Despite the discouraging stream of announcements of new coronavirus cases that have been detected in Hawaii, data compiled by Johns Hopkins University shows that as of Monday this state had the third- lowest per capita infection rate of any state.

While that is good news for Hawaii residents and the state’s health care system, experts warn it is too soon to begin relaxing the statewide stay-at-home order, quarantine orders or other restrictions that have been imposed to try to prevent the spread of the new coronavirus.

Dr. Mark Mugiishi, president and CEO of the Hawaii Medical Service Association, on Monday told the House Select Committee on COVID-19 Economic and Financial Preparedness that despite some positive signs, COVID-19 remains “highly infectious and devastating, and right now there is no vaccine, no cure, no evidence of herd immunity.”

“So, as we gain control of this first outbreak, which is really wonderfully, happily, slowly we’re starting to see the light at the end of the tunnel, but we must be careful not to trigger a second or a third outbreak in our attempts to recover,” Mugiishi said.

Adjutant Gen. Kenneth Hara, incident commander with the Hawaii Emergency Management Agency, said during the same online discussion Monday that “we really did flatten the curve,” and announced there were only five new positive test results Monday for coronavirus cases. It has become routine during the past three weeks for state health officials to report 20 or more new cases per day.

The data provided by Johns Hopkins and published by time.com shows that only Minnesota and West Virginia have per capita infection rates that are lower than Hawaii’s rate of 36 coronavirus cases per 100,000 population. That is far below the national rate of 177 infections per 100,000 population.

It is also noteworthy that Hawaii tests for coronavirus at a considerably higher rate than most states. According to data compiled by Vox, Hawaii continues to rank among the top 10 states for testing per capita, which suggests Hawaii’s infection rate may be more accurate than rates reported by some other states.

Gov. David Ige cited the state’s early push to become certified to conduct coronavirus testing as a factor that has helped cope with the pandemic, adding that “we’ve also been very aggressive in setting up testing sites across the state.”

“Also, our quality health care system has kept hospitalization, intensive care and mortality rates among the lowest in the country,” Ige said in a written statement. “And the collective actions of responsible Hawaii residents who are obeying stay-at-home orders have contributed to Hawaii’s ranking as one of the best-performing states in the country in dealing with this pandemic.”

University of Hawaii- Manoa epidemiology professor Alan Katz also has cited Hawaii’s geography as a considerable advantage, since this state has the means to almost entirely shut off the flow of people into the islands. Other states cannot exercise that degree of control over people’s travel, and therefore have less control over the disease’s spread.

“We took strong action, and I believe the population has been adhering to the recommendations” for social distancing as well as the stay-at-home orders, Katz said. “I’m not seeing the sort of aggregate crowds you are seeing on the news in other places.”

He noted news reports of people gathering to party on the Kaneohe Bay sandbar, or a couple who arrived on Kauai and ignored quarantine warnings and were finally arrested, “but I think that’s more the exception than the rule. I think people have been behaving appropriately.”

Katz said he would expect to see a downward trend in the number of infections about two weeks after the statewide stay-at-home order went into effect March 25, which appears to be happening “and which I hope will continue.”

But he said the state needs to make sure that is a true trend and not meaningless variation in the data. “I think we do have to wait until the end of the month — minimum, the end of the month,” he said.

Tim Brown, a senior fellow at the East-West Center with expertise in infectious disease and behavioral epidemiology, said the stay-home order and social distancing, for the most part, are “having the desired effect.”

There has been relatively slow growth in hospitalizations and deaths, and “because this virus usually manifests in symptoms in less than two weeks, if the virus were widespread in the community, these numbers would be growing more rapidly,” Brown told the House select committee Monday.

But before the state can lift the statewide lockdown, it must have the capacity to more rapidly test suspected cases, quickly trace their contacts and quarantine people as needed, he said. The state also needs “data to inform triggers for reimposing lockdown should the epidemic surge,” Brown said.

Hawaii health officials will need that extra lab capacity and other resources to cope with the new coronavirus for the next one to two years until a vaccine is developed, he said.

“If we were to lift the shutdown measures now and go back to our previous way of life, we could easily find ourselves in a New York type of situation within a month or two,” he said. He cited the example of Singapore, which has traced clusters of infections around workplaces, preschools, gyms, shipyards, private functions and dormitories, he said.

China is now seeing new coronavirus cases that are being imported into the country by travelers, Katz said, which also underscores the need for careful planning as businesses seek to reopen and the tourism industry attempts to restart.

“Because things are looking pretty good here, I’m hoping that we will be able to adopt the best strategic plans for getting back to normal, but it’s really sort of tiptoeing back into it,” Katz said. “You can’t just sort of say, ‘It’s over.’ It’s a slow process of what is the next step, step by step, and watching to make sure that things don’t rebound.”

The novel coronavirus has upended life in Hawaii and been an economic disaster, but Hawaii residents do have some unique advantages as public health officials fight to slow the local spread of the disease.

Even while residents watch and worry as the daily count of infections in Hawaii climbs — it stands at 224 today — University of Hawai‘i at Mānoa epidemiology professor Alan Katz points out that this state has an enormous advantage as an isolated island chain.

The history of the 1918 Spanish Flu pandemic shows that a few isolated areas that imposed tight restrictions on who could come in and who could leave survived with few impacts from that disease, he said.

“We are an island, so we have much, much better control of borders than any land-locked state does because it’s virtually impossible for some place in the middle of the United States to survey all of their boundaries,” Katz said.

The movement of visitors into Hawaii from the rest of the nation has been choked off in a way that is virtually impossible in other states, and Hawaii officials are poised to further restrict traffic between the population centers within Hawaii with an interisland quarantine.

The Hawaii Tourism Authority announced Tuesday the visitor count arriving in Hawaii on Monday plummeted to 121, down from an average of about 30,000 per day a year ago at this time. In all, 681 people arrived Monday on 41 flights, and the vast majority of those were returning residents or flight crew members.

Even within the state, much of Hawaii including the neighbor islands is sparsely populated and rural, which reduces the chances of a major outbreak, Katz said.

“Rural means less densely populated and the key risk for person-to-person transmission is close person-to-person contact,” said Katz. “That’s why social distancing is really the key for mitigation of transmission.”

Even with the travel quarantine in place along with the closures of bars and non-essential businesses and the statewide restrictions on residents’ movements, Katz said Hawaii will inevitably see more cases because the incubation period for COVID-19 is up to 14 days.

But Hawaii has also been increasingly aggressive about testing people for coronavirus. State health officials said Monday they have so far tested 8,936 people for the novel coronavirus, which is far more tests per capita than many other states.

According to coronavirus testing data maintained by the website Vox, Hawaii ranks sixth in the nation for the number of people per capita who have been tested for the disease. That puts Hawaii’s testing effort on par with Massachusetts, which has nearly 5,000 coronavirus cases.

The state’s approach of testing only people who show symptoms is “more focused and more valuable than simply going out and testing everyone who wants to be tested,” according to state Department of Health Director Bruce Anderson.

“We’re actually not far behind (South Korea) in terms of tests per capita,” Anderson told the Senate Special Committee on COVID-19 on Friday.

Hawaii’s 14-day quarantine program to try to block infected people from coming into the state “seems like it’s working,” Anderson said, but added that quarantine will not help to cope with cases that are already in Hawaii.

“I think we’re doing it better than most are,” he said of managing the cases that are already here. “Our numbers are down. We’re able to thoroughly investigate the cases that we know about and identify contacts and of course they’re being quarantined if they’re close contacts. If the numbers get much bigger, we’re going to have a much more difficult time managing that.”

Still, he added that “we all anticipate a time when we’re going to start seeing much more community spread. It’s practically impossible to avoid, and our challenge is to keep the numbers down to a level where we can manage the cases that are occurring and of course tamp down the number of cases as best we can through our contact investigations.”

The number of confirmed coronavirus cases in Hawaii has nearly doubled from 120 to 224 since Anderson made those comments, and Katz urged residents to take health guidelines seriously to avoid a major outbreak..

“The most important thing you can do is maintain social distancing. Stay 6 feet away from each other. That’s going to really dramatically mitigate person-to-person spread of this. If you’re not essential, if you’re supposed to be at home try to stay at home. Don’t aggregate in groups,” Katz said.

And while some people may be ignoring city and state stay-at-home orders, the orders are being enforced in Honolulu. Police Chief Susan Ballad said today her officers have issued about 1,500 warnings since March 23, handed out about 180 citations, and made nine arrests for violating the emergency orders.

Katz said his sense is that “folks in the state of Hawaii are behaving in an incredibly responsible manner.”

“People are basically adhering to the recommendations, the guidelines and the mandates,” he said. “I think that’s unbelievably important…Social distancing at this point — at this critical point in the pandemic — is the way we’re going to mitigate the person-to-person spread.”

“It feels a little like practicing medicine in a war and I am not ready for this …”

This was a statement from a very close friend, who is a family doctor in Canada. She was describing her anxiety around a treatment decision that required balancing concerns about bringing an older patient into her clinic for diagnosis and treatment of a chronic condition versus delaying standard care in order to reduce that patient’s risk of acquiring a COVID-19 infection.

Many of our doctors here are currently making similarly challenging treatment and management decisions. Almost no one is trained for this, emotionally or clinically.

As recently highlighted in an editorial in the Lancet, which is the world’s premier medical journal, health care workers are currently our most precious resource. They are at the frontlines of the pandemic and one of the groups most at risk of infection.

The risks taken by our health care workers are well-recognized, as is the unconscionable situation in which so many providers lack personal protective equipment, despite weeks of forewarning that a global pandemic was nearly inevitable.

Equally concerning is that health care workers can be a source of infection themselves, especially when they lack the equipment and support that would protect patients and other providers, and in a context in which it is still unclear how much transmission of COVID-19 occurs by asymptomatic individuals. There is no doubt that insufficient and maldistributed PPEs across the United States, and here in Hawaii, is an acute crisis that cannot be ignored.

However, our providers need other forms of support too, including childcare and eldercare. With schools closed, like everyone else, our health care providers are balancing personal and professional roles and responsibilities.

Our heath care workforce is much larger than just doctors and nurses. It includes staff from a wide variety of disciplines (e.g., pharmacists, information technology specialists, laboratory technicians, interpreters, social workers, etc.) all of whom are critical to the proper functioning of our health system.

One group that is particularly vital, but frequently overlooked and under-celebrated, is custodial staff. In a context in which environmental cleaning and disinfection is paramount, both in and out of health care settings, assuring the health and wellbeing of our custodial staff should be among our highest priorities.

However, all health care staff at the moment need support, as the best way through this crisis is the full and coordinated mobilization of those who are trained to care for sick patients and their families.

While health care workers are our most valuable resource, our health system is currently our most valuable infrastructure. A health system is more than just hospitals. While definitions of health systems vary considerably by professional organization, generally speaking they encompass those that govern and guide health care decisions (policymakers and departments of health), entities that finance services (insurers, Medicaid and Medicare), as well as the places where services are delivered (hospitals, private practices, federally qualified health centers, etc.)

As the number of cases in Hawaii increases, all elements of the health system will be placed under incredible strain and if our local outbreak goes unmitigated, the system will collapse under the pressure.

Extreme Measures

It is crucial to consider what health system collapse looks like to better understand why such extreme measures have been taken to slow the spread of the virus. A collapsed health system entails much more than people with the virus, and resulting disease, not getting life-saving health care. That is, it entails more than being unable to get into an ICU or onto a ventilator when a sick patient needs one.

These are terrible consequences in-and-of-themselves and have been cited repeatedly as explanations for the high case-fatality rates in places like Wuhan, China, as well as in Italy and Spain. In these places, the health system could not keep up with demand.

A collapsed health system is much worse. It means that when car accidents happen, or heart attacks, patients are directly competing for care with those needing treatment for COVID-19 infection. Similarly, it means women who need cesareans to deliver or children with asthma attacks are also competing for care, as health personnel, equipment and materials are redirected towards managing the outbreak.

It means that health staff exhaust and burn out, compromising the quality of care their patients receive. It means that providers are forced to make decisions about who can or cannot receive life-saving care, decisions that may haunt them for years.

As supplies for infection control dwindle, it means that care is provided under unsafe conditions for both patients and providers. The latter also means increased demands on a fragile health system as patients experience complications, such as secondary infections, and providers become sick and are removed from the workforce.

For all of us, it is imperative that we support all classes of health care workers and like many in the community already have, creatively seek solutions to the acute needs facing our health care staff (like insufficient PPEs).

Broader solutions for childcare and eldercare are also needed to assure frontline staff are able to focus fully on their jobs, knowing their loved ones are safe. As for the health care system, full mobilization of all resources under clear and undivided leadership is essential.

This last point is the most challenging, as the United States’ health care system is notoriously fragmented; nonetheless, it is probably the most essential for staving off some of the worst consequences of the outbreak.

As the number of COVID-19 cases surge in cities like New York, some in Hawaiʻi fear an exponential rise in the Aloha State is imminent. There is a statewide stay-at-home order in effect and practicing social distancing remains crucial to stem the spread. But ​Alan Katz​, an epidemiology professor at the University of Hawaiʻi at Mānoa, said ​because a majority of Hawaiʻiʻs communities are rural, it could help lessen the chance of a major outbreak.

“We only have one urban center in Honolulu and the rest of the islands are rural including any spot on Oʻahu that’s outside of Honolulu, that’s considered rural. So that’s good. People are less densely populated,” Katz explained. The UH Mānoa epidemiologist said it gives the state some leeway in minimizing the spread of the highly infectious virus.

Because the incubation period for COVID-19 is up to 14 days, Katz said Hawaiʻi will inevitably see more cases during the statewide lockdown but is hopeful it won’t be a steep increase. In order to avoid a major outbreak, he urges everyone to take health guidelines seriously.

“The most important thing you can do is maintain social distancing. Stay 6 feet away from each other. That’s going to really dramatically mitigate person to person spread of this. If you’re not essential, if you’re supposed to be at home try to stay at home. Don’t aggregate in groups,” Katz said.

According to researchers, ​COVID-19 is much more contagious than the seasonal flu.