Hawaii Lt. Gov. Josh Green’s whiteboard is a familiar prop.
Nearly every day Green, who is an emergency medical physician, takes to Instagram with his dry erase markers to share the latest data on how many people in the state have tested positive for COVID-19 and which ones have been hospitalized or hooked up to a ventilator to keep them breathing.
While some might consider Green’s presentations political schtick — he’s planning to run for governor in 2022 — the data he shares gives a more complete picture than that provided by the Hawaii Department of Health, which is the state agency charged with responding to the pandemic.
Not only does the DOH provide less information than Green on its COVID-19 website, the data it does release is missing what, some argue, is critical context that can better explain to the public Hawaii’s vulnerabilities to the coronavirus and the health risks posed by its spread to those living in the islands.
On April 6, for instance, when state officials announced the fifth death in Hawaii, the DOH also told the public that since the beginning of the outbreak 26 people had been hospitalized with COVID-19.
Green, however, gave a different number in his daily social media presentation. According to him, there were a total of 56 people in the hospital suffering from COVID-19 symptoms that very same day, or more than twice what DOH officials were saying publicly.
“When you put out 26 when the number is really 56 you’re downplaying the problem and giving the public the wrong impression,” said Tim Brown, a senior research fellow at the East-West Center who specializes in infectious disease epidemiology and modeling.
“I’m a firm believer that in public health you give the public the truth and let them make their own choices.”
In particular, Brown would like to see the DOH provide more information about contact tracing and the clusters of positive coronavirus cases that are popping up in the community so that individuals can use that information to change their habits. He said this will be especially important as officials consider allowing businesses to reopen and life begins to get back to some semblance of normalcy.
The number of hospitalizations are important, too, he said, because those figures highlight just how serious contracting COVID-19 can be.
“It’s valuable for people to see that this thing is not a gentle virus,” Brown said.
Hawaii’s DOH lags behind agencies in other states when it comes to sharing relevant details about the severity of the pandemic, where it might be surging and whether local hospitals are prepared to handle the load.
Some experts worry that a lack of information could mask a lurking danger or provide residents with a false sense of security when vigilance is needed to shelter in place, work from home and stay away from friends and family.
Statewide coronavirus testing results, for example, have shown a leveling off in the number of positive cases in recent days. But lag times in getting results and other gaps in the testing, such as undercounting low-income communities that don’t have as much access to health care, could skew the trend lines.
There are also differences between how the virus spreads on each island. While it appears cases are on the decline on Oahu, a recent cluster stemming from an outbreak at Maui Memorial Medical Center — the island’s largest hospital — shows an increase there.
From the beginning, DOH officials struggled to provide the public with detailed data about the pandemic, leaving some, including Green, to fill in the gaps.
Early on, the agency refused to consistently publicize the total number of COVID-19 tests that had been performed, much less how many of those were still pending at local and mainland laboratories.
Officials initially didn’t want to share information about where the positive cases were occurring in the islands saying they had privacy concerns. But they were eventually chided into doing so after repeated questions from the press and others in the medical community who wanted to get a fuller picture of the pandemic.
“I’m going to give people the best information I possibly can, and it’s going to continuously get upgraded and updated.” — Lt. Gov. Josh Green
Now the DOH is considering releasing a new round of demographic data that includes information about race and ethnicity after criticism that such data has been made available in other parts of the country, revealing that some communities — particularly lower income and black — seemed more susceptible than others.
Hawaii Department of Health Director Bruce Anderson concedes his agency could do better when it comes to providing more information to the public about the spread of coronavirus in the islands. He says he’s even open to suggestions.
“We want to be as transparent as we can on this,” Anderson said. “This is a work in progress. We’re trying to get out the information as we have it. There are no secrets here.”
For Green, some of the most critical data points that DOH doesn’t publish are related to hospitalizations. While it might be easy to miss testing someone who’s asymptomatic, it’s unlikely that person will stay home and go about their normal routine if they can’t breathe, he said.
“The categories of information that are most relevant are the number of people on ventilators, the total number of people in our hospitals and the total number of people in our intensive care units,” Green said. “It’s useful because it reflects the reality of what health care providers are doing and what they are faced with. When they treat patients, they are treating them as if they are COVID-positive.”
Green explained that the discrepancy between his figures and the ones provided by DOH comes down to testing and how you read the numbers.
The DOH publishes the cumulative total number of confirmed COVID-19 patients who were hospitalized when the case was investigated; if someone was hospitalized afterward they might not be counted.
Green, meanwhile, provides a daily snapshot of confirmed COVID-19 patients in the hospitals as well as individuals who have been screened for the virus and are seeking treatment for COVID-like symptoms.
“I’m reporting that number so people know what’s out there,” Green said. “I’m going to give people the best information I possibly can, and it’s going to continuously get upgraded and updated.”
Hawaii disseminates less detailed coronavirus data to the public than many other states. The Health Department currently posts basic data on its website about the total number of positive COVID-19 cases, hospitalizations and deaths.
The agency also shares heat maps showing cases by zip code and bar graphs breaking down positive cases by age group and whether patients are believed to have contracted the virus while traveling or through community spread.
What’s missing are detailed data points that show when tests were performed, how many are still waiting for results and where clusters are forming in specific communities. The state also doesn’t provide any information about how many hospital beds are available, the number of COVID-19 patients in the ICU or the number of people on ventilators.
The amount of coronavirus data public health departments provide online varies from state to state, although all appear to report the number of positive tests and fatalities, according to The COVID Tracking Project, which aggregates data from across the U.S.
In Alabama, for instance, the state’s COVID-19 dashboard breaks down the data by county, gender, age groups, race and ethnicity. The site also shows how many COVID-19-confirmed patients are currently in ICUs and on ventilators as well as the number of health care workers and residents of long-term care facilities, such as nursing homes, who have tested positive for the virus.
Louisiana, where nearly 800 people have died so far from coronavirus, allows the public to see what underlying conditions those individuals suffered from, whether it was asthma, kidney disease or abnormally high blood pressure.
Like Alabama, the state also tracks deaths by race, which revealed that 70% of the people who died from COVID-19 were black despite the fact that black people make up only 35% of the state’s population.
Kentucky, on the other hand, posts sparingly on its COVID-19 website, only showing the total deaths, number of people tested and positive cases. The state also provides a map showing the number of cases by county.
In Arizona, the dearth of details in the data resulted in a lawsuit against the state health department.
The legal action was brought by a number of county officials and one state representative, Kelly Townsend, who demanded the release of basic information, such as the dates and location of COVID-19 cases, the number of pending results and hospitalization numbers including details about how many ventilators were still available.
“There is power in knowledge,” Townsend said in an interview with the Arizona Republic after she sued the state. “We’re not looking to violate anyone’s privacy.”
The Hawaii Data Collaborative is among the groups that would like to see DOH release more information.
Nick Redding, executive director of the nonprofit, says the collaborative started pulling data from the DOH website and combining it with information from other sources, such as Healthcare Alliance of Hawaii, to give the public a clearer view of the pandemic.
The collaborative publishes detailed visualizations that, for example, show the number of ICU beds and ventilators in a given county and map the capacity of hospitals located in the state’s most vulnerable communities that can have higher rates of poverty, more crowded housing and less access to transportation.
“Everything should be public unless there is a specific legal or ethical reason not to make it public,” Redding said.
“The default should be to get as much data out as possible and trust people to be responsible consumers of information. I know at the state they’re going to be concerned about the narrative and people telling stories they don’t want to be told using the data. But that’s going to happen anyway even if the data isn’t there.”
Redding said it’s clear that the DOH and other government agencies are stretched thin, so the question needs to be asked, “How do you draw from the broader community of experts and professionals that can bolster the DOH’s efforts?”
An idea would be enlisting the help of researchers at the University of Hawaii to build models from DOH data that can give decision makers a better idea of the scope and breadth of the virus’ hold in the islands and determine with more certainty whether the state has hit its peak or is still on the upswing.
“The public isn’t just everyday people,” Redding said. “It’s people who are making critical decisions for their businesses, for their nonprofits and how they should donate money, or how they should volunteer their time to help out. All of that is going to go a lot better if they have the data they need to understand what’s at play.”
Anderson pointed out that the DOH recently published an epidemic curve, or epi curve, on its website to show the number of positive cases over time in the state and whether the exposure occurred via travel, community transmission or some other means.
“I don’t feel at all threatened by this, I think it’s important to get feedback from people about what they want to know.” — DOH Director Bruce Anderson
The maps, too, are new, he said, and something that could be updated in the near future to better show which communities are experiencing spikes in confirmed coronavirus cases.
Department of Health officials are currently working on a plan to release more information about the race and ethnicity of individuals who have tested positive for COVID-19, something that Anderson said could provide new insights into where and how the disease is spreading.
“There’s no reason to think that one race can transmit the disease more than any other but obviously there are socioeconomic factors that need to be considered,” Anderson said. “What they’re seeing on the mainland is a clear correlation between those who live in poverty and the increased rate of disease. I wouldn’t be surprised if we saw Pacific Islanders and Hawaiians to be of increased risk because they typically are experiencing adverse health outcomes at much higher rates than others in the community.”
In nearly every instance, the evolution in data delivery correlated with questions from members of the press who were simply sharing the concerns of others in the community who worried about the pandemic and how it was spreading through their communities.
Anderson said he’s now open to the idea of providing more detailed hospitalizations data on the DOH website, although he said that would likely require getting the information from another source, such as the Healthcare Association of Hawaii.
“I don’t feel at all threatened by this, I think it’s important to get feedback from people about what they want to know,” Anderson said. “I think it’s helpful for people to understand what the real risks are and to see it for themselves. It helps to get their compliance and support for whatever decisions we make.”
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