In 2019, Hawai‘i was ranked by U.S. News & World Report as the top state in the nation for health care. Yet, it’s no secret that problems with access to care, affordability of care, and disparities in care remain to be addressed. Now, with COVID-19 spreading throughout the state, the disease is further highlighting some of Hawai‘i’s health care deficiencies.
“With COVID-19, everything is happening so quickly,” said Dr. Jane Chung-Do, associate professor of public health studies. “Public health practitioners, who normally focus on prevention, are spending all of their time reacting to the pandemic. The resulting problems only further expose how broken our system is; the cracks are getting wider.”
Health Care Disparities
According to the U.S. Census Bureau, in 2018, Hawai‘i’s minority population comprised 78.2 percent of the total state population, much higher than the 39.6 percent that comprise the minority population of the United States as a whole.
“Hawai‘i is often portrayed as one of the healthiest states,” said Chung-Do. “But there are significant disparities in health care. When COVID-19 first hit the continental United States, we saw evidence that Pacific Islander communities were disproportionately affected. The same thing is happening now in Hawai‘i. Several months into this pandemic, we’re already seeing pre-existing disparities being exacerbated.”
According to Dr. Keaweʻaimoku Kaholokula, chair of the Department of Native Hawaiian Health at the University of Hawai‘i at Mānoa (UHM), among the hardest-hit are Pacific Islanders who make up 25 percent of the state’s COVID-19 cases, even though they comprise only four percent of the state’s population. People of Filipino descent also suffer disproportionately with 19 percent of the state’s confirmed coronavirus cases.
In a recent paper published in the Hawai‘i Journal of Health & Social Welfare, Kaholokula wrote, “According to the Centers for Disease Control and Prevention (CDC), people with underlying chronic medical conditions, such as obesity, diabetes, asthma, kidney disease, cancer, and cardiovascular disease, are highly vulnerable to severe symptoms and death due to COVID-19 if they become infected. Native Hawaiians and Pacific Islanders have among the highest rates of these chronic medical conditions and associated mortality rates in Hawai‘i.”
However, Chung-Do said, it isn’t necessarily a person’s race that makes him or her more susceptible to the disease. “Although there are some biological and physiological factors that may contribute, they don’t account for all the differences that we actually see,” she said. “People of color are born into racist structures; institutional racism is the root of racial and ethnic health disparities that we see today.”
COVID-19, she added, is revealing that health disparities often occur because of a lack of access to health care, poor education, and language barriers, among other factors. For example, in his paper, Kaholokula noted that 24 percent of the Native Hawaiian population comprises essential workers, including those in the military, security, service, and healthcare industries, and that these individuals are at increased risk of contracting COVID-19 due to more extended face-to-face interactions with patrons and co-workers.
Medical insurance coverage can also be a challenge, especially for older adults. “Since the Great Recession, preventive oral health care benefits have been stripped from adult Medicare recipients,” said Jessica Yamauchi, executive director of the Hawai‘i Public Health Institute. “This leaves enrollees with fewer options for oral health issues. Without oral health benefits, most are only able to receive services in the ER, resulting in either tooth extraction or pain relief.”
Access to Health Care
To ensure that minorities and other at-risk populations have equal access to COVID-19 testing services, the University of Hawai‘i teamed up with the City and County of Honolulu to stand up a new laboratory to serve these communities, the first of its kind at UH. Housed within the John A. Burns School of Medicine, the Tropical Medicine Clinical Laboratory is supported by $4 million in federal Coronavirus Aid, Relief, and Economic Security (CARES) funding given to the City and County of Honolulu. The funding provides for up to 100,000 tests, half of which are diagnostic nucleic-acid tests, which can determine if an individual is currently infected with the virus, and the other half antibody tests, which can show that a person was infected in the past. The lab began testing in October.
“The lab’s primary mission is to provide free testing to underserved populations, including rural, homeless, and uninsured individuals,” said Dr. Rosie Alegado, associate professor of oceanography at UH, director of the University of Hawai‘i Sea Grant College Program’s Center for Integrated Knowledge Systems, and the lab’s community liaison lead.
To get a sense of how many people stand to benefit from the lab, consider that between March 15, 2020 and May 9, 2020 88,807 jobs were lost that had employer-provided health insurance. In addition, Oʻahu alone has about 4,500 homeless individuals, and the rural-designated areas of the County of Honolulu are home to 8,200 people.
“Even for people who do have insurance, asymptomatic testing is not covered,” said Alegado. “This can be a problem for people who work on the frontlines, in the health, service, and tourism industries, for example, and who have vulnerable family members at home.”
To meet the needs of its target populations, the Tropical Medicine Clinical Laboratory is partnering with Oʻahu’s seven Federally Qualified Health Centers (FQHC), which are community-based health care providers that receive funds from the federal government to offer primary care services in underserved areas.
Dr. David Derauf is the executive director of Kōkua Kalihi Valley, a FQHC that serves 50,000 people, many of whom are minority immigrants. “We are in the community that is most adversely affected by COVID-19 right now, whether due to illness or to the economic impacts of the virus,” he said. “Communities like the one I work in are always the ones that are most adversely affected, and yet very little attention is usually paid to them. Our partnership with UH is changing that.”
Alegado said the lab’s activities will complement state and private testing initiatives, and that data from all of the testing facilities will help to track where surges are taking place and support rapid contact tracing and isolation of infected individuals, which will inform public health initiatives.
“Knowledge is power,” she said. “On an individual level, a positive COVID-19 diagnosis can indicate the need to self-quarantine, whereas a positive antibody test may signal that it’s okay to resume normal activities. At the community level, understanding where and when outbreaks are occurring can help government officials implement policies and programs that protect the greater good.”
For the Greater Good
Another public health program that will protect all residents of Honolulu is wastewater testing for SARS-CoV-2, the virus that causes COVID-19. By sampling municipal wastewater, the City and County of Honolulu hopes to spot potential outbreaks before they happen so that measures can be taken to prevent the further spread of the virus.
“Research has shown that people can shed SARS-CoV-2 in their fecal matter and that the virus can be detected in their fecal matter within three days of infection; by comparison, it takes 14 days for people to exhibit symptoms of the infection, at which point they may have been spreading it to others,” said Josh Stanbro, chief resilience officer and executive director of the City and County of Honolulu’s Office of Climate Change, Sustainability, and Resiliency. “Sampling wastewater for the virus can give a snapshot of its prevalence in the community and can give communities several extra days to plan and implement responses compared to waiting for individual test results. Sampling wastewater is also inexpensive because you don’t have to test every individual.”
Dr. Tao Yan, professor of civil and environmental engineering at the University of Hawaiʻi, has been processing wastewater samples collected weekly from around the island. “We’re definitely seeing the virus in the wastewater now,” said Stanbro. “The data are all over the board, but we’re looking for longer-term trends, especially any indications of a potential uptick in cases.”
Health is Relational
Native Hawaiians view good health as a balance, or lōkahi, among the physical, mental, and spiritual parts of a person. A problem with any one part disrupts the functioning of the whole. Key to this balance is a strong connection to family and community. In fact, Chung-Do’s research has found that a sense of connectedness is important for maintaining health and promoting wellness. “Health is relational,” said Chung-Do. “Not just for Native and Pacific Islander communities, but for many communities in Hawai‘i.” She added that because of the social distancing requirements, COVID-19 has taken away people’s sense of connectedness.
A close connection to nature is also important for achieving lōkahi. “In caring for the land, we engage in self-care that is beyond the limited self because land and people are ultimately not separate,” said Derauf.
During the mandated stay-at-home period the virus has prevented people from accessing parks and beaches.“This has been difficult for many people,” said Chung-Do, “especially those who rely on their connection to nature as a way to maintain their health and sense of wellness.”
Chung-Do advised that public health workers should be sensitive to the fact that health is relational. When possible, public workers should be hired within minority and rural communities to serve their own communities. Their intrinsic knowledge of the relationships that help maintain the health of their community can be a major asset.
That is precisely the role of the state’s community health workers (CHWs), frontline public health workers who are trusted community members with a close understanding of the communities they serve. These workers’ goals are to help bridge the divide between health services and communities, increase access to health care, ensure cultural competency of interventions, and build community and individual capacity.
“Community health workers are essential to helping communities understand what COVID-19 is and how to protect themselves from it,” said Yamauchi. “At the same time, COVID-19 has highlighted the value of CHWs in reducing health disparities as a result of their patient advocacy.”
In addition to CHWs, local businesses, nonprofit organizations, government agencies, and community volunteers are stepping up to help Hawai‘i’s hardest-hit residents. One group, led by the Hawaiʻi COVID Collaborative, recently launched COVID Pau, a website that provides residents with real-time COVID-19 health data aimed at slowing community spread of the virus. The website includes expert interpretations of statewide data and video stories demonstrating how Hawai‘i’s families have been impacted by the pandemic.
Another effort, led by Kula No Nā Po‘e Hawai‘i, a nonprofit based in Papakōlea Hawaiian Homestead that is devoted to community health and wellness, is ensuring that community members have the supplies and food they need to stay safely at home during the pandemic. Currently about 250 households, or more than half of the community, are receiving weekly boxes of basic food staples such as eggs, milk, and bread.
In Kalihi, an area in urban O‘ahu hit hard by COVID-19 spread and high rates of unemployment as a result of the pandemic, volunteer groups are working around the clock to serve residents. For example, We Are Oceania is helping community members access unemployment benefits and health insurance; Hawai‘i Cedar Church is providing food to homeless individuals; and Corona Care Hawai‘i is offering fresh local produce to the community.
Despite the tumultuousness that the COVID-19 has brought to Hawai‘i, the state’s residents are coming together to help each other. As Honolulu’s chief resilience officer, Stanbro is well-versed in the many ways in which Hawai‘i’s residents exhibit strength in the face of adversity.
“Community resilience is the ability to survive, adapt, and thrive no matter what challenges we face,” said Stanbro. “Today, our state faces an unprecedented health threat, yet we are working together to protect our community from COVID-19. In the process, we are becoming stronger and more resilient than ever.”
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