Three Punahou alumni are playing crucial roles in battling COVID-19 in Hawai‘i, leading the Hawai‘i State Department of Health. Director Bruce Anderson ’70 has appeared in the news daily since March, providing updates on incidences of the virus in the Islands and the State’s response. His deputy, Cathy Ross ’95, along with Deputy State Epidemiologist Sarah Kemble ’93 are also on the front lines, working to keep Hawai‘i safe from behind the scenes. Anderson and Kemble recently spoke with Punahou Podcast Editor Allen Murabayashi ’90 about how the pandemic is unfolding in Hawai‘i, and how they’re handling their roles at such a pivotal time.
This summer’s Punahou Bulletin magazine, which comes out in mid-August, also features Anderson, Kemble and Ross, who discuss being at the forefront of the biggest health crisis of our lifetime, and specifically about Punahou and other local schools can safely bring students back to campus this fall.
Allen Murabayashi: Thanks for joining our Team Up podcast, produced by Punahou School. I’m Allen Murabayashi, an alumnus from the class of 1990. As part of our PunsUnited coverage of the COVID-19 outbreak, we’re interviewing alumni working on front lines of this global health crisis. They’re out in force, playing instrumental roles in helping their communities across the world during this unprecedented time.
Even with the recent uptick in COVID cases here in the Islands, Hawai‘i still maintains one of the lowest cases and deaths per capita, lowest hospitalization usage rates, and one of the best contact tracing percentages in the country. This outcome reflects both the willingness of the population to adopt measures like mask-wearing and social distancing, as well as the leadership of the Department of Health and three key individuals at the DOH are Punahou alumni – Director of Health Dr. Bruce Anderson, Class of ’70; Deputy Director Cathy Ross, Class of ’95; and Deputy State Epidemiologist Dr. Sarah Kemble, Class of ’93.
On Tuesday, June 30, the trio took some time out of their busy schedules to chat about Hawai‘i’s unique challenges in confronting COVID-19, the limitations of testing, and the role that Punahou played in their career trajectories. Dr. Anderson, in the past two weeks, we’ve seen the state go from zero and single-digit increases per day to double-digit increases. In reading the news, you’ll typically see things like, “There’s been an increase, but the rise doesn’t meet the criteria for rolling back or for another shutdown.” Is there a defined criteria, or does that kind of matter on a bunch of other external factors that are going on?
Bruce Anderson: Yeah, it’s hard to come up with a single number or formula that you would use to make those decisions. A lot of it’s a judgment call. When we had 27 cases, for example, last weekend, 17 of those 27 cases were associated with one event. Happened to be a funeral that everyone went to, and we’re still looking at other potential close contacts. We may not have seen the end of that, but one single event caused the vast majority of the cases that we had that day.
Of course, if we had a threshold for shutting things down at 25 or whatever it would be, it wouldn’t make sense to shut everything down because we had one large outbreak. Same thing happened, of course, with Maui Memorial Hospital in the past, where we had 60-plus cases with one facility, and recently, we did have a nursing home, which had some cases associated with it. So it depends on where the cases are and lots of other factors. Most of the cases we have are associated with known clusters, basically large families who have extended families, and we’re finding more and more cases. We reach out and find cases associated with that cluster. That actually is a very manageable situation. We expect it to happen. As we talked about earlier, a lot of people are living together, and you would expect if they’re living together, they’re going to be exposing each other, and eventually you’ll see to the end of it. But that’s manageable.
What I would be concerned about would be having lots of unrelated cases and dozens of those. Of course, in the mainland, they’re having thousands of those, right, in every state. Hopefully we never get to that point, but if we had lots of unrelated cases that were not associated with known cases, new cases, if you will, and we couldn’t identify who they were in contact with, that would be very troubling.
Another factor we are, of course, concerned about is whether our health care system can take of the patients. It’s one thing to identify the cases, but, of course, many of those cases end up in the hospital, and, unfortunately, many of them end up in an ICU or some other facility where capacity is limited. What’s happening now in now Florida and Arizona is they’re reaching the capacity in their hospitals. Of course, when you get to that situation, you’re getting into a problem where the situation is unmanageable from a health care standpoint. So we also keep a track on the number of empty beds, ICU units, ventilators, and other things to try and understand and what the surge capacity is in the community, and that varies. On the Neighbor Islands, it’s much less, of course, than it is here on O‘ahu. So, again, lots of things are taken into account on that, but it basically boils down to our ability to contact trace, to do the things that Sarah does. 24/7 testing is an issue. We need to be able to test people who we think might be positive. We need to make sure our hospital system is well equipped to handle the cases. Then just generally, from an epidemiological standpoint, we want to make sure that we can manage the cases and the distribution of the cases, the types of people who are affected. Those do make a difference, and altogether then we can make those decisions.
So far, we’ve been able to manage very well. I think we’ve kept things down to a point where we’ve flattened the curve. We’ve followed up quickly on the cases we’ve had, and our successes are terrific. Let me add I think our community is very compliant. There are some people out there who aren’t wearing masks, but generally, people are pretty conscientious in that regard, and they’re respectful of each other. I think that’s generally true of Hawai‘i as a community. That’s not the same in lots of parts of the mainland, but here, I think we’ve got a lot of good things going for us from a community support standpoint, and I do worry that people are letting down their guard. They’re going to the beach. They’re not paying attention to the social distancing more than they did in the past. So I think a lot of the surge in cases is partly at least attributed to people relaxing a little too much, I think.
AM: So Hawai‘i, unlike much, well, all of the other 49 states, is surrounded by ocean. So I’m curious to know from your perspective as epidemiologists and doctors, what unique challenges and/or opportunities do we have in terms of public health because of COVID-19?
BA: Well, so let me start and agree, first of all, that we are certainly unique in the United States as a state surrounded by water. We also had probably the highest visitor volumes of any state in the country, and that was also a challenge to begin with. In theory, we would have been hammered as this thing developed. To the governor’s credit, we did what was the right thing to do, which was to mandate a quarantine, a 14-day quarantine, which none of the other states could do effectively, basically making it impossible to travel here without going through that period, which was the incubation period of the disease. I think that is unique to Hawai‘i, and something that we can attribute most of our success to in keeping the disease rates low. Having said that, I think we do have a really well trained workforce. People like Dr. Kemble and others here have been terrific in doing all the contact tracing and keeping the disease suppressed to a point where it’s been manageable from day one, unlike lots of other places.
So the challenge and basic challenge is, of course, we’re so dependent on tourism that our economy is suffering as a result of the quarantine period. So we’re now in a position where we’re having to make tough choices between staying essentially locked down and keeping things as they are and then opening up our economy, which I think is going to be very challenging going forward.
AM: The typical knock on epidemiologists is that they only care about public health and not the economy, and there are many people who say, “You guys just don’t get it,” but when I’ve had the opportunity to talk to other alumni who work as epidemiologists, they say, “No, the economy and health are intertwined.” So from the horse’s mouth, Dr. Anderson, what’s your viewpoint on what is often presented as conflicting goals?
BA: No, they shouldn’t be conflicting goals. Having a healthy economy does generally translate to having good health. We actually have always been ranked as one of the healthiest states in the country, and I think it’s for lots of good reasons. It’s a wonderful place to live, clean air, clean water. People are generally outdoors, living healthy lifestyles, and I think there’s lots to say for that. But our economy has been generally very healthy. Unfortunately, we’re very dependent on one industry, which is tourism, and that does present significant challenges, particularly during pandemics, when people moving around are the major risk factors. We have a lot of those who have been coming and going over the years. But certainly the two are intertwined and essential for one another, and it’s because of that we’re looking to make some compromises and try to figure out how to restore at least some of our visitor industry as we move forward.
AM: So the governor announced additional plans to open up tourism and the economy starting on August 1. We’ve heard Mayor Kawakami on Kaua‘i talking about a two test protocol with a quarantine hotel. What can we expect when tourism opens up, and what will the state’s response be if and when there’s an increase in COVID?
BA: Well, first of all, I think we are going to see an increase in cases when we open up. It’s almost impossible to set up a screening program that would prevent that from occurring, particularly given the high rates of disease in the rest of the country. We’re in the very enviable position of having the lowest rates of COVID-19 cases and the least number of deaths anywhere in the country by a long shot. We’ve been very successful in keeping this disease under control here, albeit we have had I think 18 deaths so far and, of course, over 800 cases. That’s a small number compared to what other states are dealing with.
AM: Dr. Kemble, the federal leadership has been not great, to say the least, and I’m wondering, from your perspective, what is needed in Hawai‘i to strengthen the State’s ability to fight COVID-19? Are you receiving enough federal funds? Is there enough support on a statewide basis to really deal with the increase in tourism and a, quote, second wave?
SK: So there has been an influx of federal funds to help with the COVID response, and it’s at a time where it’s much needed. So that’s definitely been a boon. My training started with the Centers for Disease Control, but I was also a field assignee in a state health department when I did my epidemic intelligence service training, and that really impressed upon me during that training time how all public health really starts from the local level and works its way upwards.
So the CDC is a much appreciated entity, and we look to them for a lot of scientific grounding for what we put forth as recommendations, but the practicalities of how you do public health really start on the ground, where you are in your local state. So I think there’s no exception here. We’re going to fight the battle against COVID, and the successes that we have come from what we figure out how to implement on the ground.
I think in Hawai‘i, it’s really about we need to have a call to action for people in Hawai‘i to take COVID seriously and continue to act with care. We need to really think creatively as a community about how we live our lives with COVID. As Dr. Anderson was saying, we’re in a new normal now. So it’s really envisioning what does that look like for our community? How do we do that with the sense of aloha and everything that we are accustomed to doing in our lives here? So I think it’s really for us to all take that responsibility seriously and think with our friends and communities about how we implement that.
AM: I’ve been heartened to see when I’m walking around that mask wearing is pretty prevalent here in Hawai‘i, at least in Honolulu. I guess as part of what you do as health officials on dealing with public health is marketing these ideas of how to overcome or deal with a pandemic. So in setting expectations for the residents of Hawai‘i, do you see us wearing masks and being socially distant for the next few years until a vaccine is widespread? Is that going to be the reality?
SK: I think we’re with this for a long time. So I do think that the things that we’re changing now, the mask wearing, physical distancing, these are concepts that are here to stay for a while. We all are watching the development of vaccines. It would be fantastic if that vaccine can be part of a solution, but we also in public health have watched many diseases with vaccine development, and it can take a lot of time. So I think we also need to be prepared for what we do up until the vaccine is available.
BA: Let me jump in for a moment and emphasize that public health, Dr. Kemble and I, we do what we can to support the contact tracing and all the epidemiology that we do, but what’s going to prevent the spread of this disease is not the testing and all the things that you hear people talking about. It’s actually every one of us adhering to the social distancing recommendations we make, wearing masks if you are in a situation where you may be in close contact with others.
Paying attention to that is what’s going to make the difference. That’s how the disease is transmitted. Testing doesn’t really help prevent any disease. It helps us identify people who are sick, but the real solution here is to collectively prevent the spread of the disease among each other. We can set up screening programs and do other things that we’re doing now, and we do have a very vigorous testing program. As you may have heard, NPR announced today we’re one of four states that has adequate testing. I think we’re in the company of Vermont and Massachusetts and Montana. I think it is typically small states without a lot of cases. Having said that, we’re in pretty good shape from the standpoint of having the capacity to respond to individual cases or clusters of cases. I don’t worry about that. What I do worry about is people letting their guard down and not paying attention to the social distancing, wearing masks, and other requirements, which really is the key to preventing the spread of the disease here. I am concerned that people are letting their guard down now. That’s what’s happening in Florida and Texas and other states where the disease is flaring up and becoming a real problem.
AM: So we heard early on that Hawai‘i had some challenges because of the multigenerational living that occurs in different communities, and I was shocked to read an article a couple of weeks ago about one household, I believe in Waipahu or Kalihi, that had two dozen people living in two bedrooms. I was fortunate enough when I was growing up to have my own bedroom. It’s hard for me and probably a lot of Punahou students to fathom the idea of that density of people. How big of a challenge is this for the Department of Health?
SK: I think the more people that are crammed into the smaller space, the more you are going to see spread of disease, and that is certainly something we encounter in the course of our contact tracing. For households that are crowded, it’s really a challenge. Early on with some of the travelers coming into the state who had means, it wasn’t too difficult, and a lot of these were returning residents, not tourist travelers. But people who travel often have means, and they were able to set up their own room with their own entrance and exit and their own bathroom, and they don’t have to see anyone else in their family for the entire quarantine period. No spread of disease, of course, right?
But we now see some families as we see some spread within the community locally that don’t have those resources, and they have to share a bathroom. They have to take care of Auntie, who’s got maybe diabetic foot infection. So there’s a lot of interactions that are going to be unavoidable for some of these families, and it’s a lot harder to prevent spread within those settings. I think those households still try to keep it all contained within the household, and that’s where we really can try to emphasize education and support that through public health. But it’s hard to prevent that spread within your own household when you’re living close together.
BA: Yeah. Let me also add that many of us who went to Punahou haven’t experienced low income housing, living, and so forth, but we’ve got pockets of low income housing, Palolo, Kalihi, and in many other places out here where we do have a dozen people living in a two bedroom apartment regularly, and, of course, they have extended family who are there as well. It’s a way of life, and many of these families are Pacific Islanders who culturally are used to that kind of living, and having to try to find a way that we can isolate cases and be sure that they’re not transmitting the disease among one another is certainly challenging.
We have, on many occasions, been able to find solutions, and most cases, we’ve resolved this, but it’s a challenge. We do have isolation and quarantine facilities, and we have moved people into those to decompress a situation where lots of people are living together and they obviously aren’t going to be able to isolate themselves.
Hawai‘i is not unique, but we do have a number of places in our State with concentrated housing. Now as we find disease problems like this, that those issues, those socioeconomic issues become even more apparent. It doesn’t make them any easier to deal with, but we do have to address that issue if we’re going to effectively suppress the disease here in the State of Hawai‘i.
AM: So much of my Punahou experience occurred outside of the classroom, doing extracurricular activities, playing in the orchestra, being in Dillingham, being in theatre productions, Holoku, athletics, et cetera. Dr. Kemble, what do you think is realistic for the 2021 school year and beyond for all of these extracurricular activities that are so enriching to the student population?
SK: I really think it depends on the specific activity. There are some activities that are going to be more conducive to still going on. So you can think of some sports, like maybe tennis, swimming, if you can separate out the lanes a little bit, where you really don’t have much close interaction. I think those are the sports to start with, and I think it’s going to be also a learning curve as we get going with the school year. So you start with the sports that are safest, and if things are going well, maybe you add a sport or two, but I think it’s going to be a long process before we’re tailgating at the football stadium.
BA: One of our jobs at the health department is to review what the counties are proposing to allow, and the city and county recently suggested allowing football and basketball. We I think all said, “No, it’s a little too early for that.” There are clearly some activities and sports that are not safe at this point in time.
Having said that, drills and fitness activities associated with those sports might be something that could be entertained. At the same time, I also recognize that sports and other activities are critical. I look back at my Punahou years, and I remember much more about the sporting events I was involved with than I do about history classes or calculus classes or other things that I didn’t do very well at. It’s going to be a challenge to try to figure out how to get that diversity of activity in place and continue those activities. But it’s important that we do that.
AM: Dr. Anderson, in the past four months, everyone has become a bit of an armchair epidemiologist by reading the news. Is there one aspect that you think the public is still misunderstanding about the spread of the disease?
BA: I think, actually, the general public has learned a lot. I mean, it’s hard to turn on the news without seeing something about COVID-19, and reading the papers, it’s on the front page almost every day. As we knew very little about it just a few months ago, many do know much more about it than they do about lots of other activities. So I would say that the general public is pretty well informed. At least the people I interact with are up to date on current issues.
I would say the one thing that there is a lot of misunderstanding about is the testing, how effective the testing might be. Everyone’s putting so much emphasis on the testing, whether you have capacity to do the testing that they’re not recognizing the limitations of the testing. It’s helpful as a diagnostic tool, of course. If someone’s sick and they’re at the hospital and have symptoms, you want to know whether they have the flu or COVID-19. For that situation, it’s very good.
But for screening purposes or surveys, where you have lots of asymptomatic people, you have a period before you become symptomatic. We call it a pre-symptomatic period, where the test is likely to be negative, even if you’re infected. Then, of course, with the new tests, the PCR and other tests that are out there, the day after you are tested, you could become infected. So it’s a point in time test. All you’re doing is getting a snapshot of whether that person or that group of people is infected at that point in time. Even then, you’re not getting a very good indication of that.
So testing is a good tool. It’s the only thing we’ve got, frankly, but it has extreme limitations. Honestly, the stuff that Dr. Kemble and others do in terms of contact tracing and finding out who people have been in contact with and strategically testing those individuals who are at high risk, close contacts, that’s why we’ve been so successful here, is we have done that, which each and every case we’ve had, we identify the case, close contacts, we test those who are working with contacts, and we’ve been very strategic about how we’re using our resources instead of just randomly testing people. I think a lots of people think that if we somehow could test everyone, everyone would be fine. Well, that’s impossible to begin with. Secondly, that’s not the solution to the problem.
But having said that, I think that’s the one area that I think people really need to understand, is that testing’s not a panacea to all the other things that need to be in place to prevent the disease. Most important, the social distancing, wearing masks, not going to work when you’re sick, those kinds of things are going to help prevent the spread of the disease. That’s where people’s minds should be at, not thinking that somehow a test would be able to stop the disease from spreading. Dr. Kemble may have some other thoughts on the matter.
SK: You said it.
AM: So Dr. Kemble, let me ask you a little bit about the contact tracing. There have been a lot of concerns with telephone fraud and people not wanting to share personal information about who they’ve been hanging out with. Have you found that the people that you’ve tried to contact trace have generally been accepting of the state’s effort to contact trace, and have there been any discussions internally about using the Apple and Google API to do digital-based contact tracing?
SK: For the most part, people have been really quite receptive to contact tracing. It’s also an information sharing exchange, right? So we’re also answering questions, providing a lot of information about COVID-19 and what it means for the case and their family, helping them to figure out strategies to get through quarantine and get through isolation and make sure they’re meeting all their needs during that time period.
Technology has really helped with some of the efficiencies, and so we’re using a web-based application called HealthSpace that allows us, once we’ve identified a contact, to send a daily text message, and that person can then reply with any new symptoms or updates on their status by a text instead of us having to call them at a designated time every day. So that’s both more convenient for a lot of our contacts and saves time on our end. So that certainly has extended the reach of our contact tracers.
We’ve been exploring other ways to use technology as well in terms of applications that might use location data to help as sort of a virtual diary that helps people really remember where they’ve been. There’s interest in some of the developments by Google and Apple and looking at Bluetooth technologies. Those are still fairly new on the scene, so that’s something we’re looking at closely and watching to see how it might help, and looking at partnerships with other app developers in the islands to harness other forms of technology that can help us understand how people are behaving when they get sick and whether they’re going to get tested. So a lot of different fronts where technology can really be a huge help.
I do think it’s really important to maintain that sense of legitimacy. So we do always start with a warm phone call by a real, live person so that people know they’re actually talking to the health department before we established that app-based contact.
AM: There’s a bit of a specter of a rise in mental health problems the longer this goes on. We’ve heard people having anxiety and depression. We’ve heard about child abuse and domestic abuse happening because more people are kind of staying indoors. Has the Department of Health considered these, and do they have plans to sort of address this for the state?
BA: Yeah, I’m certainly not an expert in that area, but we have a large behavioral health administration, which does manage a number of clinics and provides outreach services to people. But for a lot of us, people who have been home alone for long periods of time, they’re worried about their lives, their future economically, how their loved ones are. This is a very stressful time for people, and I think recognizing that and supporting people generally is really important.
If you feel that way, know that you’re not alone. That’s more and more often the case. We’ve actually done some surveys recently to try to get a better handle on the stresses that are occurring. We just did one on Kaua‘i, and the vast majority of people, the majority of people are very worried about the economy and their future. That relates to a lot of other stresses that manifest themselves in different ways, alcoholism, drug abuse, and lots of other things fall from that.
So I guess my only advice would be, of course, people recognize that this is not an unusual situation. They should talk to their family and friends about it. Then they’ll talk, and they’re going to find a lot of people are feeling the same. That helps a lot, and there is professional help available to people if they are really anxious or feeling depressed. Call the Health Department. We’ll certainly put you in touch with people who can help. That’s not going to go away. It’s going to get worse, I’m afraid. Particularly as we lose our unemployment benefits, we’re going to find a lot more people struggling just to make a living.
AM: Speaking of stress, Dr. Anderson, you’re on the front lines, and I’ve seen some very unkind things said about you on social media and on comment forum posts, et cetera. How are you handling the stress during this time?
BA: Well, beer after work helps. But seriously, I was actually Health Director before … I did one stint as Health Director, and we had our share of controversial issues there. One thing you learn in this job is not to take a lot of things personally. You have to make tough decisions, and you do and do the best you can. I think, actually, I get a lot more compliments than I do criticism from most people. There are people, of course, who are very angry about the economy and that we’re not acting fast enough. First they blame the health department or me in particular for the problems, and you just have to weather that. It comes with the job, and just have faith in yourself that you’re doing the right thing.
I’m going to say that the Punahou education I think has helped. There are lots of things we went through at school that were stressful. Although we weren’t criticized, necessarily, you’re always being measured against someone else. I think it prepares you well for life. You learn you can get through problems and come out the better for it. Dr. Kemble probably won’t say this, and I will. I think one of the things that makes me really happy about coming to work every day is the really good people at the health department. It’s the terrific, dedicated people. We have 3,000 people in the Health Department. Every one of them here is dedicated to doing whatever they can do well to try to keep our state healthy, and that keeps you going.
AM: You touched on it a little bit, Dr. Anderson, but as the last question, I wonder if you could both expand on this idea of how Punahou prepared you for this moment. I mean, none of us I think could have ever imagined a global pandemic in 2020.
BA: I’ll start. I think just graduating, for me, was an accomplishment. Going to Punahou, which was a tough school to get into and get through, I always felt was an accomplishment. I always remember being in high school, thinking, “If I ever get through high school, that’s it. I’m done. I’ve succeeded in life.” But I think it fundamentally creates a sense of confidence and self-assurance, which is really important as you go forward. Obviously, the skills you’re learning are helpful. I can’t think that I’ve ever used calculus. I was a physics major at college, and I have never used anything I’ve learned there, but just learning how to interact with people, the communication skills we learned at Punahou, frankly, the ability to cope with people who are sometimes not easy to deal with and just learn how to interact with others in a way that’s responsible.
Of course, the friendships we all made there are lifelong. I was the class of ’70, so I’ve got 50 years behind me since I graduated, and I tell you, there’s still a special feeling I have with a Punahou graduate. It’s a bond, knowing that they’ve been through the same thing we have, that I went through and so many others went through. I think there’s a connection there that we’ve learned life skills and we’re trying to do the right thing for the right reasons. I think that’s something that’s pervasive that I’ve seen in every Punahou graduate. They’re not only learning the technical issues. They’re learning life skills that are really important, going forward.
I never knew what I was going to do when I went through high school, and after high school, it was just getting through college. It took me a while. My first job was actually essentially what Sarah is doing here. I was at a state epidemiologist in Hawai‘i, and I’ve worked in the health department most of my career. So it’s been a good one, and I think Punahou has really established a good solid base for almost everything I’m doing. So thank you, Punahou.
SK: Well, I’ve just been amazed at how many former classmates and Punahou alumni I’ve ended up talking to and working with over the course of this pandemic. I’m just reminded every day of how many different industries and fields my fellow classmates are now in, helping to manage the pandemic here in the Islands. That’s quite impressive. I think It’s also all the skills that I learned at Punahou, so critical thinking, creative thinking, how to connect and come together across communities. So all of that is definitely helping me get through the current situation.
AM: This has been a real treat to talk to both of you. Dr. Bruce Anderson, thank you so much.
BA: Thank you, Allen, for having us, and we look forward to touching bases again, hopefully under different circumstances.
AM: Dr. Sarah Kemble, thank you so much.
SK: Allen, it’s been a pleasure.