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Every day, when Bryan Johnson gets home from work, he takes off his scrubs before he goes into his house and puts them in a bag to be laundered.
He proceeds straight to the bathroom to shower and change before he hugs his wife, Anamalia Su’esu’e, their 4-year-old daughter or one-and-a-half year-old son. Until then, he avoids his father-in-law, mother-in-law and sister-in-law, too.
That’s because Johnson is a registered nurse in an intensive care unit that includes a COVID-19 patient and he’s worried about infecting his family, particularly his 61-year-old father-in-law.
Johnson’s routine has become the new normal for the past three weeks as their seven-person household adjusts to the gravity of the coronavirus pandemic in Hawaii.
“It all just kind of became surreal,” Johnson said.
The spread of the COVID-19 virus is changing daily behavior throughout the U.S. People are working from home, gym classes are being live-streamed and it’s now common for friends to meet for happy hour via Zoom, a video-conferencing program.
But social distancing is harder when your household is full of people. It’s especially tough in Hawaii which has twice the national rate of multi-generational households and the highest average household size of any state except Utah, according to American Community Survey 2013-2017 estimates.
State and city officials have been telling residents to stay home to prevent the virus from spreading. But many still fear that they will accidentally infect elderly parents and grandparents living with them who are particularly vulnerable to the virus.
Dr. David Derauf, a physician and executive director of Kokua Kalihi Valley Comprehensive Family Services, a nonprofit community health center, says that the high rate of overcrowding in Hawaii is a critical, unaddressed concern as the state seeks to slow the spread of the virus.
People who live in crowded situations are particularly vulnerable because the virus spreads through close contact with an infected person, Derauf says. He adds that high-density living situations are common especially among low-income families who struggle to afford Hawaii’s high rents.
“In a patient family of mine, I’ve seen 21 people sharing a one-bedroom,” he says. “It doesn’t take a rocket scientist to figure out that social distancing there is not possible.”
When Su’esu’e got pregnant four years ago, she was living on the mainland. But she knew she wanted to move back home to Hawaii and raise her children among their grandparents and extended family the way she had grown up. Moving into her parents’ house made sense given the high cost of housing in Hawaii.
“As the oldest I know my role is to be there to help my parents in any way I can,” she says, adding that they also have been a tremendous support to her.
Her story isn’t unusual in Hawaii, where a mix of cultural and financial factors often keep adult children at home or stop elderly family members from going into senior homes. Su’esu’e is typical in another sense too — she’s part Samoan, and a 2018 state analysis of data from the 2011-2015 American Community Survey found Pacific Islanders have particularly big households.
The study found owner-occupied homes of families who were part Samoan had an average of nine people in their household, about three times the statewide average. Household size in Hawaii differed starkly by race and ethnicity: Pacific Islander families were far more likely to live in crowded homes compared with families of white or Asian descent.
“In a patient family of mine, I’ve seen 21 people sharing a one-bedroom. It doesn’t take a rocket scientist to figure out that social distancing there is not possible.” — David Derauf, physician and director of a Kalihi clinic
Apart from Su’esu’e, 26, and her husband Bryan Johnson, 32, their household includes her father, who is 61; her mother, age 55; her 20-year-old sister; Su’esu’e and Johnson’s 4-year-old daughter and their one-year-old son.
Even before Honolulu’s mayor announced a shelter-in-place policy, the family was in self-imposed quarantine, Su’esu’e says. Their greatest anxiety is that they’ll accidentally infect Su’esu’e’s father, who is fighting cancer and has hypertension and diabetes.
“With this virus, it would be devastating,” she says. “I don’t know how his immune system would handle that.”
In some ways, Su’esu’e is lucky. She’s able to work from home, and their two-story four-bedroom house has enough room for all of them. So they aren’t among the most vulnerable members of Hawaii’s community. Still, the pandemic is particularly scary to Su’esu’e because COVID-19 is deadliest for elderly people.
“It worries me because this comes after our elders, the people who hold our language and our stories,” Su’esu’e says. “As someone who is still learning my ancestral language I worry about what this is doing for our future generations and I think there is a big gap there when it comes to language and cultural learning.”
The state and city’s response to the coronavirus crisis has largely focused on telling residents to stay home. Limiting social contact — a strategy called social distancing — could help slow the spread of the virus and ensure hospital systems aren’t overwhelmed.
The state’s COVID-19 website acknowledges Hawaii’s multi-generational households and urges families and caregivers to practice good hygiene and avoid crowds and nonessential travel.
But some worry that’s not enough. Derauf from KKV says that people who live in big households or crowded conditions should redouble their efforts to be hygienic, washing their hands more frequently.
He also thinks public officials should be looking at using underutilized facilities to house people infected with the virus. Hotels that are closing due to lack of tourism could be repurposed to house people who might only have mild COVID-19 symptoms but would otherwise be living in crowded conditions and spreading the virus, he said.
“That is being done in other jurisdictions throughout the U.S.,” he said. “Why can’t we stand that up here quickly?”
The state health director, Bruce Anderson, told the news media Monday that the state is “looking at standing up temporary hospitals if we need to do so” in anticipation of a worst-case scenario, but “in the very short-term at least in handling the number of people who we’ve seen to date I believe we’re in good shape.”
It’s that worst-case scenario that has Derauf concerned.
“When you look at the amount of tertiary care we have in Hawaii,” he says, “you rapidly come to the conclusion that we better do whatever we can to prevent overwhelming that system because that is not going to be pretty.”
In the meantime, families are figuring out their own ways to protect their loved ones. Johnson isn’t working directly with a COVID-19 patient yet, but says that once that happens, he’s considering setting up a tent on his lanai where he can sleep.
Until then, “everything has just been kind of on stand by,” he says. “We haven’t had to do anything too extreme just yet.”
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