Hawai‘i Doctors Talk About Diagnostic Breakthroughs and Practicing in a Pandemic
While the ever-changing nature of COVID-19 has proven frustrating around the world, it's also the challenge that infectious disease specialists have been training for their entire career.
In March 2020, as a new coronavirus moving silently through New York erupted, bringing the city to its knees, a slight man with a Brooklyn accent began to appear on news shows across the country.
Dr. Anthony Fauci, the nation’s foremost infectious disease expert and head of the National Institute of Allergy and Infectious Diseases, delivered bad news and good advice in a steady, authoritative way. His presence brought the field of infectious disease into focus, and its practitioners into the spotlight as embattled heroes of our unfolding crisis.
Here in Hawai‘i, infectious disease experts have long worked behind the scenes to diagnose and treat often baffling diseases. With the emergence of COVID-19, they were on the front line, working to care for sick patients, control the spread of the virus, keep up with the fast-evolving science and explain what was happening. Infectious disease specialists are comfortable dealing with unknowns—even with pathogens for which vaccines or cures don’t yet exist. The physicians we spoke with say battling back a new threat is a role they relish.
For Dr. Tarquin Collis, the global spread of COVID-19 has proved the ultimate test of his skills as an infectious disease specialist. “It’s a really scary time,” Collis acknowledges. But it is also the defining experience of his medical career. He now serves as head of infectious disease at Kaiser Permanente in Hawai‘i. With his hospital team and the broader primary care community, Collis helps set protocols for treating patients and protecting medical staff. While getting these right is crucial, the newness of this coronavirus and the lack of preexisting immunity among the population also make setting standards a moving target.
“A lot of people ask me, ‘Are you scared of caring for COVID-19 patients?’” Not especially, he says. “We’re always in and out of rooms of people who have things like meningitis or tuberculosis, and we’re used to wearing strange spacesuits of various sorts. So this isn’t particularly more spooky. But what is different and remarkable is the extent to which we’re dealing with a once-in-a-lifetime event,” he says.
The intellectual puzzles of the disease keep those in the field motivated, says Dr. Erlaine Bello, chief of infectious diseases in the Department of Medicine at the John A. Burns School of Medicine and the hospital epidemiologist in infection prevention and control at The Queen’s Medical Center. “I tell my department and residents-in-training that this might be the biggest educational experience in your lifetime. It’s a tremendous learning experience.”
“We have an agent never seen in humans before. We are learning a lot, and quickly,” says Dr. Marian Melish, a renowned infectious disease expert at Kapi‘olani Medical Center for Women and Children and a professor at JABSOM. “It’s a very exciting time to be involved in infectious disease.”
This is not the first time Melish has encountered a brand-new disease. In the 1970s, as a young pediatric physician in Hawai‘i, she began seeing children with unusual symptoms: persistent fevers, inflammation in the joints, rashes and swollen feet. She met with arthritis specialists, prescribed antibiotics and scoured the literature for clues.
“It was hard to believe we were seeing something completely new,” she recalls. In the hospital cafeteria, a chance meeting with a visiting Japanese doctor solved the riddle. The visitor told her that several years earlier in Japan, a Dr. Tomisaku Kawasaki had documented the first cases of what is now called Kawasaki disease, which causes blood vessels to become inflamed and can be fatal. Melish was spotting the first cases outside of Japan. She continues to diagnose and treat young patients with the disease, which she says is 15 to 20 times more prevalent among children of Japanese and Korean ancestry. In Hawai‘i, for every 100,000 children younger than 5, about 50.4 will develop Kawasaki disease, more than double the national rate. Similar symptoms have recently been tied to cases of COVID-19 in kids on the Mainland.
Beyond rare diseases, infectious disease doctors treat a range of ailments caused by microorganisms—viruses, bacteria, fungi and parasites—from chronic infections including HIV to respiratory infections such as pneumonia. Melish believes the specialty focuses on one of the most important segments of medicine, in part because it intersects with so many other branches, including psychiatry, microbiology and immunology.
Although many conditions can be treated by primary care doctors, Hawai‘i’s infectious disease specialists are frequently called on to handle staph infections, which tend to be much more severe in tropical environments. The state also reports high rates of tuberculosis—8.4 per 100,000 residents in 2018—a result of a large population that emigrated from parts of Asia and the Pacific where the disease is more prevalent. Rheumatic fever, now rare on the Mainland, affects children in Hawai‘i at much higher rates, particularly those of Samoan descent.
Then there are the severe infections that medical staff regularly encounter. “Someone might come in with a terrible infection from an orthopedic device, or they have a heart valve infection, or they have out-of-control tuberculosis—we know what it is and the medical team needs our expertise for how to fix it,” Collis says. Other times the prognosis is less clear-cut. Collis recalls a recent Kaiser patient who appeared to have metastatic cancer of the brain and lungs. Detective work by Collis and his team revealed that what seemed to be a death sentence was a treatable bacteria.
“Most infections I can either cure or control,” Collis says. “I didn’t understand that when I went into this field. But it’s an incredibly rewarding kind of practice because you get to fix stuff, which I like to do.”
But little is certain about the novel coronavirus now spreading across the country. “COVID-19 brings completely new challenges—how to treat patients and make decisions in the face of unknowns but using common sense and lessons from history and past experience,” Bello says. “In clinical terms, COVID is most like SARS or MERS, but it is a pandemic like the 2009 influenza pandemic, though far more widespread and serious.”
To help unravel the mysteries of the novel coronavirus and how best to treat patients, Hawai‘i’s infectious disease experts are participating in original research. Bello says that The Queen’s Medical Center has joined the state’s other major hospitals to investigate convalescent plasma, which is donated by patients who have recovered from COVID-19 to use as a potential antibody-based therapy. The trials are conducted using Mayo Clinic protocols, with samples collected by the Blood Bank of Hawai‘i. Collis’ team at Kaiser Permanente is also conducting a trial of the antiviral drug remdesivir, giving patients there access to the most aggressive therapies available.
Besides COVID-19 clinical work and patient care, the physicians are all responsible for infection control at their institutions and for keeping their colleagues informed about new developments. Collis, for instance, runs regular question-and-answer sessions with the Kaiser medical staff. He draws on training he received in epidemiology, which looks broadly at a population to investigate the presence, spread and impacts of a disease or other health problem.
“I’ve been playing a much more public role than I’m used to, but it’s extremely important,” explains Collis. “A lot of the health work you see at the Centers for Disease Control and the U.S. Department of Health and Human Services involves clear communication—really trying to get messages out and having people feel that someone thoughtful is helping the institutions think through some of the challenges.” Fauci, not surprisingly, is one of his heroes.
In Hawai‘i, the state Department of Health and the front-line infectious disease experts regularly communicate. “We are required by law to report on communicable diseases to the DOH,” Bello says. “With COVID, there’s been frequent communication because we want to make sure we can track and control it in settings like homeless shelters, nursing homes and multigenerational households.”
What Keeps Them Up at Night
As the country battles the virus, the physicians are relieved that Hawai‘i seems to have avoided the often angry politicization of public health measures such as the wearing of masks in stores. The fact that a giant moat, the Pacific Ocean, surrounds the Islands is another big advantage. But unsettling scenarios still are a part of their daily work, especially as the state grapples with the risks of reopening.
“Obviously, there needs to be movement in a controlled way to bring folks back in so that our economy can restart,” Collis says. “But there’s no way that won’t introduce significant amounts of infection to the state.” Bello wrestles with how to weigh the risks of infection with the impact of a wrecked economy. Her husband recently closed Harpo’s Pizza after 30 years in its downtown location, so the question of how to balance two competing and critical needs has really hit home. As she puts it, “Do we succumb to poverty or infection?”
What is a Pandemic?
A pandemic is a global outbreak of a disease. On March 11, the World Health Organization classified COVID-19 as a pandemic, reflecting the shift from regionalized outbreak to a sweeping worldwide crisis. Examples of other pandemics are the Spanish flu of 1918, the HIV/AIDS pandemic of the late 20th century, and the H1N1 swine flu of 2009–2010.
What’s the Difference Between an Infectious Disease Doctor and an Epidemiologist?
While the two fields interlink, physicians focus on diagnosing and treating patients with infections. Their work can extend into other areas as well, including research, advocating for prevention measures, and studying outbreaks and preparing for emerging diseases. Training to be an infectious disease specialist requires medical school and a three-year residency, plus an additional fellowship in infectious diseases.
Epidemiologists look more broadly at health problems among a larger population, locating patterns about why, how and when some people contract diseases and other health conditions while others do not. Their findings inform new medical treatments and prevention efforts, as well as decisions made by health care and policy leaders. Epidemiologists usually earn master’s degrees, and some go on to get doctorates. (State epidemiologist Sarah Park is also a medical doctor.)