Covid-19 and Diabetes in Hawaii

I have learned both how poorly the medical community here in Hawaii and in the nation were prepared for the Covid-19 pandemic. However, it is impressive how calmly and rapidly the community has responded to this challenge in terms of patient care and individual social isolation. Like the rest of the country, population testing for Covid-19 is still inadequate.

Covid-19 came late to Hawaii. The first case presented March 1, so we had somewhat more time to organize for the onslaught. Six weeks later, we are in the acceleration phase of viral spread. Our Department of Health daily updates the infection-related incidence and mortality using health.hawaii.gov. As of May 27, 2020, we have had 643 cases and 17 deaths. Population education for preventing Covid-19 infection is quite good and has been well accepted. All hospitals have risen to the occasion. Nevertheless, we are just beginning phase 2 and may have an increasing infection rateas our economy opens.

Like other faculty members of our state medical school, the John A. Burns School of Medicine, I am learning how to adapt medical education and practice to the infection control principles needed to protect our students. As a result of the epidemic, technology is now a central focus for medical education. The medical school is now conducting all classes using Internet conferencing services. This includes lecture and small group learning, both central to our Problem-Based Learning Curriculum. Because of the epidemic, our first- and second-year students no longer have direct access to patients when learning and practicing history and physical examination skills. Prior to Covid-19, early patient interactions were essential and complementary components of the school’s curriculum. Now, video conferencing with selected patients and physician faculty substitute for the more direct student-patient contacts possible prior to the viral onslaught. Third- and fourth-year students continue to be part of the healthcare team in the hospital setting, but for now they will have less direct patient experience in the outpatient setting.

Distance learning will also be crucial for the development of medical school teaching locations on our neighbor Islands, currently medically underserved.

Physician practice is also changing. I am learning, along with my fellow endocrinologists, how to make telephone and telemedicine visits a regular part of endocrinology practice. So far, my patients with diabetes have been spared the increased risk of infection-related complications and death.

I am learning how much our community depends on the Visitor Industry, and how layoffs will have a devastating impact on patients with diabetes who are hourly workers in tourism. Government funding administered through technology will make temporary support of our unemployed population possible during this crisis. Perhaps, 20% of our population will be temporarily unemployed. Although we have a good safety net in terms of medical insurance here in Hawaii, the cost of living is high and the copayments for medication central to diabetes care may not be affordable even with medical insurance and government temporary support.

Many challenges in addition to medication cost and insurance are becoming more acute. Our homeless population has little access to the Internet or private physician education and care. Hawaii has the largest number of homeless in the country per capita. Their diabetes needs continue to be a challenge. Diabetes care for this population even before Covid-19 was a major burden placed on Community Health Clinics and hospital emergency rooms. Because of the many perceived difficulties placed on physicians by Medicare and Medicaid patients (increased time and effort in their care; increased documentation requirements), many physicians have restricted their practices, including endocrinologists, thus limiting access to expert diabetes care for the poor and the elderly.

In the future (after the virus), I see many new technology directions for the care of patients with diabetes, both type 1 and type 2. Telemedicine outpatient visits are now currently the rule. I foresee more telemedicine–patient interactions by primary care providers, endocrinologist, and diabetes educators in the future. Diabetes care is outrageously expensive, and I look forward to a national healthcare insurance alternative for all Americans. Medication prices must come down. Greater access to the technology of continuous glucose monitoring will be the new future for diabetes management. Continuous glucose monitoring will teach both patients and physicians how to better approach the unique diabetes needs of each patient. Greater access to care and education through technology will brighten the future of diabetes-related medicine.