Hawaii is at a critical crossroads in reining in the coronavirus that has killed nearly 100 and sickened more than 10,500 statewide, wreaking havoc on the economy and leaving thousands of residents jobless.
The Department of Health’s new epidemiologist, Emily Roberson, is leading arguably the most important effort in Hawaii, overseeing the state’s contact tracing program to bring the pandemic under control and restore public trust in state government following a series of missteps that failed to prevent the explosion of COVID-19, resulting in a second economic shutdown in six months.
The straightforward, no-nonsense chief of the DOH Disease Investigation Branch assumed the role July 16 during a time of turmoil, as internal politics and growing division appeared to get in the way of an effective pandemic response by the state agency responsible for saving lives.
As new daily cases ballooned to more than 300 from single digits earlier in the pandemic, the Health Department could not keep up with tracking the thousands of people exposed to the virus.
“When I came in it was quite obvious we did not have sufficient staff to handle the workload. Clearly everyone’s overworked, clearly everyone’s tired and exhausted and feels underappreciated,” Roberson said in an interview Friday. “It’s a pandemic. Things are not going to be ideal, but things need to be improved.”
Roberson, who worked as a field epidemiologist during the H1N1 flu pandemic in 2009 and mosquito-borne Zika outbreak in 2016 and 2017, is making significant changes within the overwhelmed contact tracing program and “realigning plans” to curb the surge in coronavirus infections.
The most “glaring problem” she found after taking on the role was that highly skilled and specially trained disease investigators were spending a great deal of time on tasks unrelated to their jobs, including administrative work, mailing, scanning and making referrals to social services. The DOH had only about half a dozen of these investigators, though there were dozens of other staff handling parts of the contact tracing work, she said.
“The whole idea that the problem with our response was that we didn’t have 500 contact tracers is misguided. We could’ve had 5,000 contact tracers and we would’ve been potentially exactly in the same spot if investigators were mailing letters and bringing people dinner,” Roberson said. “There is no magic number of contact tracers that is going to make us OK, because contact tracers are not and never were the fundamental problem that we were facing.”
Since there was not a “whole bunch of people just hanging around with that skill set you could bring from the bench,” Roberson had to bring the investigators back to their essential duties and then recruit people to do the lower-level contact tracing.
She divided the work disease investigators were doing under normal circumstances and shifted some of the less complicated duties to other types of workers she could easily hire and ramp up quickly in an emergency. That way specialized investigators could focus on investigating and monitoring the more complex, confirmed coronavirus cases.
“The stakes are pretty high. Case investigations are the most complicated and require the highest level of training and expertise,” she said.
DOH whistleblower Jennifer Smith, the epidemiologist who was suspended with pay Sept. 4 after speaking out about the understaffing of contact tracers, is one of those investigators. Smith has criticized the department for fostering a “toxic” culture of fear that impeded the work of investigators trying to stop the spread of disease, even as DOH officials claimed they had a sufficient public health workforce to identify new coronavirus cases, trace contacts and ensure those infected were isolated. Smith said the workload of investigators reached 300% of intended capacity.
Criticism of DOH revolved around the leadership of Health Director Bruce Anderson and Dr. Sarah Park, the state epidemiologist blamed for failing to build a robust COVID-19 testing and contact tracing program, and who refused help to bolster staffing from the Hawaii National Guard and testing by the City & County of Honolulu.
The city scrapped plans for mass coronavirus testing after the DOH expressed concerns about the vendor being unreliable and more expensive than local labs doing the same work.
Park was placed on paid leave Sept. 4, just four days after Anderson announced he would retire effective Tuesday. Both spoke publicly against mass testing and the need to get major help from outside the agency for contact tracing.
Within the department there appeared to be conflict over who remained in control of the contact tracing program. Roberson, who took leave Sept. 2, cited confusion in an email to her superiors regarding whose authority and which directives she should follow. She returned to the job two days later after Park left.
Since the shakeup, Roberson says she is focused on revamping the program and getting the state to where it needs to be in order to reopen the economy and save lives.
Roberson, 37, was previously the lead epidemiologist for the Department of Human Services Med-Quest Health Analytics Office responsible for streamlining health care data and reporting requirements. Before that, she was an assistant professor at Hawaii Pacific University, helping to design and accredit the undergraduate and master’s programs in public health.
“You cannot separate people’s health or wellness from the economy. Everything is all interconnected,” she said. “If people are healthy then they can go to work and be productive workers. If people are not healthy then that impacts the workforce and that impacts the economy.”
Roberson is grateful to get as much help as she can from the National Guard, which began contact tracing Aug. 3. University of Hawaii interns and students are now playing large roles in data activities and HPU has also come on board to help in the effort, in addition to staff on loan from other state departments and Medical Reserve Corps volunteers.
“It’s been wonderful having the Guard assist in this response. One of the great things they brought to the table is their structures, management and coordination experience,” she said, adding DOH is also training the National Guard to train others. “Now we have an operation where we’re able to train large groups of people to these different tasks and roles within the response and have them do some shadowing and kind of learn the ropes in a real- world setting.”
She also has established direct communication lines between herself and contact tracing staff so that if anything goes wrong — a phone line goes down, for example — employees can notify her immediately so that she can find a quick work-around. She holds multiple daily meetings to check in on what’s working and what needs to be tweaked.
To prevent future COVID-19 surges, Roberson is establishing specialized investigation teams that include interpreters, public health educators and community health workers, each responsible for tracking cases in different settings and communities, including the Pacific Islander and homeless populations and other priority groups.
As of Friday, the state had 256 staff working on different areas of contact tracing, including 150 on Oahu, 40 on the Big Island, 42 on Maui and 24 on Kauai. Included among those 256 are 60 first-contact callers and eight specialized teams led by disease investigators. Each team has 10 to 15 members. The goal is to eventually have 200 first-contact callers and 20 teams. That would put total contact tracing staff at about 500. Separately, the DOH is working on training public and private entities to do their own contact tracing.
“We’ve established these teams all based on specific targets, not on how we eliminate every single case from the state because we can’t do that at this stage. That’s not reasonable,” she said. “The same as if you have an ant infestation, you target the ant hills. The ant hills in these scenarios are correctional facilities, communal living settings and long-term care facilities — very specific targets that we have very specific actions … to be able to most rapidly detect and … prevent the proliferation of cases from taking over completely.”
Dr. DeWolfe Miller, an epidemiologist, University of Hawaii professor and fellow in the American College of Epidemiology, said the DOH must use contact tracing coupled with testing in order to be successful, as well as broad prevention programs focusing on mask wearing, eliminating large gatherings and other strategies to interrupt transmission.
“It’s the whole intervention structure we need to have in place. You need more than just contact tracing and followup to address the epidemic. A little bit of virus can go a long way. On the other hand, a little bit of prevention can go a long way,” Miller said. “It’s a big challenge. I wish her luck. We’ve got to get our economy back and we can if we do it right. But it requires us to do it together.”