When Kauai Mayor Derek Kawakami opted out of the state’s COVID-19 testing program for out-of-state travelers, his decision, which was later approved by Gov. David Ige, was guided in part by an emergency medicine physician who has long rejected the central idea behind the program.

Dr. Darragh O’Carroll and others who are part of an informal group have been speaking out against the idea of requiring only one test for people traveling to Hawaii since before the pre-travel testing program launched on Oct. 15.

Now, despite data that shows O’Carroll’s earlier prediction that the number of cases would have spiked by now simply didn’t come true, his calls are getting political traction.

A movement that started with largely shutting Kauai off to travel is being pushed statewide. Dr. Janet Berreman, a Hawaii Department of Health official allied with O’Carroll, has repeatedly called to suspend the travel program statewide until 2021.

The issue turns on what travelers – visitors, returning residents, transplants and others – must do to sidestep the state’s 14-day quarantine for people arriving from out of state. The current program lets travelers avoid quarantine by passing a COVID-19 test taken within three days of departure on the final leg of their trip. O’Carroll and others want a second test combined with a period of quarantine.

On Friday, a key Senate panel stepped in.

Citing O’Carroll’s article “How Hawaii Can Get Coronavirus Right In 12 Steps,” the Senate Special Committee on COVID-19 asked the governor to require travelers to undergo two tests – one before traveling, a second after arriving in Hawaii – and a seven-day quarantine in Hawaii, regardless of whether both tests come back negative.

That’s significantly stricter than the CDC guidelines the Senate panel also cited to justify the proposal. The CDC says people should take a test before their departing fight, and a second test when they get home, combined with a seven-day quarantine.

The panel wants a response from the governor by 4 p.m. Monday.

In the meantime, Kawakami’s spokeswoman Sarah Blane commended the group including O’Carroll for helping inform the policy on Kauai.

Kauai cases rose from less than one per day on average in October before the travel program went into effect to a peak seven-day average of 3.3 new cases a day on Nov. 25.

“This group has been a helpful partner,” she said. “They have been consistent in researching and sharing relevant health data, as well as viable opportunities for us to keep Kauai safe.”

O’Carroll didn’t respond to repeated interview requests made by email.

Previously Shrugged Off Doctors Now Guide Officials

O’Carroll has come a long way in just a few months in terms of influence. In September, O’Carroll called for all tourists to be required to take a test every day before being allowed to leave their hotels.

“A daily test conducted before tourists leave their hotel could be included in their room fee, and will remove 100% of all arriving infected persons,” he wrote in a Civil Beat opinion piece.

But the effort got little response. The Honolulu City Council, for instance, passed a resolution calling for multiple tests based in part on lobbying by O’Carroll; however, it proved a toothless gesture that Mayor Kirk Caldwell rejected.

But O’Carroll’s ideas didn’t die. Following the win on the Garden Isle, O’Carroll’s paper was cited in an opinion piece in the Star-Advertiser by Dr. Kapono Chong-Hanssen; JoAnn Yukimura, a former Kauai mayor, and Dr. Robert Weiner, a retired surgeon at Wilcox Medical Center and Kauai Veterans Memorial Hospital.

Some of O’Carroll’s main themes are that the number of infected travelers slipping through the cracks is as many as 15 in 1,000, not 1 in 1,000, as Lt. Gov. Josh Green has said, and that the best way to protect Hawaii is to require travelers to take two tests combined with a period of quarantine. O’Carroll writes that a seven-day quarantine would be safest.

Without a second test and quarantine for travelers, he writes, “cases will continue to rise, travel linked cases will seed community spread, tiers will go in the opposite direction, our medical capacity will be surpassed, and most importantly, lives will be lost.”

Berreman, Kauai district health officer, has joined the fight. Her solution: suspend the travel program statewide through December.

But proponents of the current travel plan are pushing back.

Critics Say Analysis Ignores The Big Picture

One argument they make is that metrics like new daily cases and patients in intensive care statewide have stayed level or dropped – even as Hawaii has allowed hundreds of thousands of travelers into the state with a commensurate boost in jobs. That, they say, shows the program is working as planned, allowing the economy to reopen while keeping case counts in check.

On Oct. 14, just 467 visitors flew into Hawaii; the next day, when the program took effect, that jumped to 4,874 and peaked at more than 10,800 on Nov. 21, according to the Hawaii Tourism Authority. Including other travelers, like returning residents and people relocating to Hawaii, more than 443,000 people came to Hawaii between Oct. 15 and Nov. 30, the state reports.

According to O’Carroll, Hawaii should be overrun by cases. In September, when Hawaii was struggling with as many as 300-plus new cases a day, O’Carroll, an emergency medicine doctor who works at Kuakini Medical Center, predicted what would happen by now with just one test.

“Our numbers will exponentially increase within a month of re-opening and return us to where we are now, where I am treating multiple extremely sick persons from the same family in the span of one 8-hour shift, where our hospitals are full past the brim, where we are running out of room to treat even non-COVID-19 emergencies, and our businesses remain closed,” O’Carroll wrote in Civil Beat opinion piece on Sept. 4, a day when 271 new cases were reported statewide.

That hasn’t happened. In fact, there are fewer new cases per day statewide, based on seven-day averages. Since the pre-travel testing program took effect on Oct. 15, the statewide, seven-day average new case count dropped from 89 on Oct. 15 to 86 as of Friday, according to the Hawaii Data Collaborative. COVID-19 cases in hospital intensive care units, meanwhile, dropped from 23 on Oct. 15 to 14 on Dec. 3.

O’Carroll has pivoted to more obscure data to support his thesis. For example, one of his main arguments is to point out flaws in Hawaii’s surveillance testing study, which was meant to indicate how many asymptomatic travelers slipped through the cracks.

But such work misses the big picture, says Na’alehu Anthony, a Native Hawaiian storyteller and filmmaker who heads COVIDPAU.org, which is running a campaign to educate the public about safe practices like social distancing and wearing masks.

“The leading indicators of what is going on are lower in November than in October, when we started this,” said Anthony, whose organization is affiliated with the House Select Committee on COVID-19 Economic and Financial Preparedness. “We haven’t been overwhelmed at our hospitals, our seven-day average is going down, and we’re managing with this terrible virus.”

For Green, the lieutenant governor who designed and implemented the one-test program, it’s an issue of balancing the general well-being of the community, including economic health.

Green notes that almost 48,000 people have visited Kauai as of last week; of those just 58 tested positive, Green said. Meanwhile, he estimates shutting down tourism would wipe out 6,000 jobs. After Kauai’s shutdown went into effect on Dec. 2, passenger arrivals dropped from 1,117 the day before to 110, which included 51 airline crew members.

Green has proposed tweaking the current program to require a second, fast-results antigen test for travelers who already have a negative test upon landing but not a period of quarantine. He said the Kauai mayor’s decision will make it hard for people who lose their jobs on Kauai, and Green said he is concerned that the movement against the travel program will spread to other islands.

“I think the advisers to the mayor did him a terrible disservice,” Green said in an interview on Friday. “And if it spreads to the rest of the state it could have a negative impact on hundreds of thousands of people.”

Some Hawaii epidemiologists also take issue with O’Carroll’s work.

For example, Thomas Lee, a professor of epidemiology at the University of Hawaii Manoa, said in an interview that he agrees with the general idea that two tests are better than one. And he said he originally shared O’Carroll’s concern that just having one test would allow cases to mushroom. But when that didn’t happen, Lee said, it was time to reconsider that hypothesis.

Because he is on active military duty in the Army reserve, Lee said, he could not endorse O’Carroll’s paper, which appears in electronic form on the website Medium.com.

Jennifer Smith, a Hawaii health department case investigator, also questioned O’Carroll’s credibility, saying the paper was not “peer-reviewed,” as it claims.

“Peer-review is a process that a scientific journal follows to make sure that the data and information is rigorously scientifically validated,” said Smith, a virologist who previously revealed flaws in the state’s contact tracing program. “This wasn’t peer-reviewed.”

More important, Smith says, the paper seeks to influence Hawaii policy by pointing to data from elsewhere, which isn’t applicable. She said decisions should be made on Hawaii data, which is not being used.

“We have thousands of data points from here in Hawaii that we can use to make sound policy decisions,” she said.