Kudos to Mayor Blangiardi.

As the delta virus rages, an emergency order, Safe Access O‘ahu, was announced this week. It serves to reduce the public risk of falling ill from COVID- 19, protects the young who cannot yet be vaccinated and helps those who are vaccinated from getting a breakthrough infection. Importantly, the order also respects the rights of those who choose not to or cannot become vaccinated, while minimizing their risk of both getting and spreading the disease.

Beginning Sept. 13, Safe Access O‘ahu requires employees of restaurants, bars, gyms, movie theaters, museums, arcades and other similar establishments to show proof of full vaccination or a periodic, negative COVID-19 test result. In turn, customers must show proof of full vaccination or a current, negative test.

Delta remains the pandemic of the unvaccinated and is currently, by far, the dominant mutation. Cases have already hit 1,000 per day. This dwarfs the previous surge last summer. During July and August, Hawaii COVID-19 hospitalizations increased tenfold, from 40 to 400. Beds are running out, and emergency facilities are hovering at maximum capacity. An increase in hospitalizations of another 20% will bring dire consequences.

Breakthrough infections in the vaccinated are also increasing. Those who were vaccinated during the first quarter have hit the six-month mark, and there is clear evidence that immunity tends to wane over time. Israel has already resorted to giving a third, booster shot. Here in the U.S. the Centers for Disease Control has recommended a booster shot for the immunocompromised and is further weighing a final recommendation for the remainder of the population. Dr. Anthony Fauci, NIAID director at the NIH, agrees that three doses are likely needed for full protection. For now, waning immunity in the vaccinated is further contributing to the surge in total cases but less often results in hospitalizations or deaths.

Vaccine mandates are increasingly being implemented. The Pentagon recently issued its mandate for the military immediately after the Pfizer vaccine received formal FDA approval. As of last week 24 states require vaccination for state employees, and 21 states have vaccine requirements for health care workers, Most states that do not require vaccination do require regular testing of unvaccinated employees. Six states have taken a “vaccinate or terminate” approach. In most cases there is a path for religious or medical exemption. On the other hand, at least nine states have passed laws that ban employers from mandating vaccines for workers.

Last month four of Hawaii’s major hospital systems — Hawaii Pacific Health, Kaiser Permanente, The Queen’s Health Systems and Adventist Health Castle — announced that all their employees are now required to get the COVID-19 vaccine. Since then every hospital in the state but one either has a mandate or plans to implement one. Hawaii still falls short of a statewide mandate for all health care workers. As such, small to medium free-standing clinics are on their own.

These clinics and other small businesses still face difficult decisions in keeping their employees and clients safe, without alienating staff who do not wish to vaccinate. Like elsewhere in the country, there remains a substantial minority of the population that is firmly opposed to vaccination, for a range of reasons. Although many who have held out are now choosing to vaccinate, it’s clear that some will not vaccinate under any circumstances.

COVID-19 vaccination raises ethical issues for society that we have not seen before and pits the notion of personal freedom against public safety. There is no clear answer and the stakes are high.

Ira Zunin is a practicing physician. He is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.