Hawaiʻi healthcare workers surveyed in 2020 were primarily concerned about contracting COVID-19 at work and transmitting it to their families, according to a recently published University of Hawaiʻi at Mānoa public health study.
It has been widely reported that COVID-19 disproportionately impacts several communities in Hawaiʻi, including Pacific Islanders and Filipinos. But less attention has been given to the role of chronic disease. High underlying rates of illnesses such as heart disease and diabetes have put these groups at elevated risk of contracting and dying from COVID-19.
Wearing a cloth mask over a surgical mask, also known as double-masking, provides substantially more protection against COVID-19, according to new data released by the Centers for Disease Control and Prevention (CDC). The research found that double masking with a cloth mask over a surgical mask, as well as knotting the ear loops of surgical masks with tucked-in sides, reduced exposure by more than 95%, compared to wearing no mask at all. University of Hawaiʻi at Mānoa public health studiesprofessor and graduate chair Alan Katz said this is important new information, especially with the new fast-spreading variants of the COVID-19 virus.
“This is how to optimize the use of the mask,” said Katz in response to the CDC findings. “Besides what we all know about covering your nose and your mouth, this is going a step above that, looking at maximizing protection. What they are concerned about is loosening masks or single layered masks, which may not be that helpful.”
Other proven options to improve mask fit according to the CDC include wearing a mask fitter and wearing a nylon covering over a mask. Katz said the key takeaway is that snug face coverings better prevent the spread of airborne COVID-19 droplets and that appropriate masking and social distancing continue to be the two most important COVID-19 prevention steps.
“Even with the vaccine, individuals could potentially get an infection, not get sick, and still potentially infect others. Even as people are getting vaccinated, we want to make sure people who havenʻt been vaccinated are protected,” he added.
More residents want to get vaccinated
On the vaccine front, Katz said a recent statewide survey where 91% of respondents say they plan to get the COVID-19 vaccine is welcome news. The survey report (PDF) commissioned by the HawaiʻiDepartment of Health (DOH) showed that attitudes about the vaccine are rapidly shifting since vaccinations first began in mid-December.
“Nationally, the figures are way, way lower than reported in Hawaiʻi,” said Katz, citing a CDC survey released this week that found 49.1% of the people in the U.S. plan to get vaccinated. “Kudos to Hawaiʻi; that is so heartening to hear.”
According to the state survey, 55% plan to get vaccinated as soon as they are eligible, and 36% will wait before receiving their vaccinations. The survey also showed more than a third, or 37%, of Hawaiʻiresidents are less concerned about the impact the virus has on their health, and instead are now primarily focused on the pandemic’s economic and financial impact.
The survey was conducted from December 30, 2020 to January 11, 2021, and included 445 adult Hawaiʻifull-time residents statewide.
The COVID-19 pandemic has worsened many of the problems faced by Native Hawaiian communities, but in a new paper, public health researchers detail the numerous efforts of Native Hawaiian-led groups that show these communities’ strength and resilience.
Since the start of the pandemic, Native Hawaiians and other Pacific Islanders have faced a higher risk of contracting COVID-19 than other groups in Hawaiʻi. They also endured high levels of unemployment and economic insecurity.
“This paper highlights the power of Native Hawaiian communities during these trying times,” said Jane Chung-Do, senior author and associate professor with University of Hawaiʻi at Mānoa’s Office of Public Health Studies within the Thompson School of Social Work & Public Health. The paper is published in the Journal of Indigenous Social Development.
Nonprofit efforts
The nonprofit group Ke Kula Nui O Waimānalo (KKNOW), whose aim is to promote health and support the self-sustainability of the Waimānalo community, has partnered with other nonprofits, businesses and governmental agencies to provide food for Waimānalo families. Since mid-March, the group has distributed 24,000 prepared meals and 3,550 boxes of fresh produce. KKNOW also delivered seeds and seedlings of traditional Hawaiian crops such as kalo (taro) and ʻuala (sweet potato) to families and community members who are vulnerable to food insecurity, economic instability and other social challenges.
“The goal of KKNOW is to build community resilience by helping fellow Native Hawaiians grow their own food before further disruptions strike,” said Kirk Dietschman, president of Ke Kula Nui O Waimānalo and a co-author of the paper.
Other nonprofits have also pitched in. The meals were prepared by chefs and students in a culinary training program, coordinated by the nonprofit KUPU Hawaiʻi. Meal delivery was led by Aloha Harvest, and the Department of Hawaiian Home Lands and the Waimānalo Market Co-Op, which provided the sites for the daily food distribution.
“These efforts succeeded because these Native Hawaiian-led groups anticipated the needs of the community and leveraged existing resources and relationships to meet those needs,” said Ilima Ho-Lastimosa, the lead author of the paper and a community coordinator at the Waimānalo Learning Center of the UH Mānoa College of Tropical Agriculture and Human Resources (CTAHR). “It is key that these organizations all have history with the community and have earned the trust of the members.”
Producing long-lasting results
Historically, efforts to address health disparities have used western-centric methods and have often failed to produce long-lasting results among Indigenous peoples, the researchers wrote in their paper. They concluded that place-based, culturally-grounded interventions show promising results with Indigenous peoples and will be needed to restore the health of Native Hawaiians.
The co-authors on the paper also include LeShay Keliʻiholokai, Kaua Kassebeer, Hae Kassebeer, Joseph Awa Kamai, Ikaika Rogerson, Kenneth Ho Jr., Manahā Ho, Kamalei Ho, and Denise Kaʻaʻa, of Ke Kula Nui O Waimānalo; Alexxus Ho, of the HawaiʻiPacific University College of Health and Society, and Theodore Radovich of CTAHR.
This research is an example of UH Mānoa’s goal of Excellence in Research: Advancing the Research and Creative Work Enterprise (PDF), one of four goals identified in the 2015–25 Strategic Plan (PDF), updated in December 2020.
To provide COVID-19 information and recommendations in Ilocano, Marshallese, Chamorro, ʻōlelo Hawai‘i and other languages, a group of young public health ambassadors are creating videos to help keep Hawaiʻi healthy during the pandemic. The effort arose from the Native Hawaiian & Pacific Islander COVID-19 Response, Recovery, and Resilience Team, and is supported by the University of Hawaiʻi at Mānoa Office of Public Health Studies, Papa Ola Lōkahi and the Hawaiʻi State Department of Health.
The TikTok-style video challenge was launched by Next Gen Hawaiʻi, a collaboration of organizations involved in the state’s COVID-19 response efforts.
Many UH Mānoa public health students and graduates have participated.
“The public health ambassadors bring creative energy to public health messaging around topics such as mask wearing, staying together over distances and flu shots,” said Tetine Sentell, director of the Office of Public Health Studies.
“They are social influencers with important information to share. We believe this is key to leveraging community strengths and trusted relationships within intergenerational households to promote well-being and healthy behaviors during this stressful time,” Sentell added.
Next Gen Hawaiʻi
Next Gen Hawaiʻi public health ambassadors are teens and young adults who create social media content focused on public health awareness and resources in multiple languages spoken in Hawaiʻi. For the remainder of 2020, Next Gen Hawaiʻi will host two TikTok challenges monthly, which will be shared widely.
“The goal of the Next Gen Hawaiʻi project is to amplify voices of the youth of Hawaiʻi in their languages to support better health in their communities, especially in Pacific Islander, Native Hawaiian, and other communities that have been so impacted by COVID-19,” said Momi Tolentino, communications and community relations assistant at Papa Ola Lōkahi, who is helping run the program.
“We want to bolster health, a sense of belonging, and in-language outreach to Hawaiʻi communities during COVID-19,” Tolentino added.
As the University of Hawaiʻi football team gears up for its 2020 season, and other UH athletic teamsprepare for their seasons to begin, experts from the Department of Mathematics and Office of Public Health Studies spoke to teams about keeping themselves COVID-19 free.
Professor Monique Chyba and Assistant Professor Thomas Lee shared the latest data on COVID-19 and emphasized the importance of wearing face masks to stop the spread of the virus with student-athletes, coaches and staff.
“The health and safety of our student-athletes, coaches and staff remain our highest priority,” UH Mānoa Athletics Director David Matlin said. “We appreciate the efforts of Professors Monique Chyba and Thomas Lee for sharing their expert knowledge about COVID-19 and reinforcing the importance of stopping the spread of the virus with our teams.”
Chyba emphasized that although state and county governments have increased testing and contact tracing, compliance from individuals is also important to lower the daily case count. Chyba said that data shows daily counts have been plateauing, however, mathematical models predict this is an atypical situation. Even though the number of cases may drop in one day, it is not time to let your guard down.
“A big part of my message was to tell them that this is a very unstable situation and that there is no wiggle room,” Chyba said. “It just takes a little spark to bring it back up.”
“I’m glad that the UH athletics community had the privilege to listen to both Dr. Chyba as well as Dr. Lee,” said Jolie Rasmussen, a senior women’s volleyballstudent-athlete. “Hearing updates about the pandemic directly from an epidemiologist and mathematician was very beneficial as they could provide us with the most factual and up-to-date information regarding the virus. We must continue to do the right actions now to ensure a safe future for tomorrow.”
Chyba, who teaches many student-athletes in her mathematics courses, said many of them shared with her that they want to get back to playing the sport that they love.
“They really want to play and they seem to be eager to do what it takes to be able to play,” Chyba said.
Starting in April, 2020, Ms. Ronquillo and Ms. Talana initiated a months-long project to support the needs of their peers in public health. They did this by systematically compiling a list of resources for those affected by the Covid-19 pandemic and by completing a needs’ assessment among students in the public health program at the University of Hawaiʻi at Mānoa (UHM). Both students are in their 2nd year of a Master of Public Health (MPH) and highly engaged in student governance.
In late March, 2020, the UHM announced an abrupt shift to online learning for a period of three weeks, which was later revized to the entire semester. Shortly thereafter, as was the case across most of the United States, the Governor of Hawaiʻi ordered a statewide shutdown of all non-essential businesses and activities. The consequences to the local economy have been dire and enduring. One of the groups most impacted by the shutdown orders is university students.
University students are disproportionately employed in the service and retail sectors, with many supporting their education through part- to full-time employment at restaurants, bars, nightclubs, and retail locations (e.g. clothing stores). Students are often very low income, deeply indebted, and many experience food insecurity. In fact, estimates in Hawaiʻi place university students among those most impacted by food insecurity, especially those who identify as Native Hawaiian, Other Pacific Islander, and Filipino.
Not only are students negatively economically impacted by the response to Covid-19, many experience challenges achieving their educational objectives. For some, the costs of a degree program are too high without the income from jobs lost to the pandemic. While for others, the difficulties have been more direct, such as finding practicum placements for their MPHs and/or getting enough hours to fulfill university requirements. For the past five months, Ms. Ronquillo and Ms. Talana provided considerable assistance to their peers struggling with some of these issues.
Both MPH students worked long-hours to compile and organize a list of (presumably) all resources available in Hawaiʻi to those negatively affected by the pandemic. This resource guide, which can be viewed here, was carefully collated and organized in an easily accessible manner divided by categories. For example, it includes resources about housing assistance, telehealth, child and eldercare, food distribution sites, utilities, and even services for pets. As of September 20, the resource guide was accessed by at least 291 unique users since its release in May. Further, to help students and potential MPH practicum sites, they also compiled a carefully annotated list of sites seeking volunteers. This resource proved especially invaluable for undergraduates in public health. Further, for many public health students, it provided an opportunity to provide service to the community and be a part of the larger response to Covid-19.
Finally, over the summer, Ms. Ronquillo and Ms. Talana conducted a rapid needs assessment of the public health student body in order to assess their current and ongoing needs, including perceived concerns about and barriers to returning to school in fall. Critical findings were high levels of anxiety among students, as well as substantial concerns about basic needs. Public Health students reported difficulties getting enough food and affording medical care. Tuition relief, scholarships, and other financial assistance were requested by many. The students, and their supervisors Dr. Pirkle and Ms Kehl, have engaged in multiple efforts to disseminate these findings to assure that public health faculty are aware of multifacetted issues facing their students. Moreover, they have made efforts to engage the UHM and the broader community to increase awareness of challenges facing students at this time.
Underlying health conditions such as heart disease, obesity and diabetes increase the risk of severe illness from COVID-19. Managing chronic disease, and preventing it when you can, is critical during this public health crisis. This helps with the pandemic and will keep our communities and families healthy over time.
Recent research from Centers for Disease Control and Prevention (CDC) reported that three-quarters of those who died from COVID-19 had an underlying medical condition. The three most common conditions were cardiovascular disease, diabetes and chronic kidney disease, which were present in 60%, 40%, and 21%, respectively, of deaths due to COVID-19. These conditions, especially diabetes, were even more common among young and working age adults who succumbed to the virus.
Despite Hawaii’s reputation as one of the healthiest states in the nation, a disproportionate number of our residents suffer from the very chronic diseases that place us at greater risk for severe COVID-19 illness. An estimated 1 in every 2 adult residents in Hawaii has diabetes or prediabetes. Of those with prediabetes, more than 80% do not know that they have it. A recent study found high rates of chronic disease, including diabetes, in young people in Hawaii.
Preventing and managing diabetes is not always easy. The pandemic makes this harder. Thankfully, Hawaii has many options to assist people in managing their prediabetes or diabetes, even during the era of coronavirus. Experts agree that people should continue the same critical steps of managing their disease which include: being physically active, managing stress, and eating a healthy diet.
People should also keep monitoring their blood sugar, keeping appointments with their primary care provider, and maintaining a supply of their medications.
While it can be hard to take many of these steps at the moment, there is support and guidance available. Hawaii has 24 accredited or recognized Diabetes Self-Management Education and Support (DSMES) sites across the state. These DSMES programs provide coaching and tips for managing diabetes to help people maintain control of their blood sugar. Many of these programs have modified their delivery to accommodate virtual appointments, recognizing the importance of continuity of care for people especially during the outbreak.
Additionally, across the islands, the National Diabetes Prevention Program (DPP) is offered in a variety of community and health care settings, including community health centers, retail pharmacies (KTA Super Stores, Times Pharmacy) and medical centers (Kauai Medical Clinic, Queen’s Health Center) — often at no cost to participants. (Find options at www.healthyhawaii.com/ prevent-diabetes/ find-a-cdc-approved-dpp/.)
The DPP is an evidence-based lifestyle change program, that can prevent or delay the onset of Type 2 diabetes. It supports participants in modifying their eating habits, being physically active, and losing weight. HI DPP will soon be offered by several CDC-recognized organizations that will allow more people to participate in DPP from the comfort and safety of their home.
Ultimately, prioritizing and sustaining prevention and management programs is vital both to short-term and long-term healthcare and economic stability. Diabetes costs the state $1.8 billion in direct health care costs and loss of productivity.
Without an intervention program, a significant number of people with prediabetes will develop diabetes. This in turn will ultimately increase the economic burden on our families, communities, and health care system. Prevention programs, such DPP, and disease management programs, such as DSMES, are essential to our COVID-19 recovery and long-term viability for both our state and our communities. And they can help us recover and stay healthy together.
Blythe Nett is the chronic disease detection and control section supervisor at the Hawaii Department of Health (DOH); Kevin Watanabe is DOH’s diabetes program coordinator; Tetine Sentell is professor/director of the Office of Public Health Studies, University of Hawaii-Manoa.
In her Commissioned Editorial for the prestigious British Medical Journal, Dr. Catherine Pirkle discusses the recent findings of a living systematic review by Allotey and colleagues (doi:10.1136/bmj.m3320). Their work provides needed insights on evidence-based care for pregnant women with suspected or confirmed covid-19. Dr. Pirkle helps place the research in context and highlights critical areas for future study. The systematic review and linked Editorial provide essential and timely information to assist health care providers caring for pregnant women during these very uncertain times.
With the alarming growth of COVID-19 cases, our state’s media and leadership have obsessively focused on the public’s “bad behavior.”
All summer, we have read stories about people breaking quarantine and gathering in large groups. In many of these articles, experts and non-experts alike out those who went to work while sick or speculate on whether or not the infected person was wearing a mask when around others.
In nearly every daily news digest from the COVID-19 Joint Information Center, the public is reminded to take personal responsibility. They are shamed for their lack of regard for others: Governor Ige had strong words for people who have let their guard down contributing to the surge in cases.
All state leaders echo the personal responsibility rhetoric, using a public relations strategy that is known as framing. They directly attribute spikes and surges to a misbehaving public, one that is unable to take responsibility for its actions.
Here are a couple of examples.
A top public health official said, “As long as individuals in our communities fail to accept personal responsibility for the spread of COVID-19, we are unfortunately going to see continued days of triple digit numbers.”
Or, from our governor: “It’s clear that many across the state has relaxed their commitment in fighting against this COVID-19 infection … We have to take action to embrace the personal responsibility, to do what we can to slow the spread of COVID-19 in our community.”
Our major media outlets reinforce these sentiments, as demonstrated by a July 8 editorial in the Honolulu Star-Advertiser entitled, “Bad time to let down our guard.” Or more recently, in an Aug. 10 article in Civil Beat that asks, “So how badly are people behaving?”
Should we expect anything different? A story about an office where workers diligently wear their masks and sit 6 feet apart is hardly click-bait.
Nor are perhaps the more important questions about that office: Did the employer provide enough hand sanitizer? Is there sufficient ventilation? Do the workers have sick leave if they get ill? Are they paid enough to take time off?
Responsibility Rhetoric
While there is certainly evidence of poor decision-making, and we must all do our part, blaming the public for the current crisis obfuscates the responsibility of state and local leadership.
If the public is to blame for the current surge in infections, then our leadership is no longer responsible. It is an evasion technique that avoids asking hard questions, making hard choices, and more than anything, it avoids accountability.
Blaming the public allows for inaction on contributing factors to the spread of infection. These include limited access to health care for certain groups and for those that have lost their jobs, the lack of sick leave for many, insufficient wages to match the astronomical cost of living, and overcrowded housing that disproportionately affects our highest risk groups.
The use of personal responsibility rhetoric is one that the tobacco industry mastered in the early 1980s. As evidence mounted that Big Tobacco was responsible for the deaths of millions, it needed a public relations strategy that shifted blame elsewhere.
Through some trial and error, Big Tobacco realized that framing a public health crisis around personal responsibility was highly effective at reducing public outrage and in minimizing litigation. The tactic is so successful that it continues to be used by many other industries and interests to avoid accountability for public harms (e.g., gambling, firearms, etc.).
In the past month, Governor Ige reiterated the importance of personal responsibility at nearly every daily press briefing. Nearly all mass media venues have parroted this language, as have all the most prominent elected and appointed leaders involved in the response to COVID-19.
To be fair, our state leadership is not alone in using this framing. The rhetoric of personal responsibility is also coming from the federal government.
For example, here is a transcript from the Centers for Disease Control and Prevention: “We owe it to our nation’s children to take personal responsibility to do everything we can to lower the levels of COVID-19.”
Knowing the occupants of our executive branch, should we really be surprised that the federal government is applying techniques learned from Big Tobacco to defer responsibility for the crisis?
Punitive Action
If a badly behaving public is responsible for out-of-control infections, then a natural extension of this logic is to punish the public when it misbehaves. The criminalization of previously normal and healthy behaviors, such as walking on the beach or in a park, reflect this logic.
Our state is currently using police and other security personnel to enforce restrictions on a variety of behaviors for which such actions would have been unimaginable six months ago. What’s more, it is unclear if the targeted behaviors currently pose a risk to public safety.
State officials appear unable to provide epidemiological evidence to justify many of the restrictions. The lack of evidence of major outdoor transmission events, especially when juxtaposed against other known sources of outbreaks, threatens the perceived legitimacy of these restrictions.
Crucial consideration of the fairness and proportionality of the punishments for our misdeeds is lacking. Bad behaviors, such as hiking, walking in a park, and going to the beach, are all now subject to criminal misdemeanor charges that can result in a fine up to $5,000 and/or a year in jail. In other words, members of the public who engage in these behaviors are subject to the same punishments (actually, in many cases, less) as those who committed a DUI, assault, or minor drug crime.
A Cautionary Tale
Personal responsibility rhetoric is effective until it is not. In the face of public demand for greater accountability brought on, in part, by whistleblowers leaking evidence of the deliberate misleading of the public, Big Tobacco became vulnerable to a flood of litigation in the late 1990 and early 2000s.
The public relations strategy of Big Tobacco ultimately failed because the public can only take personal responsibility for their behaviors when they are empowered to do so.
For combating COVID-19, this means doing much more than giving daily press briefings and public safety announcements. People need clear messages, articulated in ways and languages they understand and across media platforms they actually use. They need support to follow the messages.
As we are learning, not everyone can access masks and other personal protective equipment. And, many people do not have or cannot afford to take sick leave.
For those with low incomes and no sick leave, the choice is often between paying for food and rent or staying at home when sick. Asking people to change “their bad behaviors” under such circumstances not only lacks empathy, but is almost certainly doomed to fail. Other actions are thus needed, including in this case, policy change to provide sick leave to our most vulnerable.
A Final Warning
The engagement of police in public health is risky business. As articulated in this excellent commentary, the use of police to enforce measures perceived as illegitimate fundamentally damages the relationships among the state, police, and public. This, in turn, can generate disorder and damage the foundations of democracy.
When done well, police can be successfully engaged in outbreak control, but their application needs to be targeted and information driven. The United Kingdom, for example, is using an approach built on the concepts of “engage, explain, encourage” and “enforce” only when necessary. It is an approach that seeks to build public cooperation, which is a necessary prerequisite to managing the virus.
COVID-19 restrictions will have to be applied to varying degrees for months to come. We need a maximum of public goodwill and cooperation.
Unfortunately, our response is eroding these fundamentals. At the end of the day, the question really begs asking, who is it again that is behaving badly?
About the Author
Catherine Pirkle is an associate professor in the Office of Public Health Studies at the University of Hawaii Manoa. She is a global health researcher and life-course epidemiologist who has done work in sub-Saharan Africa, Latin America, and the Canadian Arctic. She is also a lead investigator for the Health Hawaii Initiative Evaluation Team, which works in close collaboration with the Hawaii Department of Health.
