As Honolulu Mayor Kirk Caldwell prepares to begin reopening the economy of the state’s most populous island in a week, there’s one area in which Caldwell says the community is woefully unprepared to manage a potential rise in cases of COVID-19.

Echoing a chorus of other government officials and business leaders, Caldwell says Hawaii has only a fraction of the public health workers needed to quickly track down the folks who’ve been in close contact with those who test positive for the virus.

By Caldwell’s reckoning – and he’s not alone — Hawaii needs hundreds of additional contact tracers for Oahu’s population. It’s not enough to have people on reserve, waiting to be called up and trained when they’re needed, Caldwell said.

Mayor Kirk Caldwell says Hawaii needs hundreds of additional contact tracers to reopen the economy safely. Cory Lum/Civil Beat/2020

Opening safely, he said at a recent press conference, “can only happen if we have in place the components now – not building a plane as we fly – but now.”

Everyone agrees contract tracing is key to safely allowing businesses to reopen and get people going out and about again. It’s necessary to quickly respond to and control any resurgence or community spread.

But state and local officials are publicly disagreeing over when and how to get that element in place — even as Gov. David Ige is already allowing more businesses to get back to work and Caldwell hopes to open up retail and other businesses on May 15.

Department of Health Director Bruce Anderson and State Epidemiologist Sarah Park say the state has enough contact tracing capacity for the current low level of cases. They say they have a framework in place to scale up and train people as needed using existing DOH staff.

But other top government officials like Caldwell and Maj. Gen. Kenneth Hara, who is leading the state’s response to the COVID-19 pandemic as the head of the Hawaii Emergency Management Agency, as well as members of the House Select Committee on COVID-19 Economic and Financial Preparedness say the department is behind the curve when it comes to contact tracing.

Discord Under A Surface Of Harmony

One of the most startling aspects of the divide is that it appears to have come from nowhere — just when it looked like there was unity between Ige’s office, the HI-EMA, Ige’s newly appointed recovery chief Alan Oshima and a public-private partnership consisting of the heads of the state’s major corporations and government officials.

Dr. Mark Mugiishi, the president and chief executive of HMSA, the state’s largest medical insurer, referred to the cohesion when he went over the elements of a recovery plan, which includes contact tracing as a central pillar.

“I think maybe the most important thing I can say today, which is just the best news of all, is that there’s just a lot of alignment and we are coordinating,” Mugiishi said during the meeting on Monday. “All of us together are totally working toward a common solution, which is going to be critical when we start sharing this with the public and helping them to understand what we’re trying to do together.”

But it quickly became clear that the “big boat” that the group said it was trying to build wasn’t ready to sail — and that a key player wasn’t on board.

Carl Bonham, the executive director of the University of Hawaii Economic Research Organization, was the first to assert at the meeting that there aren’t enough contact tracers.

He pointed to the Department of Health’s website, which says it had 30 contact tracers as of April. The department says it now has more than twice that number but since it hasn’t updated its site, Bonham and Caldwell continue to cite the April number.

Maj. Gen. Kenneth Hara, left, the incident commander for the state’s COVID-19 response, said he would ask the governor to order the Department of Health to accept help. Cory Lum/Civil Beat/2020

Regardless, even the revised, bigger number is much lower than what most state and public health officials want. According to standards published by the National Association of County and City Health Officials, which the committee is using, a locale with a population the size of Hawaii would need about 420 contact tracers during a pandemic.

“Having enough trained people to do the contact tracing strikes me as a problem in terms of building the big boat,” Bonham said. “And yet there are thousands and thousands of workers without jobs who have health care training.”

Mugiishi added the University of Hawaii nursing school had offered up several hundred more students with medical backgrounds who could quickly be trained to contact trace.

“I think you all know there’s a little bit of pushback from the Department of Health,” Hara told the committee.

Then Hara dropped a bombshell, saying he was asking the governor to order DOH to accept help to beef up its contact tracing.

“We’re working with the governor to try to convince them by way of a formal order now that this is important,” Hara said.

“We’re all aligned,” Hara added. “It’s just kind of frustrating trying to convince DOH that it’s important.”

Later that day, during a press conference, Ige downplayed Hara’s request. And Anderson said the department has all the contact tracers it needed.

But the next day, Caldwell insisted the state needs hundreds more.

Public Confidence At Stake

The sudden discord at a time when the public is looking for reassurance just as the economy is beginning to reopen has left many people worried.

“Everything is not in place,” said Sumner LaCroix, a University of Hawaii economist who wrote a paper that included a rough framework of what’s become the state’s plan to reopen.

Robust contact tracing capacity is a prerequisite, along with systems to screen and test people who might be sick, and to isolate those who test positive and their close contacts. The idea is to be able to quickly put a lid on the small group of people and not have to close businesses again and order everyone to stay at home.

“We need to up our game in testing, contact tracing and providing isolation for people who have been exposed and test positive,” he said.

“We need to be planning on how we are going to be able to deal with more cases when tourism opens.” UH economist Sumner LaCroix

LaCroix said he would have been satisfied to hear Anderson and Park say they were taking concrete steps to add more contact tracers by a certain date.

But the department’s message has simply been that it has enough people.

LaCroix said DOH needs to be proactive, working toward the ultimate goal of opening Hawaii to tourists.

“We need to be planning on how we are going to be able to deal with more cases when tourism opens,” said LaCroix.

He is one of more than 80 business executives, community leaders and medical professionals who signed a letter that was delivered to Ige Wednesday, urging the governor to follow specific guidelines in order to start reopening the economy. The letter also cited better contact tracing as a key to reopening.

“Contact tracing is a central and essential component of an effective containment intervention and its expansion is critical for success,” the letter said. “Expanded contact tracing capacity needs to precede re-opening to prevent explosive outbreaks as we re-open.”

One of the major issues is that the national criteria for contact tracers, laid out in a widely cited paper titled “Building COVID-19 Contact Tracing Capacity in Health Departments to Support Reopening American Society Safely,” calls for a lot of tracers: 30 per 100,000 of population during a pandemic.

Lt. Gov. Josh Green, who is a medical doctor, cited the paper’s standard during a news conference on Wednesday with Ige. Factoring in hundreds of thousands of tourists per day in Hawaii, Green said the state could need more than 500 contact tracers when tourism rebounds.

“Do I think we have enough contact tracers in place yet?” Green said. “For today we do. We only have one person (as a new confirmed COVID-19 case Wednesday) and we’re only tracing that one person and their close contacts.”

But that will change as Hawaii opens up, he said. “We would need a lot more tracers, as we know.”

Dr. Sarah Park, the Hawaii state epidemiologist, says the Department of Health has enough contact tracing staff to deal with the current level of COVID-19 cases and has a framework for hiring more workers and effectively containing the virus when the economy opens. Cory Lum/Civil Beat/2020

The Framework For Ramping Up

Park, who heads the Department of Health’s Disease Outbreak Control Division, said it is not a simple question of hiring and training a certain number of contact tracers. During a recent Facebook Live event, Park declined to specify how many additional contact tracers she thought the health department needed to open the economy to residents and then tourists.

That’s partly because the answer depends on the number of active cases there are. The number of new cases per day has dropped, from a peak of 30 per day to the single digits, Park noted.

Needs during the peak would be different from now, she said.

There are also other issues that affect the ability to contain the virus, like the extent to which people will continue to stay home and take simple steps like washing hands frequently once things open.

The DOH says it now has 77 contact tracers including 15 unpaid volunteers.

Although that’s far fewer that what Caldwell and others want, Park said it’s enough within the broader context of what’s happening now.

“It’s not about how many more contact tracers do we need,” she said. “It’s more about do we have the framework in place, not just in public health, but throughout society to be able to reopen.”

Concerning the ability to bring on people quickly if cases flare up again, Park used the term “surge from within,” which meant hiring from within the DOH. Park said this could be done quickly, and she said the department is strengthening ties to other institutions that have offered personnel support, such as the University of Hawaii.

While Park said it’s true contact tracing can be laborious, requiring tracking down as many as 43 people in one case, she said the vast majority of cases require far less legwork. The average close contacts is around two people, she said.

“It’s not everyone that has this gargantuan close contact network,” she said.

Still, Caldwell said earlier this week that if Hawaii waits for more cases to flare up it will be too late. Caldwell plans to allow reopening of certain businesses, like retailers, on May 15, with restaurants and others following later.

The additional contact tracers could be paid with federal relief money, the mayor said.

But the big question is still what happens to Hawaii’s tourism industry, which provides about one in six private jobs in the state. Tourists flying in from all over the world pose risks.

For now, a mandatory two-week quarantine for people coming to Hawaii has kept visitor numbers low. But Hawaii’s economy and tens of thousands of jobs depend on throngs of people coming back when the quarantine lifts, and Hawaii has to be prepared for that, the mayor said.

“The only way we make sure that we protect our public is by having many more people hired and trained now and ready to go,” he said.

“As more people come, as they travel, the virus will travel, and it can reinfect our population,” he said. “And we need to be immediately ready when that occurs — to test, to contact trace, and isolate. We need to do it, and we need to do it starting today.”

Civil Beat reporter Eleni Gill contributed to this report.

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