I did my best to warn people at the end of February that bad things were coming at us fast.
And so I lost faith in official pronouncements before a lot of my colleagues. But I didn’t become angry until a patient — a person who worked in tourism — began coughing. I was refused a COVID-19 test by the DOH. Why? Because the patient hadn’t travelled to a “high risk” area. I pointed out that this was ridiculous, as there were already large epidemics happening in Korea, Iran, and Italy, with cases documented in numerous other countries.
But our state officials stuck to their outdated policy, and I never did find out if that patient was infected. We now know that cases were circulating in the United States as early as January, and that testing restrictions allowed hundreds of people to become infected in secret. But that failure isn’t what made me mad. What made me mad was the thought of thousands of doctors and nurses exposing themselves every day to potentially infected people, and that our Health Department, rather than sticking up for us, was repeating a bunch of talking points. I try to be generous towards my colleagues, because I’m far from perfect in my own life. But I’m not a tool, and I still haven’t forgotten this treatment.
When we were hit by the first wave a few weeks later it became apparent that the DOH had no intention of ramping up its testing to anything close to a sufficient level, and their testing criteria remained inappropriately narrow. This wasn’t a matter of being slow. It was a policy of minimizing risk and undercounting cases. The evidence is that for months now, even at times when capacity hasn’t been a bottleneck, they have refused to test close contacts of infected patients.
What saved us in April was the effort of private labs, who ended up diagnosing the vast majority of infections in the islands. And we were saved by drive-in testing, much of it organized by Scott Miscovich, whose blunt criticism of the state response made him a hated person in government circles. I have no doubt that without those private efforts we would have been hearing “the risk is low” right until our ICUs filled up.
During the lockdown there was a lot of talk of successful re-opening. But the problem was always the reliance of such an opening on our public health infrastructure. To have a successful re-opening, you need to seek out the virus, trace contacts in a timely way, and establish effective isolation and quarantine.
All of those are DOH functions, and the emergency response structure at HI-EMA — the Hawaii Emergency Management Agency — should have helped them ramp up capacity. But none of this happened. This wasn’t due to a lack of effort and communication. I have largely refrained from criticizing DOH and HI-EMA in public, as have most of my colleagues. This is because we were desperate (too desperate, I now realize) to understand them and work productively with them. We assumed, as decent humans do, that they must need help. But what we encountered was an impermeable wall of arrogance. No mistake admitted. No desire to be proactive. No transparency. No accountability. And the constant insistence that only they could provide core functions that they were, in fact, unwilling to provide.
WE’RE NOW living with the consequences of that. It’s become obvious in recent weeks that the contact tracing operation on Oahu isn’t just inadequately staffed, it’s qualitatively poor. There are marked delays in contacting people, and this was happening even before the surge in cases. People are infecting each other in crowded apartments while hotels sit empty. Close contacts are being refused testing by the officials responsible for testing them.
And when the inevitable results of this callous system crashed down on a million residents of the islands, what was the new talking point? That contact tracing isn’t all that important after all. And that the people are to blame for not being attentive enough to state dictates.
Personal behavior does of course matter, and it hasn’t all been good. But Hawaii has done much better than the mainland on this score. The vast majority of Hawaii residents have supported every government effort to control transmission, including the ones that inflicted deep economic injury. This epidemic was 0-3 cases per day in May, and that’s because the people listened. A robust public health system would have eradicated COVID from these islands. A competent one would have at least allowed us to prevent it from doubling every 8-10 days. Instead we’re looking at 200+ cases per day, and that’s with 90% of the tourism industry dead. The numbers here are staggering. There’s no excuse for them. It’s failure on an immense scale, and it can’t be hidden or deflected.
But that doesn’t mean we won’t see an effort to confuse people. Even now, there’s a veil of obfuscation. The latest ploy is to define down their responsibilities to the point where they become meaningless. “We don’t test,” is a recent refrain. Contact tracing also isn’t their thing. And after six months, they haven’t begun to mobilize hotel rooms to the point of being able to separate infected and uninfected people. What do you call a public health effort that doesn’t test, doesn’t contact trace, and doesn’t quarantine? I can think of a few colorful words, but none of them are polite.
The counties are now having to stand these services up in the face of an emergency, and they’re right to do so. At least local government in Hawaii — though imperfect — is trying to meet its responsibilities. But the state is another matter. In conversa- tions I have had with state officials, I have been surprised — and I suspect the public would be, too — at how often it’s just assumed that this virus will rip through the community. Losing isn’t just acceptable to these people, it’s a habit.
MANY OF US have asked pointedly and repeatedly to see basic metrics on the efficiency of DOH contact tracing. The former CDC director — whom they ought to respect if they don’t respect ID doctors — has called for transparency from all state departments of health. But like students seeking to grade their own test, they want to define what is shared and what is kept secret. Even basic information on the location of cases remains obscure, crippling public awareness and the response of the counties, with patient privacy rolled out as the lame cover.
I don’t know what else to say or do, other than to call it out. This is the opposite of science-based health care. Because science requires humility. It requires that you notice what works and what doesn’t, and adjust your approach accordingly. It requires openness. It requires collegiality. It requires personal accountability. The state doesn’t lack access to brains and talent. But our state bureaucracies worship control, and their administrators (I refuse to use the word “leaders”) are critically short on these other qualities. What they’re not short on is spin, excuses, and hostile redirection.
Gov. David Ige, for his part, has been content to put up with this. He’s aware of the shortcomings in the state response. I know that, because I’ve told him, as have numerous other doctors. But he’s stood by his current team and allowed more talented individuals who work for the state to be ignored and silenced. The emergency structure he established, through HI-EMA, has been crippled by many of the same personalities that made DOH ineffective. Ultimately it is the governor’s job to break these impasses. The buck stops with him, and the full weight of this epidemic is now on his shoulders.
He may shift around a few jobs at DOH while defending the broader failure. But I hope the people of Hawaii — who are funding this wreckage that’s now making them sick — stop putting up with it. We should all demand better. Because it’s our good will, as well as our health, that the state has squandered.
Jonathan Dworkin, an infectious diseases doctor, was the antimicrobial stewardship physician for The Queen’s Medical Center from 2015 to 2020; he now lives on the Big Island. This piece is also posted on his Face-book page.