On March 1, Governor David Ige extolled the state’s Safe Travels program, saying “Hawaiʻi is still the only state in the nation to have implemented such a program that we know has saved lives.” He urged residents to keep taking COVID-19 seriously, mourned the continuing mortalities as a “tragic loss to our community,” and concluded that “If there is one thing you can take away from today’s announcement it is this: The pandemic is not over.”

This rhetoric made it all the more shocking that the purpose of his press conference was to actually announce the ending of the—in his words—uniquely effective Safe Travels program, which required incoming travelers to quarantine if they weren’t vaccinated against, or hadn’t tested negative for, COVID-19.

A week later, Ige would announce the end of the state’s indoor mask mandate while simultaneously (and correctly) emphasizing that “masks are still an important tool in preventing the transmission of COVID and other respiratory viruses.”

One must wonder about this confusing logic. If the state’s pandemic mitigation policies are so successful—according to state leaders themselves—why end them at such a delicate moment before the pandemic has truly abated?

“Another COVID-19 surge is not some abstract likelihood, but something that already looks predictable in the near future,” Governing reported on March 21. “And the general political message of the moment – that the pandemic is receding into the rearview mirror – is making people complacent heading into potentially a dangerous time.”

Protective policies didn’t deter economic recovery, nor were residents asking for them to end

Since the beginning of the pandemic, state leaders have often said there is a need to “balance” public health and the economy, as if they weren’t inextricably intertwined.

Yet the state’s last remaining protective measures were evidently no deterrent to our economic recovery. In January, the state’s Council on Revenues “more than doubled its forecast for Hawaiʻi’s general fund tax revenue for this fiscal year,” as Hawaiʻi Public Radio reported.

Perhaps most significantly, domestic passenger arrivals have recovered and are already above pre-pandemic levels, according to the state Department of Business, Economic Development & Tourism. In fact, DBEDT Director Mike McCartney noted that “Visitation by the U.S. visitors has been surpassing the 2019 levels since May 2021.” (International travel has not yet recovered, but Safe Travels doesn’t impact foreign visitors, who “must still adhere to federal entry requirements,” including vaccination and testing, and their own countries’ policies, as the Star-Advertiser reported.)

It shouldn’t be surprising that COVID-19 mitigation measures would be not only a precondition for tourists to return, but in fact an incentive. State leaders recognized this as early as May 2020, when the Star-Advertiser reported that “plans are already in the works to begin marketing the state to tourists as ‘the safest place on earth.’” Far from being a barrier to visitors, the Safe Travels program allowed domestic tourism to surge to pre-pandemic levels while minimizing the virus’s ability to enter the state.

There was also no apparent community groundswell aching for the end of pandemic protections, unlike in other states. In fact, most Hawaiʻi residents seemed to be happy with them. On March 11, the Star-Advertiser conducted an informal online poll asking, “Will you continue wearing a mask routinely even after March 25, when Hawaiʻi drops its mandate?” Only 21% of respondents said “no.” A majority, 57%, said “definitely,” and the remaining 23% said they would wait and see.

These are similar figures to public opinion polling conducted by Civiqs, which has asked “How satisfied are you with your state and local government's current response to the coronavirus outbreak?” since March 2020. As of the most recent data on March 24, 56% of Hawaiʻi residents were “completely” or “mostly satisifed.” (The only subgroup that was mostly dissatisfied was Republicans.)

Ige himself observed this community coherence in his March 1 press conference, where he praised residents’ “willingness to put the community ahead of private interests,” saying this led to the “best outcomes in the nation, amongst the lowest COVID infection rates, and the lowest death rates in the country.”

It’s not just Hawaiʻi residents who prefer protective policies. Nationwide, recent polls have also found that a majority of Americans support policies “trying to control the spread of the coronavirus, even if it means having some restrictions on normal activities.” A plurality would also support “a policy that made it mandatory to wear masks in public indoor places,” even though such policies had already ended in other states.

Protective policies rapidly ending statewide

A handful of protective policies still remain, like the state’s indoor mask mandate for public schools and the federal government’s mask mandate for public modes of transportation, including TheBus and airplanes. (The latter is set to end on April 18, though on March 23, several airline CEOs, including the head of Hawaiian Airlines, asked the federal government to end it “now.”)

But many other protective policies have already ended with similarly abstruse logic, like the City and County of Honolulu’s Safe Access Oʻahu program. Until March 5, Safe Access required those entering high-risk indoor businesses like restaurants and gyms to show proof of vaccination or a negative test for COVID-19.

As Safe Access ended, Mayor Rick Blangiardi acknowledged that “we know [it] helps spur vaccination levels” and without the program, there would likely be “less incentive” for people to get vaccinated and boosted. Indeed, Safe Access was “largely supported” by the restaurant industry, Hawaiʻi News Now reported.

The city’s popular sidewalk dining program also inexplicably ended on March 5, which restaurateurs had praised and hoped would become permanent. “Most of the guests are choosing [outdoor dining] because it’s a safe option today,” one proprietor told Hawaiʻi News Now after the city abruptly disallowed sidewalk dining. (Indoor dining is inherently more conducive to COVID-19 transmission because of the virus’s airborne nature, and with few exceptions, there has been little effort to systematically reduce risk and improve indoor air quality.)

Counties are scaling back or suspending their free COVID-19 testing operations. And as of March 25, residents statewide can no longer create digital vaccination records, nor access their previous records if they weren’t properly saved, due to the state’s curious decision to host those records on the Safe Travels platform, which was taken offline.

Aesthetic of “normal” shouldn’t supplant necessary precautions

Hawaiʻi, of course, is not alone in ending its protective policies; most states and the federal government are curtailing mitigation measures and funding.

But although the “worst of the Covid-19 pandemic may be behind us … pretending that it is over will not make it so,” the New York Times Editoral Board wrote on March 26. “In the face of this uncertainty, it would be reckless for the government to reduce its efforts to minimize new cases and help those who fall ill.”

Local experts are echoing this concern. Infectious disease expert Tim Brown told the Star-Advertiser he would “strongly recommend that people keep masking indoors” and said the Department of Health should go back to daily COVID-19 updates, instead of weekly. “People are tired of COVID, but that doesn’t make COVID any less dangerous going forward,” he said.

Daniel Ross, president of the Hawaiʻi Nurses Association, told Hawaiʻi News Now that with Safe Travels ending, it could “bring new variants to Hawaiʻi.” Libby Char, the Department of Health director, also acknowledged that “what we're worried about is the next surge related to another variant.” When asked if she expects an increase in COVID-19 cases with the ending of the indoor mask mandate, she responded, “I sure hope that it doesn’t increase.”

Across the country, “many people said they feared dropping their guard now only to invite a pernicious new variant to dash their hopes yet again,” the New York Times reported on March 10. “Some said that loosening restrictions would actually make them feel less secure about going to supermarkets or bookstores, driving them back into their homes. … Parents of children younger than 5, who are not eligible to be vaccinated, said they had been left exposed as the restrictions lapsed.”

Instead of “using this lull to prepare for the future,” as Governing recommended, leaders are encouraging an aesthetic of pre-pandemic “normal,” characterizing caution as “fear” and fixating on “personal responsibility” without giving residents the tools they need. Nobody wants to repeat the past two years of the pandemic, which is why the rush to drop protective measures at such an uncertain juncture remains mystifying.

For better or worse, we live in a society where other people’s actions inevitably affect us. Although there are important actions we can take as individuals to protect our health—and the health of our community and economy—there are some things only governments can do. At a minimum, our county and state governments should at ensure residents have the tools they need to really take “personal responsibility.”

Increasing access to vaccinations, and promoting booster doses, is a good start, but it’s clear it’s not enough. So let’s steal these ideas that other cities, counties, states, and countries have already put into place:

1. Educate the public about how COVID-19 spreads in shared air. Not enough people realize that enclosed, poorly ventilated spaces are inherently riskier because of COVID-19’s airborne nature. With more accurate information, people can make better decisions.
2. Provide free high-filtration masks. Many may not realize that cloth masks aren’t enough to protect themselves and limit community spread. N95 masks do a far better job at protecting the wearer and reducing transmission from infected people — and they can be quite comfortable.
3. Provide free rapid tests. At-home antigen tests can reliably tell people if they’re contagious at the moment they take the test. This is especially important if someone is infected but asymptomatic. However, they’re prohibitively expensive for many people.

“With good ventilation, filtration, and masking, it’s easy to get a factor of 100 reduction in [COVID-19] dose,” Boston University professor and environmental health expert Jon Levy tweeted in December. “In the coming weeks, you will be in a room with someone with #COVID19. But that doesn’t mean you will get infected. The dose makes the poison, so your goal is to reduce your dose as much as possible.”

Those three ideas are discussed in greater detail below. And it’s important to note they’re not alternatives to more comprehensive public health measures. Systemic solutions would be ideal, including temporarily limiting indoor gatherings, as Hawaiʻi County has done; monitoring and improving indoor ventilation; moving high-risk, unmasked activities like dining to the outdoors; and ensuring all workers have paid sick leave, so they can afford to stay home when they or their kids are sick.

Paid leave, in particular, is something we really ought to ensure. Only 45% of Hawaiʻi’s leisure and hospitality workers have paid sick days, and service industry workers face systemic workplace risks and disproportionate exposure to COVID-19. When Governor Ige was asked back in August how working parents could keep their sick kids home without paid leave, he said he would be “sending a letter to CEOs [asking them] to be supportive,” but “it’s not a mandate.” A bill was introduced in the 2021 legislative session to ensure workers have paid sick days, but it died without a hearing.

The pandemic should have taught us by now that individual actions are not enough to fix systemic problems. “Structures inform our individual decisions every day, and…system-informed free will has real human consequences,” a February 2021 article in Slate argued, noting that “limiting one’s own public interaction is a privilege only afforded to the upper and middle classes.” This focus on individual actions creates inequities that “yield disproportionate COVID-19 disease, disability, and death in oppressed and excluded communities,” a recent paper noted, and comes at the cost of “the kind of collective actions we need to actually defeat an infectious disease,” Pulitzer Prize-winning journalist Ed Yong recently observed.

But at a minimum, since “personal responsibility” is now the primary policy for most of Hawaiʻi’s population, then residents need to understand how the virus is actually transmitted, be able to properly protect themselves in high-risk indoor environments, and have access to rapid tests with actionable results.

It’s like when you get into a car: Making good decisions is necessary, but not sufficient, to drive safely. We also ensure safety through government-mandated protections like seatbelts, airbags, and stoplights, and we drive confidently with a collective understanding that government requires—not merely encourages—everyone else to follow the same rules of the road. In other words, the government creates the conditions that allow individuals to take “personal responsibility.” We should do the same with the pandemic.

1. Educate the public about how COVID-19 spreads in shared air

By now, there is a firm scientific consensus that the virus spreads in shared air, even across distances greater than six feet. This means COVID-19 is spread more easily in certain settings, particularly indoors, including closed spaces with poor ventilation, crowded places, and close-contact settings—also known as the Three Cs.

But public messaging often continues to emphasize handwashing and sanitization of surfaces, which of course are important in general but not really relevant to how COVID-19 spreads. With an extremely transmissible variant like Omicron, it seems paramount that people actually understand how the virus spreads, and thus gain a better intuition about identifying risky situations.

State leaders are increasingly acknowledging the virus’s airborne nature, as I noted back in September, and encouraging people to spend time outdoors or ensure indoor spaces are well-ventilated. But this message needs greater attention and consistent reinforcement.

In November, the UK launched a media campaign, “Stop COVID-19 Hanging Around,” which demonstrates the “importance of simple ventilation techniques to reduce the risks of catching COVID-19.” Researchers there found that:

… almost two-thirds (64%) of the public did not know that ventilation was an effective way to reduce the spread of COVID-19 at home. And only around a third of people (29%) are currently ventilating their home when they have visitors over.

It’s a simple, memorable, and immediately actionable message:

Other videos show a simulation of COVID-19 particles building up in an enclosed space and emphasize the importance of fresh air in restaurants.

Perhaps most notably, Japan popularized and emphasized the Three Cs model from the very beginning of the pandemic. They also created a video illustrating five situations made inherently risky by the Three Cs:

Standout media coverage on this issue includes “A room, a bar and a classroom: how the coronavirus is spread through the air” (October 2020) and “Why Opening Windows Is a Key to Reopening Schools” (February 2021).

2. Provide free high-filtration masks

The time has come to upgrade our face masks. This is a clear recommendation from health experts. As New York Magazine wrote recently, “high filtration respirators like N95s or KN95s — which are quite comfortable, provide gold-standard protection against airborne particles, and have been widely available from reputable sellers in the U.S. for a long time — are what everyone should now be using and what every institution should be making available.”

Dr. Tim Brown from Hawaiʻi’s East-West Center echoed this message at the end of December and suggested that the state provide them for teachers and students. The state could go further and follow Connecticut’s lead, which recently announced plans to distribute 6 million N95 masks—enough to give each resident about two masks. It’s not just happening on the state level: In New York alone, a public school district, a county, and New York City all handed out N95 masks. Milwaukee is distributing 500,000 N95 masks, and LA County will require employers to provide high-quality masks to workers in high-risk environments.

Salt Lake County has taken an even stronger stance: It will require people to wear N95 or KN95 masks indoors in public. It’s also providing free N95 and KN95 masks at senior centers and libraries.

High-filtration masks are important because they provide a high degree of protection for the wearer. They substantially reduce “the chance of becoming infected with Covid-19 while in close contact with someone who has the disease.”

Linsey Marr, “one of the world’s leading experts on viral transmission,” told the New York Times that:

If I’m in a situation where I have to rely solely on my mask for protection — unvaccinated people may be present, it’s crowded, I don’t know anything about the ventilation — I would wear the best mask in my wardrobe, which is an N95. We need to wear the best masks possible in high-risk situations.

N95 masks are now widely available. I’ve been getting the 3M 9205+ Aura Particulate Respirator from a local distributor, Aloha Mask, which lists them at $1.75 each. I actually find this model quite comfortable—even more so than cloth masks—and others have agreed. (In fact, the FDA cleared similar models for “use by the general public in public health medical emergencies” in 2008, according to 3M, but they were “discontinued in 2013 following a long period of inactivity.”) One could imagine that the purchasing power of a county or the state could make them even more affordable to purchase and distribute on a large scale. The nonprofit Project N95 also helps local and state governments source authentic products.

High-filtration masks can even be reused “many times” until “they are dirty, damaged or difficult to breathe through,” according to 3M’s helpful guidance on respirators for the general public. The inventor of the N95 mask material suggested having three or four masks could be enough, if you use one per day and rotate them, because “SARS-CoV-2 viruses on the mask will be dead in 3 days.”

3. Provide free rapid tests

Rapid antigen tests help people answer a critical question with a high degree of accuracy: Am I infectious right now? They can be taken at home—before heading out to work, school, or a social gathering—and produce results in about 15 minutes, whether or not you have symptoms.

If everyone used rapid tests regularly, they could be a “good way to see who is infectious and who can return to public life,” as Zeynep Tufekci recently wrote. Back in February 2021, an article in Nature argued rapid tests could “help to curb the pandemic by quickly identifying the most contagious people, who might otherwise unknowingly pass on the virus.” Researchers believe a significant proportion of cases are unwittingly spread by infected people who don’t have symptoms—a problem that may be exacerbated with Omicron.

But there’s a big problem. Rapid tests are pretty expensive (about $10-12 per test) and, especially during the Omicron-driven surge, hard to find. For families who can afford these tests, the costs are quickly reaching hundreds of dollars, the New York Times recently reported.

Although President Biden pledged to make 500 million rapid tests available to the public, that quantity is only enough for an average of 1.5 tests per person. Here in Hawaiʻi, Maui County has twice distributed at least “a few thousand” tests, which is a commendable start. (Also, last fall, the state Department of Health participated in a federal pilot project that distributed free tests to 125,000 Oʻahu residents.) Governor Ige told the Star-Advertiser today that the state is trying to procure rapid tests but “can't find a vendor who wants to sell it to us.”

The current surge underscores just how valuable rapid tests could be. Hawaiʻi’s county and state governments could follow the lead of others across the country distributing free rapid tests. This is just a small sampling:

• Washington, DC: Residents can pick up two kits (four tests) per day at public libraries — there’s even a live inventory tracker
• Washington: 5.5 million rapid tests
• New York City: 500,000 tests
• Sacremento County: 91,000 tests distributed at public libraries
• Miami-Dade County Public Schools: Tests available for students and employees
• Select airports (though none in Hawaiʻi so far)

Even these laudable efforts pale in comparison to other countries. In October, CBS reported that in England, “they're readily available at pretty much every pharmacy in the country. Anyone can just walk in and ask for them – and they're completely free, usually distributed in boxes of five or seven. You can go back and get as many as you need.” You can even order one free pack (seven tests) per day right from the government. In Singapore, the government “began mailing out six rapid test kits to every household in September” and in Canada, “businesses can request free rapid test kits for their staff,” according to The Independent.

The free mass PCR testing sites organized by the state, city, and private partners continue to provide an important diagnostic service. And rapid tests aren’t perfect. A negative test “should not be used as a ‘green light’ to act as if you definitely don’t have Covid,” nor “stop exercising caution in crowded spaces,” a British expert recently wrote in the New York Times. “It can make activities much safer, but not completely ‘safe’ from infection risk.” But he continued:

… when these tests are cheap and easy to get and use, they can greatly help aid or even replace reliance on expensive and often time-consuming PCR test screening programs in communities, especially in places like schools. If rapid tests are used immediately before an event, like a holiday gathering, they can lower risk of infections and make gatherings safer. Using rapid tests regularly should become a social norm. … If you want to maximize the benefits of rapid testing, take your test immediately before going out, not the day before.

December 1, 2021

AP: “Hawaii: Petroleum detected in tap water near Pearl Harbor”

December 3, 2021

Today Show: “Military families without clean water, sick after petroleum detected in water near Pearl Harbor”

NBC News: “Navy finds drinking water well near Pearl Harbor contaminated with petroleum”

December 4, 2021

Fox News: “Hawaii military families complain of chemical smell, oily sheen in tap water as jet fuel leaks into supply”

December 5, 2021

CNN: “Honolulu shut down its largest water source in Oahu due to reported contamination of Navy well near Pearl Harbor”

The Hill: “Honolulu shuts down water well amid fuel contamination concern”

December 6, 2021

USA Today: “Navy suspends use of military tank farm above Hawaii aquifer after petroleum leak”

Fox News: “Hawaii governor urges Navy to suspend operations at World War II-era fuel tank amid water contamination”

AP: “Navy halts use of fuel storage complex above Hawaii aquifer”

December 7, 2021

Today Show: “Watch Hawaii military mom's heartbreaking plea for answers over toxic water”

ABC News: “Navy ordered to suspend operations in Hawaii following water contamination”

PBS NewsHour: “Navy's water contamination flub in Hawaii follows 8 years of warning signs”

Washington Post: “Water contamination at Pearl Harbor in Hawaii forces over 1,000 military families from their homes”

CBS News: “Hawaii health department issues emergency order after petroleum products found in Navy water system”

Business Insider: “Hawaii governor orders the Navy to shutdown its WWII-era fuel storage facility at Pearl Harbor after petroleum leaks into water supply”

CNN: “Hawaii health officials order Navy to clean up contaminated drinking water after families are forced out of their homes”

AP: “Navy contests Hawaii’s orders to suspend, drain fuel tanks”

December 8, 2021

CNN: “Navy says it will pause operations at Hawaii fuel site linked to tap water contamination”

ABC News: “Navy shuts off 2nd well in Hawaii following water contamination”

December 9, 2021

CNN: “'We've often been viewed as expendable:' Failed infrastructure is to blame for Honolulu's water crisis”

The Hill: “Navy says petroleum contamination detected in second water source in Hawaii”

AP: “Navy halts Hawaii fuel tank operations during investigation”

December 10, 2021

CBS News: “Hawaii residents could be displaced for 6 to 8 weeks amid water crisis, Army officials say”

CNN: “Navy reports contamination at a second water shaft servicing Hawaii base, state officials say”

December 11, 2021

New York Times: “In Hawaii, Fears Grow Over Unsafe Levels of Petroleum in Drinking Water”

AP: “Navy blames Hawaii water contamination on jet fuel spill”

Axios: “Navy's polluted water forces Pearl Harbor families from homes”

December 13, 2021

AP: “Navy dive team is trying to remove fuel from Hawaii water”

December 14, 2021

AP: “Defense secretary monitoring Navy fuel spill in Hawaii”

December 15, 2021

NPR: “Thousands displaced from Oahu military base due to contamination in Navy water system”

On December 6, Navy Secretary Carlos del Toro said Red Hill fuel tank operations were suspended on November 27. Back on December 1, the Navy disclosed said it had shut down its Red Hill water shaft on November 28. Yet on November 29, the Navy still said its water was safe, amid public outcry.

This newly revealed order of events raises some pressing questions: What did the Navy know, and when did they know it?

I compiled this timeline to start making sense of the timing of the Navy’s disclosures. (Click here for the version on Twitter.)

On December 7, after I compiled the timeline, the Navy said it would fight the state’s order to suspend Red Hill operations and de-fuel the storage tanks.

It is now extremely well-established scientifically that COVID-19 spreads in shared air — across distances greater than six feet in enclosed spaces. But public recognition of this fact still lags, probably because of messaging that counterproductively suggested the main risk lies in shared surfaces and short-range transmission.

The latest Hawaiʻi Department of Health cluster report, published on October 28, 2021, continues the reports’ laudable trend of attempting to correct this public misunderstanding. The October 28 report centered on a cluster of “30 COVID-19 cases associated with an elementary school on Oʻahu.”

In its investigation, DOH found that the school did take multiple steps to mitigate risk, including “mask wearing, physical distancing, and student, faculty, and staff screening and testing on campus.” One thing the school did not do? Ensure proper classroom ventilation. “Teachers were reported to be keeping windows and doors closed to limit outdoor noise levels, and to maintain the central air conditioning,” according to the report.

In response, “DOH provided the school with options and guidance that would improve classroom ventilation,” according to the report. “Implementing techniques to improve airflow in classrooms, in addition to the core essential strategies, adds an extra layer of protection to prevent the spread of COVID-19 between students.”

This is not a surprise

Earlier this year, the New York Times published a story about this exact scenario, with the headline “Why Opening Windows Is a Key to Reopening Schools.”

The article simulated what would happen in a classroom with just nine students, all sitting six feet apart, wearing cloth masks, similar to the Oʻahu school described in the DOH report. Yet “[w]ith all of the windows closed, the room would lack sufficient ventilation. That’s a problem with an airborne virus,” the article points out.

In this shared-air classroom environment, where about “3 percent of the air each person in this room breathes was exhaled by other people,” an infected student’s virus-laden particles quickly envelop the room — even reaching students more than six feet away.

Just opening one window makes a huge difference in the article’s simulation, getting the classroom to four air exchanges per hour. Adding a fan and air cleaner with a HEPA filter gets the classroom to six air exchanges per hour. (“The Healthy Buildings program recommends four to six air exchanges per hour in classrooms, through any combination of ventilation and filtration,” according to the article.)

“It has been shown that the virus remains viable in suspended particles indoors for more than an hour,” said University of Wisconsin-Madison professor Timothy Bertram. “In rooms with good ventilation and/or in-room filtration, the amount of virus present in the air may be cut in half in less than 10 minutes. For rooms with inadequate ventilation, this time could be more than an hour.”

To clean the air, it is key to use a proven technology like HEPA (“High Efficiency Particulate Air”) filters. Some schools are using pseudoscientific “ionizers” that may sound cool but are, at best, ineffective and at worst, actively harmful. The Hawaiʻi Department of Education published a memo in September 2021 warning schools not to use unproven ionizers, and just use tried-and-true HEPA filters instead.

Vaccination remains fundamental

With the approval of the first COVID-19 vaccine for children ages 5-11, vaccination can now play a key role in mitigating risk for younger kids — both in the classroom and in the greater community. The DOH cluster report affirmed that its number one risk mitigation strategy, shared with the DOE, is still “vaccination of eligible students and staff.” Of course, not all children will be vaccinated immediately, so other mitigation strategies — like improved ventilation and/or air filtration — are also essential.

Yes, this is a workplace risk as well

In September, I wrote about the disproportionate risk of COVID-19 exposure that Hawaiʻi’s essential workers face in the workplace. But the risk of transmission via shared air in poorly ventilated indoor spaces is present for office workers and other professions, too.

In September, the New York Times published an article, “6 Questions to Ask About Covid and Air Quality at Work,” which suggested that “[a]sking about efforts to improve indoor air quality can help you make decisions about how much time you might spend there, whether to mask up or buy a portable air cleaner or whether to change your work schedule or work from home, if it’s an option.” Those six questions, which largely mirror the factors identified in the classroom simulation, are:

1. What improvements have you made to the ventilation system?
2. Can the windows be opened?
3. What is the air change rate?
4. Are you using portable air cleaners?
5. Who is monitoring air quality?
6. Does the building rely on unproven technologies?

Some may note that there’s no suggested question about plastic barriers. This is because those plastic barriers can actually “change air flow in a room, disrupt normal ventilation and create ‘dead zones,’ where viral aerosol particles can build up and become highly concentrated,” according to recent research.

If this seems like a workplace safety issue, scientists are increasingly agreeing. “Ventilation is really built into the approach that OSHA takes to all airborne hazards,” Peg Seminario, who “served as director of occupational safety and health for the A.F.L.-C.I.O. from 1990 until her retirement in 2019,” told the New York Times in May. “With Covid being recognized as an airborne hazard, those approaches should apply.”

This raises the question posed by a September article in The Atlantic: “We don’t drink contaminated water. Why do we tolerate breathing contaminated air?” The article notes that this goes beyond just COVID-19: “We’ve long accepted colds and flus as inevitable facts of life, but are they? Why not redesign the airflow in our buildings to prevent them, too? … SARS-CoV-2 is unlikely to be the last airborne pandemic. The same measures that protect us from common viruses might also protect us from the next unknown pathogen.”

More context on Hawaiʻi public schools

How are schools doing overall? After COVID-19 case reports peaked in late August with a daily average of 96 cases, they reached a low in mid-October, then have been steady at about a dozen daily average cases for the past week.

I continue to update my public school COVID-19 tracker daily. Unfortunately, the Department of Education’s Data Governance and Analysis Branch doesn’t provide its case data in a spreadsheet format, unlike the Department of Health, so I continue to maintain a specialized program to analyze the DOE data.

Much of the discourse around COVID-19’s spread in Hawaiʻi has centered around the risk of tourists bringing the virus into the state. But less attention has been paid to the tourism industry — specifically, the risk of COVID-19 exposure that hospitality and food service workers face at their jobs.

Hawaiʻi has a disproportionately high number of non-healthcare workers at high risk of workplace exposure to COVID-19 — perhaps the largest share of any state — according to my analysis of publicly available data. Although many employers may be taking precautions, Hawaiʻi Department of Health reports have confirmed that some types of workplaces are still a significant source of transmission. This prevalence of systemic occupational risk undermines the notion that “personal responsibility” is enough to stop the spread of COVID-19, and underscores the direct connection between individual health and economic health.

Nearly 3 in 5 Hawaiʻi workers (outside of healthcare) have jobs with high degrees of workplace risk factors, according to state-level employment data applied to a framework published in March 2021 by the Council of State and Territorial Epidemiologists. Those risk factors — “routine in-person interaction with the public,” “working indoors,” and “working in close physical proximity to others” — are most common in the “essential” jobs that generally can’t be done from home. (In this framework, healthcare workers are presumed to already have high occupational risk for COVID-19 exposure.) The researchers write that understanding workplace risk factors is essential to “protect workers and, in turn, the communities in which they work and live.”

This aligns with the Hawaiʻi Department of Health (DOH) cluster reports, which have frequently homed in on transmission at workplaces — the same ones that the CSTE methodology considers high-risk. The reports frequently discuss clusters initiated between employees at high-risk occupational settings, including:

• Restaurants and bars (November 27, 2020; April 22, 2021; June 3, 2021; July 8, 2021; July 22, 2021; September 2, 2021; spread among restaurant patrons was also discussed on February 11, 2021)
• Hotel and accommodation settings (January 28, 2021; July 22, 2021)
• Construction and industrial settings (January 21, 2021; May 20, 2021; July 22, 2021)
• Agricultural settings (February 4, 2021)

Indeed, 26 of the 31 DOH cluster reports in 2021 include clusters at restaurants, and 24 reports include clusters in the “travel, lodging & tourism” category. (In comparison, 23 reports include clusters attributed to social gatherings. The most frequently mentioned cluster category is correctional facilities. Educational settings are also mentioned in 26 reports.)

California researchers have also found concrete evidence of the importance of workplace COVID-19 transmission. A groundbreaking study published in June 2021 found that COVID-19-related deaths in California were linked to occupational risk. “Our analysis of deaths among Californians between the ages of 18 and 65 shows that the pandemic’s effects on mortality have been greatest among essential workers, particularly those in the facilities, food/agriculture, manufacturing and transportation/logistics sectors,” wrote the researchers.

High-risk jobs — in service, hospitality, and other industries — share common factors

The risk of transmitting COVID-19 is highest in closed spaces with poor ventilation, crowded places, and close-contact settings, particularly if people aren’t wearing masks and aren’t vaccinated. These systemic, occupational risk factors are often out of the control of the workers who are most affected, such as cooks, housekeepers, food suppliers, and construction workers. It’s not hard to imagine why certain occupational settings present a higher intrinsic risk, even though some businesses may already be implementing mitigation measures. The DOH cluster reports provide some anecdotal insight:

Restaurants and bars: “Cooks and other kitchen staff often work in more cramped conditions and spend longer cumulative periods of time in close contact with their coworkers … Working for long periods over a hot cook line can also make it difficult to fully comply with mask mandates. If a few employees call off work, short-staffing can add further risk as remaining employees may be forced to cross-cover multiple roles leading to increased mixing among staff.” (April 21, 2021)

Hotel and accommodation: “Hotel workers might come into contact with the virus when in close contact … with other people at work, which can include both guests and coworkers. Because hotel industry employees have contact with travelers arriving from parts of the world that may be experiencing outbreaks of COVID-19, concern is heightened that those working in and adjacent to the hotel and accommodation industry could be a source of local outbreaks if they contract COVID-19 at work and then transmit it to household members and other community contacts.” (January 28, 2021)

Construction and industrial: “Their occupations can require sustained physical exertion and working in uncomfortable environments … Workers reported hot temperatures, poor ventilation, and removing their masks due to uncomfortable conditions inside the building. In addition, workers reported not being able to physically distance the recommended 6 feet while working and not practicing social distancing during lunch.” (May 20, 2021)

Agriculture: “Workers in these settings often have close and prolonged contact with one another in the fields, during breaks, when sharing transportation, or in shared housing. Depending on the setting and type of work, shared housing or transportation services for agricultural workers may be provided or arranged by the employer, a contracted service, or by the employees themselves.” (February 4, 2021)

The occupational risk framework from the Council of State and Territorial Epidemiologists characterizes about 13% of non-healthcare jobs as having the highest risk factors for workplace COVID-19 exposure. These are jobs in which employees work in very close proximity to others (either coworkers or the public), primarily indoors, and in public-facing roles. This category includes the jobs described above — like waiters, food service workers, cashiers, and hotel clerks — along with retail salespeople, teachers, and child care workers.

Hawaiʻi has a disproportionate number of workers employed in those highest-risk jobs, my analysis shows — over 30% of non-healthcare workers, which is again the highest of any state.

Another factor worth considering is a lack of paid sick leave. Research consistently shows that low-income and service-sector workers are less likely to have paid sick leave. A 2019 study found that just 45% of “leisure and hospitality” workers in Hawaiʻi had paid sick days. (There’s no national paid sick leave policy, and most states — including Hawaiʻi — don’t mandate paid sick leave, either.) “Given that many of these workers are also perilously close to a financial cliff, they face a strong incentive to work even when sick,” Daniel Schneider, a sociology professor at UC Berkeley, noted in 2020. Even though the pandemic hasn’t ended, the social safety net is already being scaled back — expanded unemployment benefits have ended, the state eviction moratorium has expired, and few isolation and quarantine units are available.

Workers have voiced similar concerns, like this fast food employee in California cited in a 2021 report: “Even though there have been many cases of COVID-19 among coworkers at this McDonald’s, I have never been notified that I was in close contact with anyone. This does not make sense to me because I work in the kitchen, and the kitchen is small, so we cannot maintain physical distance. And [others] also work in the kitchen with me, and they all had COVID-19.”

(Under the American Rescue Plan Act, certain employers that voluntarily provide workers with paid sick and family leave related to COVID-19 can receive federal tax credits to offset their costs. However, those employees are not entitled to paid leave — employers must opt-in — and these tax credits are also expiring on September 30.)

Finally, researchers argue that occupational exposure helps to explain racial and ethnic disparities in COVID-19 cases and deaths. One study found that “[p]eople of color were more likely to be employed in essential industries and in occupations with more exposure to infections and close proximity to others. Black workers in particular faced an elevated risk for all of these factors.” This was echoed by the California excess mortality study, which found that “[b]oth Black and Latino workers experienced substantial excess mortality during the pandemic.”

This is also true in Hawaiʻi: Native Hawaiians, Pacific Islanders, and Filipinos, which have been disproportionately affected by COVID-19, “are more likely than other racial/ethnic groups to work and live in environments that increase their risk of exposure to COVID-19,” according to a March 2021 report published by the DOH. “Collectively, these three groups make up nearly half of the essential workforce in Hawaiʻi, especially in the tourism, hospitality, retail, and food industries,” the report continues.

Reiterating those concerns, the Council of State and Territorial Epidemiologists paper suggests that policymakers take into consideration occupational risk factors to reduce health inequities:

“Given that people of color are disproportionately employed in service and manufacturing occupations, which unlike many professional jobs, cannot be conducted from home, this information is also critical to reducing health inequities. … These jobs are often precarious, low-paying, and lacking in social benefits. Fear of job loss, economic need, and lack of paid sick leave are disincentives for staying home when workers fall ill or are exposed to SARS-CoV-2. Lack of health insurance may prevent infected workers from seeking health care, delaying treatment, and leading to more severe disease. Language barriers, poor working conditions, and concerns about immigration status may also lead to disparities in morbidity and mortality. It is critical to consider ways to assure equitable and effective application of interventions across all populations.”

Vaccination, ventilation, and other mitigation strategies

Early, anecdotal evidence suggests that the burgeoning vaccination mandates for workers in, and patrons of, high-risk industries appear to be successful in giving people the nudge they need to get vaccinated, which is increasing vaccination rates. The COVID-19 vaccines, which are safe and effective, are the cornerstone of protecting individual workers in risky occupational settings, along with their families and communities. New federal rules requiring employers to provide paid time off to get vaccinated, and requiring employers with 100 or more employees to ensure their workers are vaccinated or tested recently, should also increase uptake. Wearing a mask — which has steadfastly remained a requirement under state policy — is also fundamental.

Over the past year, the Hawaiʻi DOH cluster reports have suggested additional mitigation strategies that employers can implement. Improving ventilation has been a frequent suggestion. For example, the April 21 report noted that “[b]ecause the physical layout of restaurant kitchens and the nature of prep and cooking work make physical distancing difficult, other mitigation strategies, such as engineering controls, adequate ventilation and proper mask usage, need to be applied in combination to the greatest extent possible.” The July 8 report also highlighted the risk of an “enclosed kitchen with poor ventilation and limited ability to physically distance,” as did the latest report on September 2, which cited “tight working spaces with poor ventilation, which probably contributed to the spread of COVID-19.”

DOH cluster reports also identify “employee work breaks” — when co-workers may eat and socialize without masks or physical distancing — as risky. Echoing CDC recommendations, the DOH writes that employers should “close shared employee spaces such as break rooms.” The CDC has recommendations on improving ventilation for workplaces in general and for restaurants specifically, and as I noted earlier this month, Hawaiʻi Governor David Ige has started emphasizing the risk of enclosed, poorly ventilated spaces. Some local restaurants have already started improving air quality.

Across the country, state-level data that analyzes COVID-19 cases by occupation or industry appears to be rare; more data could also provide more actionable insight. Washington released a report in December 2020, which found that the “health care and social assistance” industry had the highest percentage of cases, followed by retail, manufacturing, agriculture, construction, and accommodation and food services. This aligns with the California excess mortality study and the framework from the Council of State and Territorial Epidemiologists.

Technical notes: Data on workplace risk by state

In March 2021, the Council of State and Territorial Epidemiologists published a framework for “identifying occupations in which workers when present in the workplace are likely to be at increased risk of exposure to SARS-CoV-2.” Specifically, the CSTE paper focuses on non-healthcare workers, as state and federal authorities already consider healthcare workers to have a high risk of exposure. The authors identified three occupational factors that contribute to risk of exposure (“routine in-person interaction with the public,” “working indoors,” and “working in close physical proximity to others, either co-workers or the public”). They then scored about 700 occupations using those risk factors using data from O*NET, “a national database with information on occupational characteristics.”

The CSTE paper analyzed national employment data and suggested that “[s]tates electing to make use of [this framework] should consider using state level workforce estimates.” Such state-level workforce estimates from every state except Maine is available from the Projections Managing Partnership; Maine data is available through its state website. These workforce estimates use pre-pandemic data.

The maps in this blog post use that state-level employment data, categorized by the CSTE framework. Specifically, both maps use “Close Proximity Measure 2,” which combines O*NET scores with expert review. (Download the CSTE paper for more explanation about their methodology.) The first map uses all occupations in “high exposure combinations,” or “[o]ccupations designated as having the highest exposure level for at least two of the three exposure measures.” The second map uses occupations in “Combo 1,” which have the highest exposure levels in all three measures. The underlying data for both maps is available here.

The CSTE framework estimates risk for about 89% of all workers nationwide. The framework excludes 106 healthcare occupations (about 10% of workers) and another 47 occupations missing from O*NET (about 1% of workers).

The CSTE researchers note the limitations of their approach, such as a lack of data on “duration of exposure or population density in a work environment” and “what protective measures are in place.” This framework also does not analyze every single occupation. However, they note that this approach has nonetheless “proved to be a valuable method in occupational epidemiology in the absence of individual exposure data” and should be considered “baseline information on the potential risk of exposure to SARS-CoV-2 at work.”