Editor’s note: First of two parts. Read part two on Monday.
Sitting on a lanai overlooking Kalapaki Bay, Lt. Gov. Josh Green watched as a cruise ship sailed into port on Kauai, where he was attending a conference.
It was late February 2020 and he had just been briefed about cruise ships being overrun by a novel coronavirus first discovered in the Chinese city of Wuhan.
“I remember very vividly thinking if there’s a big outbreak on this cruise ship or other ones like it, it could completely overwhelm Kauai or any of our islands,” Green said. “I remember thinking to myself this could hit us like a nuclear bomb … if we’re not careful.”
On March 5, Gov. David Ige declared a state of emergency after the death of a passenger from California on a cruise ship that visited the islands. The next day, Ige announced the state’s first COVID-19 case — a Hawaii resident who sailed on the Grand Princess in February.
“That may very well be when the virus was seeded into Hawaii,” Green said.
Ige had been at the National Governors Association’s winter meeting in Washington, D.C., in early February when the Centers for Disease Control and Preventionand the Federal Emergency Management Agency warned state leaders about the impending public health crisis, and the governor learned he would virtually be on his own in navigating the pandemic with little help from the feds.
At the time, government officials and health experts were telling the public that masks were not effective in protecting against the virus and that people should not overreact.
“In the early days we really didn’t know what would work,” Ige said. “A year ago we didn’t know what you could do to avoid getting infected, so it was difficult to make decisions because everybody had a difference of opinions. Hindsight is always 20/20.”
What followed was a frenzy of internal meetings between state officials, health experts and economic leaders who were tracking the virus’ progress as it rapidly spread across the globe. The state formed a unified command center, but there was significant division among its members on how to handle the pandemic response.
“There were factions fighting within the command structure about how many people should be tested, how many contact tracers there were — that became the single largest disagreement and conflict,” said Green, who pushed for more testing and tracing, while Health Department officials, including then-State Epidemiologist Dr. Sarah Park and then-Health Director Bruce Anderson, argued it was unnecessary and a waste of resources.
“A fundamental debate formed between those who thought we had to test almost everybody, including close contacts, and (those who felt) we’d just test symptomatic people or whether we trace everybody or we just let it run its course. Those of us who fought hard ended up testing,” added Green, who tested positive himself for COVID-19 on Sept. 11.
The rift went so far that Green, an emergency room doctor on Hawaii island, was eventually ousted by Ige from daily news briefings, but later ended up back in the fold.
“We had a difference of opinion, but in the end, the governor decided I was important to have as part of the response,” said Green, who continues to provide his own daily COVID-19 updates via social media. “For a day or two it was tense, but afterward we had a good meeting and buried the hatchet.”
A test of leadership
Meanwhile, Hawaii health officials scrambled to assess the extent to which the virus was spreading in the community while struggling with a shortage of test kits, personal protective equipment and other supplies. Within weeks, the Department of Health’s State Laboratories Division became one of the first in the country to be certified for coronavirus testing on Feb. 28.
But the initial capacity of 250 tests a week were reserved for the sickest coronavirus patients. Private laboratories eventually became certified to test for COVID-19 but did not have enough supplies to ramp up testing, resulting in strict guidelines on who was eligible for testing and a public outcry to detect the virus in the community.
That left an opportunity for Dr. Scott Miscovich to swoop in and fill the testing void. In early March, the private Windward Oahu physician started the first coronavirus drive-by testing in Kaneohe and rapidly worked to establish programs across the islands.
“What was crystal clear even in March was that testing had to be the No. 1 thing you were doing, followed by contact tracing and quarantine. It was at that point, working closely with the lieutenant governor — he had me chairing his COVID-19 committee — I was getting broad support,” he said.
“But very quickly there was an immediate change … directed by Bruce Anderson and Sarah Park. They did not believe in (mass) testing and they began to attempt to have my testing efforts and others like me shut down throughout the state. There were threats of lawsuits and even a threat of having me arrested.”
But Miscovich continued to press forward with programs modeled after those in South Korea, Taiwan and other countries that were successfully tamping down the disease’s spread. He was called upon by county mayors to help identify infections, including at Maui Memorial Medical Center, where he tested more than 4,000 people during the state’s largest hospital outbreak.
With an average of nearly 270,000 visitors in the Hawaiian islands on any given day at the start of 2020, Hawaii was poised to be one of the worst hit by the emerging disease, said Anderson, who retired in September, in an interview from his ranch in Virginia.
“We were probably at more risk than any other place on earth from COVID-19. I’m amazed we didn’t see much higher rates than we did. The virus had everything going for it: We had much higher numbers of tourists than most places, a very transient population and an elderly population as well,” Anderson said, adding that a large segment of Hawaii residents live in crowded conditions ripe for contagion.
“There wasn’t much in our favor except that we had some political leadership willing to take somewhat Draconian measures … including the mandatory 14-day quarantine (on incoming travelers). That was probably the most effective thing that was done to prevent the spread of disease in Hawaii.”
Former Honolulu Mayor Kirk Caldwell contends those measures weren’t taken soon enough. For weeks, he insisted that the state needed to be overly cautious and took it upon himself to secure the city’s own testing partner, hire dozens of contact tracers and contract with hotels to quarantine the sick or those exposed to the virus.
The mayor, however, was shot down by health officials, including Park, whose stance was that large-scale testing would not be effective in controlling transmission. So Caldwell’s plan to scale up testing was scrapped.
“They really embarrassed me as mayor. They said what we’re doing is illegal and that the lab wasn’t approved. Everything they said was wrong,” he said.
At that point, the mayor reached out to White House Coronavirus Response Coordinator Dr. Deborah Birx, who had previously worked at Tripler Army Medical Center. She put him in touch with U.S. Surgeon General Jerome Adams, who coordinated surge testing on Oahu.
Park, who could not be reached for comment, instead implored the public to take basic precautions, including mask-wearing, social distancing and hand-washing. The epidemiologist, who was criticized for failing to build a robust testing and contact-tracing program, was placed on paid leave Sept. 4 and is no longer with the Health Department.
The collapse of tourism
In March, as cases climbed into the double digits, state officials made the painful decision to virtually close down travel to the islands to keep COVID-19 from infiltrating the community. Hawaii became the first state in the nation to subject returning residents and arriving visitors to a mandatory 14-day self-quarantine, dealing a crushing blow to its bread-and-butter tourism industry.
As Mufi Hannemann, head of the Hawaii Lodging and Tourism Association, watched visitor counts plunge from 35,000 a day in 2019 to less than 1,000 daily, he and other industry leaders created what he described as a “war room” at the Hawaii Convention Center, where he and members of the Hawaii Tourism Authority and Hawaii Visitors and Convention Bureau met daily to strategize how to manage the widening crisis.
“It was important to have all of us singing off the same hymn book. We were in trouble, and if we didn’t work together we would be in deeper trouble,” Hannemann said. “We had some very lively discussions.”
State officials were working on a pre-arrival testing program that would allow travelers testing negative for the virus to avoid the quarantine. But the program was delayed several times, not launching until Oct. 15, as infections surged on the mainland and elsewhere.
“At first we thought maybe by summer we’d get back to some kind of normalcy, maybe in the fall, then maybe we’d open up a week before the end of the year. There were some major disappointments along the way,” he said. “When we opened up at the end of October, we all breathed a huge sigh of relief, thinking that would catapult us during the holiday season.”
But the hoped-for recovery did not materialize, with visitor arrivals ending the year down 74% from 2019.
“We knew that we were in for a long haul. If you think getting through the pandemic is going to be a challenge, getting back to the path of economic recovery is going to be even more daunting,” Hannemann added.
‘We need to do more’
On March 22, Caldwell issued a “stay at home, work from home” order. On March 25, “stay at home, work from home” went statewide, further stifling the economy and causing businesses to close and lay off workers.
Caldwell was first to pull the trigger after receiving a text message from Bank of Hawaii CEO Peter Ho, Hawaii Pacific Health’s Ray Vara and the Hawaii Medical Service Association’s Mark Mugiishi. They wanted to alert the mayor to a graph they’d put together illustrating the virus’ trajectory, warning that if he didn’t take decisive action, Oahu would see a spike in cases that could overwhelm the health care system.
“The chart they showed me was breathtaking. I needed to do something or by the end of March or early April we were going to have people down the halls of Queen’s and Kapiolani (medical centers),” Caldwell said. “When I woke up (the next day) I said, ‘I don’t care if I’m overreacting, we need to do more.’”
Oahu’s lockdown order took effect after the close of business on March 23. The move left businesses reeling, heightened anxiety among residents and signaled that this was not business as usual.
“On Tuesday morning I got up around 3 a.m. and I looked across the valley (in Manoa). There were no cars or traffic. It was quiet, no winds and I cried because I realized how much impact I was having on the lives of the people of Oahu,” Caldwell recalled.
“I knew that I was probably going to save lives, but I knew I was disrupting everyone’s lives. People couldn’t have birthday parties, weddings, funerals, they couldn’t to go to church. All these things that are important to people I was preventing from occurring, all for public safety. It was going to cause businesses to fail. These were people’s livelihoods, it’s their dreams put into reality that’s now going to be crushed because of the pandemic and the actions the city was taking.”
During the course of the pandemic, Hawaii recorded among the highest jobless rates in the nation at over 20%. But while acknowledging the decision would be life-altering for most residents, Caldwell said he didn’t hesitate in doing what he thought was necessary to save lives.
No break from the virus
At the peak of the pandemic during the summer, infections rose to more than 300 new cases per day, prompting the counties to place controls on virtually all aspects of everyday life and commerce, requiring mask-wearing and social distancing, limiting gatherings and business operations, and curtailing outdoor activities.
Many schools that switched to distance learning at the start of the pandemic are still mostly online a year later.
“There were different opinions and I think there was a lot of frustration from others on how things were going, and everyone, of course, was an expert on COVID and felt they had the answer that often wasn’t on target,” Anderson said. “We did what was most effective and we came out of this as well as we could expect.”
Hospital capacity became an urgent concern during the summer surge, recalled Green.
“On Aug. 26, we were at 318 cases. I remember getting a call that we had less than 10 ICU beds available. When we touched the high-water mark we were at less than 10 ventilators and it was going to be a big crisis,” he said. “When we started to peak in July and August, we started wondering whether we had to build 1,000 additional hospital beds. Fortunately we never had to do that.”
On Aug. 27, a second stay-at-home order took effect in Honolulu and by the fall months the virus had reached the most vulnerable nursing home populations and isolated communities, including Kalaupapa on Molokai and on Lanai, as well as Hawaii prisons and other congregate settings.
“Obviously, there hasn’t been a day off since the virus arrived, and that always has been a challenge, just keeping the energy up and making sure that I’m aware of what’s happening so that we can make decisions as appropriate,” Ige said.
“Certainly a lot of the criticisms and disagreements end up focused on my office, and I do understand that’s a part of the job. Trying to respond to all the criticism is always a challenge. I do understand uncertainty and not knowing doesn’t help people. The whole nature of Hawaii is so much about family and so much about interacting with each other in virtually everything that we do, and so the entire community had to change how they looked at things and how they approached things.”
Dr. Sarah Kemble, acting state epidemiologist and an infectious disease physician, said she will remember 2020 as “the year of very little sleep” because there was always something new keeping her up at night.
“I was up every night thinking this is what I trained my whole life to do and this is overwhelming, so how do I put one foot in front of the other every day and make sure each thing I do is to protect the health of Hawaii? Being a physician in public health, even though I can look and see that Hawaii has done well compared to other jurisdictions, each life lost feels like I’ve lost another patient.”
With the first shipment of COVID-19 vaccines arriving in the islands in December, residents began to take hope in a return to pre-pandemic life. But even as the state has ramped up its immunization program, with an estimated 336,901 doses administered as of Friday and 14.4% of the population receiving at least one vaccination, its most recent concerns are the highly contagious and potentially more lethal coronavirus variants that have made landfall in Hawaii in recent days.
“Everybody thinks with vaccines COVID is over — not a chance,” Miscovich said. “We’ll be able to hug our tutus during the holidays this year, but still the chances we’re going to have to keep our eyes out for COVID in the years to come is pretty much a guarantee.”