 I am Vice President and Director of Research at the East West Center and host of East West Center Insights. The Center is a cutting-edge research and capacity-building institution and we're based here in Hawaii and our more mission is to afford a deeper and understanding and connection between the East and the West. So every two weeks here on the show which is a Tuesdays 2 p.m. Hawaii time I have a conversation with an East West Center expert or a guest from our global network about critical Asia-Pacific issues. So check us out at eastwestcenter.org-slash-insights. So our guest today is East West Center Senior Fellow Dr. Tim Brown. Tim is an expert in behavioral epidemiology and infectious diseases and directs the UN AIDS Collaborating Center at the East West Center. He has consulted on HIV AIDS for the World Health Organization, the United Nations Fund for Population Activities, and Save the Children Fund among many others. Tim's expertise as an epidemiologist and I just want to give myself a reward for saying that properly has been a guiding voice for our community amidst this COVID-19 pandemic and has testified before the Health Select Committee on COVID-19. So Tim, Dr. Brown, thank you for joining us today. My pleasure. So your latest research publications called The Fiest Urgency of Now has received quite a lot of media attention at both the state level and the national level and it seems to have catalyzed some state action. So first of all, to kick us off, could you please tell us in your views of what's happening in Hawaii right now and then if you could tell us about what The Fiest Urgency of Now is about. Okay. I think the real issue is that right now we're in the middle of a major public health failure here in Hawaii. We've gone from less than one case per day on average toward the end of May, early June. To over 200 cases per day over the last two to three weeks and this really is just the tip of the iceberg. There are actually many more infections than what we're detecting. I mean, CDC would actually estimate about 10 times as many. So we're actually looking at a significant percentage of the population that's actually probably infected with COVID at this point in time. Now, a number of factors have contributed to this. I mean, there's been inadequate testing and there's been a refusal to test asymptomatic individuals in a disease where 50% of the transmission is occurring from asymptomatics. There's been a failure to set up a contact tracing system, which I think is very well known at this point. And now they're just really getting started on that in the last week and setting that system up. There's been a poorly designed and badly enforced quarantine system. That's been a complete failure, I think, in keeping a lot of people at home. Fortunately, I think most returning residents have tended to stay at home, but those visitors coming in basically have not. And there's also been a complete failure really to educate the public about what the new normal needed to be before we reopen. And so when we reopen, people just assume they could go back to the way they were four months ago, five months ago, and basically just get out there, start socializing, start getting together with their families again. And that basically is what has led to the explosive growth we've seen now. But the fierce urgency of now is really about a crisis within that crisis. So we do have a crisis at statewide level, but within our Pacific Islander community, we have a complete failure to work with them to stand up the resources necessary for them to protect themselves. And can we have the graph? And as you can see in this slide, basically the Pacific Islander community here has about 10 times the infection rate of the rest of the population here in Hawaii. And that really is a major failure within the failure, basically, to stand up the resources that are necessary basically to help these communities to protect themselves. Geez, thank you, Tim. That is quite the picture. And for those of us here in Hawaii, I think we totally agree. I feel like I haven't left the house in five months without exaggeration. But the obvious question is why? Why do these start disparities in terms of access to health care and quality of health care testing rates, mortality rates? Why do they exist for Pacific Islander communities here in the state of Hawaii? Okay, there are actually a large number of factors that have contributed to this. I think a lot of it is that many of the Pacific Islander communities are here under the Compact of Free Association. And that's basically an agreement with their home nations and the United States basically that they can freely move and work within the United States. But the challenge of that is that they've actually always been treated second class by the system as we're forward here. The 1996 Immigration Act basically cut them out of Medicaid. They were no longer eligible basically for receiving public assistance, really for health. The state of Hawaii then picked that up under the MedQuest program. But under Linda Lingle, we basically started to cut that. So Linda Lingle basically cut the MedQuest coverage for these groups. And then that was continued by the Democratic Governors for the next two terms after that. And so as a result, they basically have really been denied access to the public health system, to a great extent. And they've had to rely on community health clinics, which fortunately have been stood up and are doing some great work, working closely with these communities and trying to meet their needs. But especially with the COVID crisis, those community health centers are radically overburdened. They don't have the resources basically for doing the amount of testing that's necessary. The community itself has a number of preexisting health issues that are related to a lot of US nuclear testing and so on that went on, for example, in the Marshall Islands back when we were still doing above ground testing. And this has created a major health need within this community that's been very, very difficult to meet. So I think that, you know, the community clinics being challenged has been part of the problem. I think some of the other difficulties we face here are that these communities are most often taking service jobs and frontline jobs that really put them at high risk of exposure. And then they live in multi-generational households, very often very crowded because of the high cost of living here in Hawaii. And as a result, basically, their potential exposure to COVID is extremely high. So I think those are some of the contributing factors that we've seen here. Yeah, I am being a member of that community by our recent migrants. Some of that is familiar to me, but the part about sort of the structural exclusion in terms of Medicaid is brand new. And I recently saw a study published by the University of Hawaii on that very topic. Is there well known that sort of the insurance issue amongst decision makers, do you think? I think it's well known, but I think it's been a conscious choice. And in fact, personally, I feel it's been a discriminatory choice that we didn't want to basically absorb the needs. The feeling was part of this is a state federal conflict. The state says the federal government should provide for people's needs. The federal government says the state should provide for it. And so they're really just trying to pass off the hot potato to somebody else. And as a consequence, the result is basically people fall through the cracks. The kind of thing that happens all the time. Right. Of course, this is topical right now, not just because of the COVID-19 crisis, but also because the the compact negotiations between the US and the three freely associated states are happening right now. And we'll be happening until the end of the year. So we'll be continuing to monitor that to see if there's any reference to that in the in the new negotiations. But in contrast, what's happening here in Hawaii, there are currently 10 countries in the world that are still free from COVID. And all of those countries are in the Pacific of Palau, Marshall Islands, FSM, Nauru, Kibbus, Samoa, Tonga, Tupalu, the Solomons and Vanuatu, I thought it was worth naming them all. And some of them are very small populations like Kibbus and Palau, and some of them are much larger like the Solomons. So, you know, why have those 10 nations been so successful at combating COVID-19 and predicting their populations? And yet Pacific communities here in Hawaii seem to be left behind by the state? I think there are several factors. I think first is those nations recognized very early on that they had limited healthcare infrastructure and resources, that they often had crowded living conditions, and that because of their comparative isolation, they were particularly vulnerable to infectious disease. And you know, and then, for example, in Samoa, the measles outbreak that occurred toward the middle to end of last year, basically, I think I kind of prepared them for an infectious disease outbreak. And so they were very concerned. I think they took these issues very seriously right from the start. They were some of the first places in the world, basically, to stand up entry restrictions. In fact, the Marshall Islands put the first travel ban in place on January 24. That's right. And Federated States of Micronesia followed shortly and expanded that travel ban, where I know as of March, they were already banning people from 84 countries. And basically, they've been very good about that. They've respected their travel ban. And they've made it very difficult for people to come in from the outside, which has helped to keep their their island nations COVID free. So I think they've also done things that sometimes were against their economic self interest. The Cook Islands, for example, actually banned cruise ships. You know, they they, by March, I know they had kicked they had basically refused 11 cruise ships permission to dock. And that hurt them economically, obviously, because they're very dependent upon that tourism. But at the same time, it kept them safe. And I think that's one of the really critical issues there is they recognized that they were vulnerable to this. And they took the measures necessary to protect themselves. So I think they have successfully kept COVID out. Yeah, I would agree. I think people think of those sorts of Pacific Islands as a really small population. And that and therefore the decisions are not as difficult for say, like, like the US or the state of Hawaii. But in the Cook Islands, example that you mentioned, something like 70% of its GDP is generated from tourism dollars. So it was a massive decision to make. And they yeah, and they certainly have seemed to have benefited in terms of the lives of their citizens. But coming back here to Hawaii, I'm not sure if you saw this for three days ago, the news outlet Politico published an article called Paradise Lost, which is questioning why things have gone so wrong here in Hawaii. So the article described Hawaii as a as a cautionary tale. And now the US Surgeon General is here ramping up testing. And actually, it looks like you and your colleagues really have focused the minds of those who make decisions and actually catalyzed action. So I wanted to congratulate you and all your colleagues in terms of research for that. Thank you very much as a as a citizen here living in Hawaii. But your research has not just focused on identifying problems, you also focused on finding solutions. So right, and in all the COVID articles that you publish this year, I noticed that you were quite particular about listing policy recommendations. So can you share your thoughts about what you think needs to happen now? I think if you actually go back to our earliest paper that we put out back in April. Fundamentally, the policy recommendations we made then are the policy recommendations that still apply today. The first is we need to move from a reactive to a proactive stance. We need to get ahead of the virus, not constantly try to be playing catch up with it. That means we need to anticipate where it's going to go and we need to get there first. Now, we should have done that, for example, with Pacific Islander communities. We knew that the health care issues within the communities, we knew the housing problems. Many of them are in public housing, which we know is overcrowded in general. And that's obviously been an issue. And from the very start, we were recommending that surveillance be stood up in those public housing units in the nursing homes, in the prisons. And fundamentally, the Department of Health failed to do that. You know, even when they found infections in nursing homes, they would only test a relatively small percentage of people within the nursing home when they should have tested everybody else. But then fortunately, normally, the nursing home would bring in external testers Scott Miskovich and his team, for example, Holly Nani, who would then come in and would test everybody else within the building. But Department of Health would restrict it to know we're only testing within the ward where the infection was found. And that's obviously not a very proactive approach. That's very reactive. And it's help you really need to control the spread within those nursing homes. As a consequence, we've now had at least 94 infections. As of a couple days ago, that was the number of nursing homes in Hawaii. That never should have happened. We should have been had an eye on that. We wouldn't have over 340 people infected in the prison system right now. Had we done what was logical? But no, instead of observing the 14 day quarantine on intake for incoming prisoners, basically, oh, we're too busy, we have too many people coming in, we're going to cut that short and put people into general population without completing the quarantine. And as a result, we now have on the order of 340 something infections within the prison system, both staff and prisoners. And that never should have happened. That should have been averted if we were being proactive about this. We said, before reopening, three things really had to happen. You had to stand up a solid contact tracing system. Okay, that would test all close contacts and get services to them to cut off the chains of transmission. Because having a contact tracing system that reaches people five days or six days out is too late. Right. It has to reach people within 24 hours. And we said this back in April that this needed to be stood up and we know what happened. It never happened. Do you think people understand why it's too late? You talked about there's not enough information. It's not the best of upskilling education, educating the public. Do they, do you think people understand like what's happening in that time why it's so devastating? I don't think a lot of people understand that. I think, you know, the real issue there is the timeframe on which this virus operates. Basically, you're infectious with this virus from about two days before you start to show symptoms until seven or eight days after you show symptoms. There's about a 10 day window there. Right. When people are infectious with this virus. And a large number of people remember never show symptoms. 40% CDC estimates never show any symptoms at all. But they're still infectious. They can still spread the virus. So if we're not testing, we're not finding those asymptomatics. And if we're not doing contact tracing quickly, right, if we get the test result back five or six days later before we actually start to contact close contacts, then basically we let the infections continue within the community for that entire period of time. That's why speed is of the essence here. You know, in countries like New Zealand, basically, yes, you know, almost 100% are reached within two days. And the vast majority 80% are reached within the first day. And that's what we should have been setting up here, but we didn't. Right. And that should have been coupled with wide testing, testing of asymptomatics that we refuse to do. I mean, when one of the kids tested positive at one of the summer schools, the family members and the other children could not get test unless they had symptoms. And that was just idiotic, because basically we allowed transmissions probably to occur within those families without intercepting them. And that's a real issue. Why was that, Tim? Is it a rule? Is it a state rule? Is it something to do with the insurance not covering it? It was a foolish adherence to early CDC guidance, which was wrong about not testing asymptomatics, which CDC eventually changed, but now they moronically have changed it back. And I say moronically, because every public health official in this country will tell you it was a bad decision on CDC's part. And in fact, you've seen that criticism in the media. And when you don't test asymptomatics in disease where 50% of the people who transmit disease are asymptomatic, you're not going to pick up that half of the transmission. And so you forego any opportunity basically to stop it. And so it's really an abysmal failure. And the adherence to that held within our Department of Health long after CDC even had changed their own guidance in terms of testing asymptomatics. And it never made sense from day one, even for CDC. But CDC, I'm afraid, has been compromised by the Trump administration and is no longer really representing the interest of public health, at least at the front-facing side, are really reflecting the needs of the Trump administration, not of the American people. And so given the state of things now here in Hawaii, I mean, is it possible to get back on track? I mean, can we still, can our leaders here in the state of Hawaii follow the lead of the Pacific nations or New Zealand's and even possibly eliminate it again or get in front, like you said? I think it is. But we basically need to set those systems up that we described early on. We've got to get a solid contract tracing system with the number of contact tracers that people talked about on the order of 400 contact tracers. So that basically we can reach people within 24 hours, that we're not waiting five days, six days, and in many cases never reaching people. We know of far too many people who have tested positive. I mean, I know one woman, her son had dinner with her. He tested positive for COVID, so she was a close contact. She self-isolated for two weeks. Neither her son nor her ever heard from Department of Health through that entire period of time. I mean, that's the kind of contact tracing we've had so far. We need real contact tracing. That is serious. And when we get contact tracing, it needs to get people into quarantine and isolation. And when people are there, they need to be contacted on a daily basis by Department of Health to make sure that they are adhering to the quarantine. Because adhering to the 14-day quarantine is critical to not allow the spread of COVID within the community. So we've got to stand that system up. Now, the good part is we're starting to see some steps in the right direction. The contact tracing is obviously being set up and stood up at the Convention Center. The National Guard have been pulled in and are already actively doing contact tracing. That's a good thing. The Mayor has offered to hire 250 to 400 contact tracers and provide them to Department of Health. That's also a good thing. Yes. On the quarantine side, the Mayor has been working basically to identify contracts with hotels that will provide the opportunity for quarantine for people from crowded households. So many of our Pacific Islander households when a member of the household test positive, they could be moved out of the household and moved into quarantine. And that in a separate location where they basically no longer run the risk of transmitting further within the household. But to do that we've got to test everybody within the household because we need to know who's infected and who's not to get all the infected cases out of the household as quickly as possible. And so I think, you know, we need again to expand our testing and we need to get, you know, make sure we do not refuse to test asymptomatics any longer, especially in household settings. There it's absolutely critical. But I think if we do those things, yes, we can get this under control. But the other thing we've got to do, and this is really critical, is we got to be straight with the people on where this epidemic is and be very transparent on what our plans are for dealing with this. Okay. I don't ever want to hear this was expected about 200 cases a day from anybody ever again. Yes. Which is what the Department of Health has been spouting for the last four to five weeks. No, it was not expected. Personally, what I expected is New Zealand. I expected us to be seeing zero cases a day until we opened the tourism and then I expected a strong enough testing and contact tracing operation and quarantine operation that we would control the introduction from tourists. We didn't get that. Okay. And we need to be transparent with people. The state auditor tried to get the Department of Education to tell him what their plans were basically if they detected positive children or positive teachers in schools, they wouldn't provide it to him. And they won't give it to the state auditor. The parents here in Hawaii have no clue of what Department of Education and Department of Health have planned for them when they send their kids back to in-person schooling. And I'm sorry, but I believe that people have the right to that knowledge so they can make informed decisions about whether or not to send their children into a potential risk situation. Not to mention potentially expose themselves and their grandparents and others to extreme risk because we know now, you know, the evidence is very clear now, children can transmit COVID. In fact, younger children can even transmit COVID at higher rates than older children. So it absolutely is a major issue. Transmission will occur within the schools and we need to have a plan for dealing with that. And that needs to include if a kid tests positive in one class, every other kid in that class needs to be tested. All of their families need to be offered testing and have testing available to them. And that needs to be in a solid plan that is available to the public so people know what to expect because if we're not being transparent about our responses, we're being unfair to people. I would agree. And what can parents and interested people, teachers, for example, do other than utilize their right to vote? I mean, should they be writing to their congressman, writing to the senator, writing to the DOA, trying to DOE? I think be writing to the governor. I think the governor is the one calling the shots on this. I would flood the governor's mailbox and email box basically with messages saying, look, we want to know what's going on here. Stop keeping us in the dark. Tell us what's actually happening within the schools and what's going to happen. And that's true of all the plans for responding to this. Tell us the truth about what's happening with contact tracing. Give us the statistics on what's actually happening with quarantine. How many people are taking advantage of the quarantine opportunities at the hotels? How many people are getting tested daily and how many asymptomatics are being tested? We should start tracking that information so that people have a clear picture of how the response is working here and what's really happening because I think until we're transparent with the people we're not going to be able to get them on board to support us. Right now they get conflicting messages from everybody. They have no idea what to expect. I think everybody would agree with you Tim and in terms of your your plea to tell us the truth. And I think I mean it's such a it's a key sort of cross-cutting intersectional issue. Even at the East West Center, those who have, those of our staff who have children are like directly impacted. Firstly they're concerned about their kids but also it impacts their ability to work. So you know I have found the sort of the school policy and the opacity around the plan is just really difficult to understand and certainly in contrast with the more successful jurisdictions for example like New Zealand. But to change tack just because we're getting towards the end and I've always wanted to ask you about what you've spent the bulk of your career actually actually researching and contributing to since you you run an entire regional center funded by UNAs at the East West Center. So and I wanted to tie it in to the research you're currently doing about COVID-19 and then also particularly about Pacific communities. So I'm not sure if many people know but over the last year they've actually been three major disease outbreaks across the Pacific. The measles which you mentioned earlier and then Hawaii actually made a really significant meaningful contribution to helping Samoa in particular fight measles. I think Lieutenant Governor Josh Green and a whole collection of doctors traveled down to Samoa, a friend of mine, she's the head of Pediatrics at Queen, she traveled and I still I always like to mention them and give them a shout out because I'm Samoan and it's something really tragic like 70 79 babies died and that so it was a real tragedy. So I'm grateful to the State of Hawaii for that but there was also a major dinghy fever outbreak in the marshals and of course it's COVID-19. So given that you've spent your career fighting another disease, HIV, AIDS, what are some of the lessons and I think this might be a last question that you was telling me, what are some of the lessons that you learned that can help leaders here respond effectively to COVID-19? Well I think the first lesson is to listen to the communities that are affected by any disease. They know their situation, they know what their problems are, they know the things that keep them from taking preventive measures, they know the things that expose them to greater risk. That knowledge resides within the community. It does not reside among outsiders and so it really is critical to listen to the communities and use their knowledge basically to guide the response. That also means putting them at the core of the response. They need to be co-equal leaders in terms of any public health response that has stood up. They need to be part of that, they need to be providing the leadership, they need to be working with their own organizations, with the agencies for example community health centers that work with them and helping them, you know, helping them basically to implement programs within the community. That way the community is engaged, the community becomes more aware, they become much more active and they're addressing their own problems and ultimately the solutions really have to come from within the community. And the third thing I think we've learned in HIV is that you've got to address all of the different factors that keep people from protecting themselves. That goes far beyond just the public health factors. It's not just a question of getting access to test. It's a question of having the economic ability basically to stop working for two weeks if you need to go into quarantine to protect the others in your household. You need to have the access basically to those types of quarantine settings. You need to be able to get your boss to allow you off work for two weeks without losing so much income that basically you can no longer put food on the table. Those are the types of things that need to be part of a comprehensive solution. So it goes far beyond just the public health side. It's got to deal with the socioeconomic factors and the other cultural factors that may actually inhibit effective responses within the community. And again unless you're working closely with the community you can't do that. And so I think for example for the Pacific Islander communities right now I know one of the questions that was proposed was well how do we address that when we come out of lockdown? I would say we don't address that when we come out of lockdown. We need to address that before we come out of lockdown. The needs of those communities are even potentially being exacerbated by the lockdown. They're in crowded housing settings. So if we're locking them down in those crowded housing settings with somebody with COVID we're potentially spreading the virus. So we need to get the testing in there now not after the lockdown is over. We need to get the testing to those communities now. That's why I'm glad to see for example they're testing in Kalihi. That's good you know but it's not enough you know we need to expand that testing make it and we need to move that testing into the households if necessary. So I think you know we need a vastly expanded response basically for those communities even before we come out of lockdown. If we wait till we're coming out of lockdown it's too late. Well Tim thank you very much for coming on the show again and on behalf of the East West Intercommunity but also our community here in Hawaii. I just wanted to thank you and your colleagues for the contribution that you've made for doing what you can to help keep us safe. Thank you very much and take care out there. Oh my pleasure and everybody stay safe.