Hawaii Is Riding Out the COVID-19 Storm. But Geographic Isolation Isn't the Blessing it May Seem

Bodyboarders leave Kahanamoku Beach in Waikiki on Friday October 16, 2020 in Honolulu, HI.
Bodyboarders leave Kahanamoku Beach in Waikiki on Friday October 16, 2020 in Honolulu, HI. Credit - Kent Nishimura - Los Angeles Times / Getty Images
As Hawaii's coronavirus infections rose in late August, Honolulu Mayor Kirk Caldwell visited doctors in the COVID-19 department at Queen's Medical Center, the state's largest hospital. "I could see it in their faces and in their eyes," says Caldwell. "The worry and fear they had that for the following week, if things didn't change, they would not be able to take care of people, that they would have to put them in tents outside."
It was a crisis that the leaders of the 50th state hoped would never face. Between March and May when a stay at home order was placed, there were only a few new cases a day on average in Hawaii. However, when some restrictions were lifted in June, creating a patchwork of state and local regulations, the numbers soon began to spike. In late July, Hawaii was metaphorically on fire, with the bulk of the cases centered in Oahu, where two-thirds of the state's population lived. The island recorded 119 new cases on July 30; In mid-August the average was over 200 per day.
Four days after his hospital visit, Caldwell issued a second lockdown warrant with more than 350 people hospitalized for COVID-19 symptoms on his island with the blessing of Hawaii Governor David Ige. "Our hospital administrators had informed us if we didn't do something that they would be overwhelmed," says Ige.
Three months later, Hawaii's response appears to have worked. As a new, deadly wave of coronavirus infections emerges in the United States, Hawaii is one of the few states in the country to have seen relative reparation. According to the Johns Hopkins University, 113 new cases were reported on November 23, slightly more than the weekly average of 106 new cases each day. Only Vermont reported fewer cases that day.
Hawaii, the 40th most populous state, has a low case count even when you factor in population - as of November 23, it has a weekly average of 7 cases per 100,000 people, the lowest in the country (compared to the highest case). The head numbers belong to North Dakota (160) and Wyoming (154). Infection rates in Hawaii have remained relatively constant since mid-September, while almost every other state has seen an increase. However, it remains to be seen whether a slight increase in the last few days could mark the start of a new uptrend.
How has Hawaii avoided another major COVID-19 surge so far? The clearest reason can be seen on every map of the world. "Geography is so obvious, but it plays such a big role," says Thomas Lee, assistant professor of epidemiology at the University of Hawaii at Mānoa and co-chair of the pandemic applied modeling group in Hawaii. That spring, he was also the lead outbreak modeler and forecaster for the Hawaii Emergency Management Agency.
For Hawaii, the Pacific helped make it the largest moat in the world. Travelers arriving there by plane - essentially the only way to get to the state on closed cruise lines - have had to self-quarantine for two weeks since March (although visitors have been able to avoid isolation since mid-October if they are within Negative test 72 hours of arrival). While the rules may have deterred visitors from forming new clusters of infections, they have also devastated Hawaii's tourism sector, which accounts for nearly a quarter of its economic activity.
Some Hawaiian leaders still don't believe they are doing enough to prevent infection - part of a larger split among Hawaiians over whether and how to welcome visitors again during a pandemic. Kauai County's Mayor Derek Kawakami says new infections on his islands are related to the reopening of travel from the continental US. He has suggested that travelers need to be tested a second time after they arrive. "This virus requires layer-by-layer intervention and mitigating measures," says Kawakami. "We have to be able to react quickly and boldly because it can spread like wildfire."
Kauai's recent surge is tiny in relative terms - six cases were reported on November 20, the second highest one-day number to date. But Kawakami has good cause for concern: Kauai, home to around 72,000 people, has only nine ICU beds and 14 ventilators. In isolation and with limited healthcare capacity, an uncontrolled outbreak can quickly lead to disaster. "The holy grail is prevention, so here on Kauai we put our blood, sweat, and tears to use," says Kawakami. "We're almost always on the red line."
A similar imperative applies to the entire state of 1.4 million people. When the Hawaiian health system is overwhelmed, those responsible have no choice but to proactively tackle COVID-19 outbreaks. "We're geographically remote, so our health system is really fragile," says Catherine Pirkle, professor of health policy and management at the University of Hawaii at Mānoa. "There really is a strong motivational factor in trying to keep those numbers under control."
So Hawaii's isolation is a double-edged sword. Thousands of kilometers of ocean are a great way to deter travelers from forming new coronavirus clusters. However, when infections get out of hand anyway, support can be a long time coming. "We focused on the science and public health recommendations from the start because we are 2,500 miles away from any aid," said Ige, the governor. "We learned a long time ago that we have to be independent and act as a community."
Epidemiologists say it is difficult to attribute Hawaii's relative COVID-19 success to any factor, including isolation. For one, cold weather, which forces many Americans into indoor spaces where the virus can more easily spread, is unknown in most parts of Hawaii. The forecast for Thanksgiving Day in Honolulu is 82 and sunny. Other government measures may also have played a role. Unused hotel rooms in Oahu have been repurposed to isolate COVID-19 patients, and restrictions on travel between islands have prevented the local spread.
Wearing masks also helped. Mask mandates were introduced in Kauai and Oahu in April, while a survey in August found 96% of Hawaiians mask. Unlike many Americans, wearing masks for disease prevention is not a completely foreign concept to Hawaiians. Public health experts say this is likely due to the state's relative proximity to Asia, where face coverings tend to be more common. Many Hawaiian residents who commented on this article also cited the state's heritage and cultural values ​​as reasons for high adherence to public health mandates. "We have a culture here that comes from the first peoples, the native Hawaiians," says Caldwell. "The term Kuleana ... means responsibility and permeates the people of Hawaii."
Still, Hawaii leaders have come under pressure over COVID-19 restrictions. Caldwell says people sometimes drive down his street to yell in front of his house, either him or his wife and daughter. Some people certainly have cause for alarm - travel restrictions have devastated the state's tourism-dependent economy. Hawaii's unemployment rate was over 14% in October, the worst in the country for the second consecutive month, according to the U.S. Department of Labor.
Caldwell says he understands people's frustrations but needs to make public health a priority. “The people are affected. Your businesses are affected. Your lifelong dreams are affected, ”he says. "I understand why they are upset. But I also believe that in order to protect health and safety, whatever is most important, everything comes first. And I think it is also directly related to the economy."
After months of travel restrictions, the state's pre-trip testing program is finally drawing visitors in and helping Hawaiians get back to work while COVID-19 levels remain stable, according to Ige. Despite the low number of cases in Hawaii now, it remains to be seen whether heads of state can revive a tourism-based economy while preventing a devastating surge in cases - which would likely put the tourism business back on hold anyway.
"We depend on travel," says Ige. “But every day I get comments from members of our community that further entry of visitors to Hawaii during this time is really endangering our community. This puts a lot of stress on me and the mayors every day as the number of viruses increases on the mainland. "
- With reports from Emily Barone
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Kirk Caldwell

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