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Swiss cheese can still save Kaua‘i

Dear Dr. Berreman and Mayor Kawakami,

I listened to your video on Friday, Nov. 13, with the usual respect and admiration that I have always had for your handling of the dilemmas caused by the pandemic on Kaua‘i. When Dr. Berreman gave her full and careful explanation of the science supporting the requirement for wearing masks, I found it masterful. Masterful, yes, but nevertheless insufficient.

Although it seemed apparent to me that no matter how much we, as individuals, wear our masks, wash our hands, sanitize our environment, stay home, or meet outdoors and only in very small groups, we as individuals will never be able to stem this pandemic without other conditions being fulfilled as well.

We will require stronger and well- enforced regulations that control risks that individuals, acting on their own or in small groups, will not be able to control.

All that night I searched my mind for a way to explain this to others.

A single-pronged approach is rarely sufficient to solve a complex problem, and Covid-19 is clearly a complex problem. Protecting the public health is clearly a complex problem.

I knew that leaders and advisors need to do more than influence individual behaviors. And I knew that some of the needed changes could be accomplished only by leadership.

But what escaped me was how to create a convincing appeal to a population, its advisors, and its government.

The following morning a solution to this dilemma arrived in my email inbox in the form of an article in the Wall Street Journal. In a piece entitled “How the Swiss Cheese Model Can Help Us Beat Covid-19,” Nicholas Christakis, an eminent physician and sociologist, director of the Human Nature Lab at Yale University, and Sterling Professor of Social and Natural Science, affirms that “no single solution will stop the virus’s spread, but combining different layers of public measures and personal actions can make a big difference.”

Christakis argues that “governments will need to consider a diverse and sometimes disruptive range of interventions.” He affirms that there is only so much that individuals acting on their own can achieve, no matter how much they wash their hands, wear masks and maintain physical distance. Christakis specifically calls for interventions “of the type that are usually coordinated and mandated by governments…These policies include…closing borders, restricting movements, shutting schools, banning gatherings, closing businesses,…and issuing stay at home orders….”

In developing his argument Christakis draws on a classical model of problem-solving, called “The Swiss Cheese model.” It was developed by British psychologist James Reason to conceptualize the best way to deal with hazards that involve a mixture of human, technological and natural elements, and the model has been used extensively in Health Care, Risk Management, Aviation, and Engineering.

The image that the Swiss Cheese Model is meant to convey is that we need to think of extreme dangers such as pandemics requiring multiple layers of defense, with each layer providing a barrier that isn’t fully impervious. He likened these successive barriers to a stack of slices of Swiss cheese.

As danger passes through a hole in the first slice it is caught in the second or the third, etc. (as long as the layers are sufficient in quantity that the holes in the stack never line up).

What does this mean for Kaua‘i? It means that we need Dr. Berreman to urge publicly that Mayor Kawakami reconsider his acceptance of the state’s pre-travel test exemption from quarantine. Together they should announce that the current increase in numbers is not acceptable.

Together Dr. Berreman and Mayor Kawakami should announce that this island is opting out of the “one-size fits all” assumptions developed in the very different environment of Oahu.

Together they should develop a plan specific to this island. That plan should include the following: a negative pre-arrival test with results received prior to travel, a full two-week quarantine period for all arrivals, with the only exception being that those who test negative on a second test after seven days, may then be released into the community.

There is not much time left before even this solution will be too late, and community spread will be firmly entrenched.

If this plan is implemented rapidly, the stack of Swiss Cheese will be as strong a barrier as is compatible with allowing tourism to continue, schools and businesses to remain open, and Kaua‘i to be saved.


Phyllis Albert, Ph.D. is a resident of Koloa
Source: The Garden Island

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