Episode 3 – Health & Wellness, CHANGE Event Series, Part 1

(01:21) Steve Petranik: Mark, I’m going to start with you. Some people with tickets to today’s event did not come. We were almost sold out. So you can see there’s a lot of empty seats, I’m guessing, because of a fear of the Coronavirus. I don’t want that topic to dominate our conversation, but I think we need to address it. Please tell me briefly, what are the main things individuals can do to protect themselves and their families, their children, and their friends?

(01:49) Mark Mugiishi: I think to understand that, the first couple of things to understand is that COVID-19 or this Coronavirus that we’re dealing with right now is an infectious respiratory virus. So the way those types of virus’ spread is they tend to spread the droplets. So if someone coughs or sneezes, that droplet will hit your hand or a surface, or your face, and it will enter through a mucous membrane like your eyes, your mouth, your nose. So if you are either too close or if you’re not careful about where you touch it, then you touch your own mucous membrane. You can catch it.

This is the way you prevent getting any of these respiratory viruses is to be careful with hygiene and all of that. But the reason why this one is a little bit more concerning is there’s a couple of reasons. One is we actually don’t have enough information to know how lethal it is.

We know how many people in the world are kind of getting critically ill or dying from this. We don’t know the denominator. How many people are actually sick. We’ve been unable to get that. So until we know that, we don’t know how lethal it is. The other thing that’s important to understand is this is what’s called a novel coronavirus, which means it’s mutated and it’s the first time the human species has seen it. Usually the biggest barrier to these infections is that we have our own natural immunity.

We’ve been sick before. We’ve had the flu before. So even if we get it weeks, to some degree, we can fight it. We don’t have that built up yet. Everybody, all the human beings are what we call “naive.” Their immune systems have to learn that this is foreign and that you have to fight it. And because of those two reasons, it’s important that we are especially careful about the preventative hygiene methods that usually prevent respiratory infections. That’s washing your hands very, very carefully, washing down surfaces, avoiding social events that are unnecessary, especially large ones.

Besides the standard hygiene, I think the biggest advice I can give to everybody is analyze your movements with a risk-benefit, approach to everything you do. Why am I doing this? Is it worth it? What’s my risk? So if somebody actually, as is older and has chronic medical conditions, their risk is always going to be higher. So something better be a really big benefit before they do anything. And if not, then don’t do it. Stay home.

For younger people, you would have a different risk benefit analysis. But you should start, I think, to protect your family. You should start having this conversation in your head before you do anything. And then that will help you decide what to do.

(04:43) Steve Petranik: Mark, we have a lot of leaders in this auditorium, people who have to think about themselves and also their employees. What about workplace risk analysis?

For instance, some people, to do their job really well, they have to be in the office. Others don’t. Can you take us through some of those things that leaders should be thinking about?

(05:11) Mark Mugiishi: Sure. Mitigating the spread of this does involve, as I mentioned, standard hygiene and also what we call social distancing. So keeping people far away from each other so that they can’t, you know, spread it.

So if if you have employees who are capable of working from home, you should look at that, right? And the most important thing, if somebody is actually sick, tell them to go home or tell them don’t come to work in the first place.

And that is a communication, a message that you have to communicate over and over and over again, because so many people in Hawaii are used to just saying, “oh, I’m just a little under the weather, I’m going to come to work.” That’s not okay now. So we have to keep over communicating that if you are sick, you should stay home.

You know, we’re we’re a health organization, so we have to balance people who have to take care of our population, that have to take care of the people. We can’t all work from home because we have to be there when the people of Hawaiʻi need us.

So, again, we’re doing risk benefit in our own organizations of who has to be there and who can work from home.

(06:21) Steve Petranik: Jill, we were talking about this earlier, but this is a crisis. It’s officially a pandemic now. But we can learn from crises. Can you talk about some of the things we’re learning and maybe some procedures, some methods that are accelerating because of this crisis?

(06:40) Jill Hoggard Green: Yes, thank you. And I really appreciate Mark’s update.

And it’s critical that we do everything we can not to spread the disease at this point. And we know that this is an unprecedented time and we’re seeing a disease emerge. So there’s lots of things we need to learn. But some of the things that are really critical that actually can be beneficial to us is first, it’s really enhancing our collaboration.

Whenever you look at an emergency, the more we collaborate, the more we communicate, the more we’re going to figure out what’s the best thing to do and how to do it. And we always find innovation in that.

So what I’m watching already is the health systems. We’re having conversations, whether we’re competitors or not. We are working together to make sure that we’re doing the right things for all of us to serve you well.

You’ll see at Queen Sale System, we’re putting up tents in front of Queens at Punchbowl so that you can come up and get your testing if your doctor recommends you to have the testing. The rapid kinds of ways we’re working on testings.

If you looked at testing and you were tested for COVID-19 four weeks ago, it took about two weeks before we’d had the test results. Now that’s down to three days. I’m hearing and I was on a call this morning with CDC and FDA where that speeding up and very rapidly, it’s going to be quite accessible and very rapidly. That level of innovation doesn’t happen that rapidly without something that says we need it and we need it now, and let’s all of us work together.

I’m seeing how are we thinking about the best way to make sure that we care for you in your home. So we all have talked about telemedicine and telemedicine is critical. It’s always been critical on the island. Right now, it’s even more critical. You can, by way of your phone with several of our providers, do a FaceTime, and they could actually help you identify. Should I be coming into the clinic or is this likely to be a cold and I can care for myself at home?

We do telemedicine between our hospitals and our ED’s every day. I think what you’ll see leapfrog over the next couple of weeks is a lot more virtual and telemedicine happening in our daily work, which will continue after the pandemic is is over.

There’s lots of innovative ways that we can improve care. There are lots of ways that we can work together even more effectively and have better care the way you want it, and when you want it. Now’s the time to make sure that we’re communicating effectively, that we’re doing things virtually when we can and making sure those basics are being done in terms of helping you stay healthy. And the last thing that I’d like to share is it’s critical for us to make sure that our caregivers are saying safe and and able to deliver the care.

If we look across the world at that pandemic. So we’re spending a lot of time making sure that we’re doing every innovation we can to keep them well, which means they should stay home if someone’s sick, even though we want to be there to take care of anyone. We’re doing everything we can to keep people well. If you come into our hospitals right now, we’ll actually ask you, do you have any symptoms? We’ll be checking your temperature. And we do it for all of us to make sure that if we have anything at an early stage, we’re not spreading that as we do this work.

(10:21) Steve Petranik: And I’m guessing those innovations that are happening now after this crisis pass passes, you will be able to use them in order improve care in other ways?

(10:30) Jill Hoggard Green: Yes, no question. And again, go back to telemedicine and virtual care with telemedicine. Yesterday I saw one of our clinicians who was, of course, an island away doing care within five minutes with a patient that had a stroke and that made a difference in her outcome. And she got best care, even though she was coming to a small critical access hospital.

Telemedicine, as we’re using it now to get virtual care, I think will become a way that we’ll probably do about 30% of our care three to five years from now. So I do believe that this is a time of importance, that we’re working together, that we’re communicating, and that as a community, we look for every way possible to make sure we’re addressing your needs and using the technologies and creating technologies to help us do that better.

(12:13) Steve Petranik: Keawe, the average Hawaiʻi person, the Hawaiʻi resident is among the healthiest people in America. But there are groups in Hawaiʻi who suffer far more from chronic diseases than the average person. And there are underlying causes for that. Can you explain what the the underlying causes are for those disparities?

(12:34) Dr. Keawe Kaholokula: Sure, I can explain. Let me first explain what our health disparities we face. It is actually defined by federal law. Health disparities are differences in the prevalence, incidence and risk factors of diseases or illness across different populations, many subpopulations.

For example, differences between ethnic groups, difference between native Hawaiians and whites on diabetes risk, difference between urban versus rural people, difference between those who are wealthy versus those who are economically challenged. That’s what we mean by health disparities that differ across ethnic groups.

We hear a lot about biological and genetic determinants. and a lot of the dialogue is really around that –the resources, funding and research have been really focused on the biological and genetic determinants of risk. But what’s often ignored is the social determinants of health.

So in Hawaii, like everywhere else in the U.S., what determines risk for chronic disease especially and differences between ethnic groups and other subpopulations really are different. It has to do more with whether we have livable wages, whether we can actually afford to own a home or rent, whether we have access to quality public education. All these things really contribute to a health and well-being. Education when the strongest predictors of health and wellness and longevity in the U.S.

Numerous studies show, for example, incomes, associated with education and income predicts longevity. There’s been a study that was published across all 50 states. The data was collected, including Hawaiʻi, and across all 50 states the more you made, the longer you live. We also see income benefits among low income women as far as adverse health outcomes and other things. Those are examples of how health disparities really work.

So we talk about diabetes and heart disease. You know, we got to talk about preventing that and it’s avoidable. So the thing about health disparities, they’re avoidable. Infectious diseases are a little different. Okay, let’s talk about chronic disease, heart disease, diabetes. They are avoidable.

(14:44) Steve Petranik: And those are going to kill a lot more people than this virus.

(14:47) Dr. Keawe Kaholokula: Sure. Yes.

(14:50) Steve Petranik: And so so you’ve explained these underlying factors. What are some first steps we can take to deal with these underlying factors and move forward? And, you know, you talked about so many things like the the income and the education. They often we we talk about zip code, that your your health is determined by your zip code because those things align with education and income.

(15:11) Dr. Keawe Kaholokula: Yes. So, you know, some of the solute potential solutions. So right now, we’re talking about raising the minimum wage to $15. Right? The plan is to raise it to $15 in a couple of years from now. It was supposed to be $15 several years ago. $15 is no longer a livable wage.

So we really need to move today to increase the minimum wage and look at livable wages. And it’s a political decision. I know there is some contention around this. The idea is that a lot of small businesses especially will feel the burden of higher salaries and so forth. But studies after studies of states that have moved towards livable wages $15 an hour show that more people make, the more they spend, even poorer people. So it does have a benefit to the overall economy. So all those concerns can be addressed with some good data from other states.

The other thing is we need to invest more in our public school systems. Most of our people at risk for chronic disease and native Hawaiians, other Pacific Islanders and Filipinos are more likely to be educated in our public school systems than in private schools. And we need to strengthen our public schools. We have great teachers, great administrators, but they need the resources to make the schools great and really reduce the burden and make sure they have quality education comparable to private schools. I think that is another potential solution.

Another thing we need to do is look at the communities and really address some of the issues. Waiʻanae really has no legal sidewalks and no median strip. The highest pedestrian fatalities, head-on collisions in the state is in Waiʻanae, an economically lower community area. Go to Kahala, Hawaiʻi Kai, they have sidewalks you could play handball on

median strips you can play football on. That’s an affluent community. That’s a political decision. That’s a resource allocation decision. And because of that, more native Hawaiian men, young men especially, are dying before their time in Waiʻanae. That could be solvable. Those are the things we’re talking about when we talk about health disparities and social determinants of health.

(17:17) Steve Petranik: Well, that’s a good segue to ask Rich a question. You agree that that a narrow focus is is not the solution to these health disparities. So you run the why not Coast Comprehensive Health Center? Talk about your more holistic efforts in health on the one I coast.

(17:36) Richard Bettini: Yeah, I’d like to do that but I’d like to tie this back to the first question about the virus, because there’s a linkage here. I was on the phone today with a good friend of mine that runs the health center in Chinatown in San Francisco. And you know, what he told me is that their visits have dropped off 40%.

And, you know, at the Waiʻanae Health Center, we do 220,000 clinical visits a year and two thirds of those are the people in poverty. And I want to make a point that how you address health disparities, how you address health indices, how you address messaging when it comes to change is different when you’re in a community like Waiʻanae.

So we looked at four things and how we’re going to respond to this virus. And of course, we’re doing the telehealth. I signed a contract last night that will be operational in two months. But the more provocative thing is how do we get the message out? And my friend, I followed up with some texting to him and I said, “well, you’ve got a 40 percent drop in visits. How many of your patients have been diagnosed?” Zero. I said, “Why is that? Now, I know that most of your patients are Chinese or they have families in China. There’s a lot of that communication.

He said, “Yeah, that that was a major factor. But the real factor is a lack of trust in who’s delivering the message.”

In Waiʻanae, I come up with some ways to get the word out and I’ve got some of my staff here and they came up with the extraordinary idea. On Monday, March 16, we’re going to be launching a message referral system, using our friends from the community and people that know the meaning of messages that we convey, that we do it in the right way, that it’s positive and we address fear.

So I did want to say that we are doing things like telehealth. We are very, very satisfied with the leaders of this state that are taking care of supplies and materials. They’ve been fabulous with us. I think we got the right team in the state to address it. We just have to get into some of the refined, sometimes not realized consequences when somebody loses 40 percent of their visits. And yeah, maybe we can capture half back through telehealth.

We really do need to look at how we can maintain a revenue stream, cash flow, keep people employed. And so that’s our big challenge right now. I’m going to tie this back to the social determinants and to the great opportunity we have right now. We’ve got a fabulous waiver from the federal government to begin supporting the social determinants of health. And we have really good partners to do that.

Dr. Mark Mugiishi has been fabulous. HMSA has basically said to us, “you guys know how to address this. We’re going to invest some funds in you addressing, you know, the social needs. But you’re going to have to prove to us that it has an effect on outcomes.”

And so we really respect that point of view, trusting the local community to solve its own problems. So I’m very hopeful because of that.

(20:53) Steve Petranik: And you’ve talked to me about data before. You want to operate more like a business and sort of looking at the data. What is success? And you say that in the Medicaid system, some of the money is not effectively spent because of the system. Can you talk about that?

(21:09) Richard Bettini: We’re talking about a program that’s a billion dollars a year. That is opportunity money. And I think we need to refine our metrics on how that’s used, what influence it has.

We need to really change how we do risk stratification, where the dollars are allocated. We all need to be better at that. We’re working with fourr other communities in the state, low income Hawaiian communities to aggregate data, to put together accountable care dashboards. And we need to prove to the plans that we can deliver for them. They are the agents of our state and our taxpayers. So I think there’s a lot of growth in that area, but ‘m very optimistic that we can be doing some great things.

(21:50) Steve Petranik: Connie — one of our biggest health problems is mental illness. And like what we’ve already heard, there are underlying factors that lead to mental illness, the lack of treatment of mental illness. Can you talk about some of those contributing factors that make it into a big social as well as personal problems?

(22:11) Connie Mitchell: Steve, before I go into the contributing factors, I think it’s really important to talk about mental illness on a continuum. Mental illness and mental health sometimes are thrown together. Serious mental illness and serious and persistent mental illness is also confused sometimes. And it’s unfortunate because I think when people use the term, you know, one person is talking about it in one way and another person is talking about another.

So I’m going to start with mental illness. Mental illness is the most extreme and is biologically based. A lot of it is also genetic. When people actually experience it, it’s through no fault of their own.

And it’s also something that can be treated. I think there’s a lot of stigma attached to mental illness. And so people think, “oh, well, they made a choice to do this or that or, you know, they’re acting in strange ways and it’s their character.” But it’s really something that they don’t have that much control over. It’s a brain disorder. And just like diabetes and heart disease, there are medicines that can help that.

But a lot of times people don’t realize that that is the case or they’re thinking about medications that were used 50 years ago that are no longer being used. And they have a lot of stigma again attached to it.

For us, today in Hawaii, our prevalence here is not that much different from any of the other states in the nation. But I think what confounds it a lot is the fact that we have a serious substance abuse issue here, particularly with methamphetamine.

Crystal meth is just such a powerful drug and it has been so impactful in our community for so many years. I think when it became the drug of choice, you know. And actually right now for adults, second, if you take alcohol out of the equation, it is the most common drug that is used.

And with homelessness, there’s a lot of people who end up just really getting sucked into it. Homeless people are very much preyed upon and they’re given the drug a lot of the time. The contributing factors are the fact that we have methamphetamine abuse in a very, very extreme manner here in Hawaii. The other thing is that we live with a lot of stress, as Dr. Keawe had talked about. And I think that the stress of the economy, the cost of living in housing is particularly difficult here. And that makes it more of a problem for a lot of people.

But I think you mentioned access to treatment also. That is probably the most difficult thing when I want to get mental health treatment for someone, it’s not that easy to get it. I think our legal system and the general public, you know, thinks that it’s really something that should be treated. People think that you have to protect people, that they can’t make the decision or they can make a decision about treatment.

They refuse the treatment. And it’s actually something that they can’t help because they don’t understand that they’re sick.

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