Thomas Lee, phd

PH: Hello, today is August 21, 2021. The time is 8:55 AM. We are conducting an oral history interview this morning with Dr. Thomas Lee. So thank you for being with us again, Dr. Lee. And just to start things off, can you please state your full name?

TL: Sure, full name is Thomas Ho Won Lee.

PH: OK, and where were you born, Dr. Lee?

TL: I was born at Queens Medical Center right on Oʻahu Island.

PH: And just getting right into your career, can you talk about when you developed an interest in microbiology and what first interested you in public health and epidemiology, specifically?

TL: Yeah, so I would say in undergraduate as a pre-med major trying to think about... Take all the courses for med school or veterinary school. That was my first exposure. Really took an interest to virology biology. But it wasn't until 2013 when I started my Masters in Epidemiology where I really started to grow an interest in population level infectious diseases and how that would impact the country, the state depending on if we had a pandemic. And then obviously, you know, once I got my doctorate and then covid hit, I think everybody's focus kind of shifted to better understanding covid from whatever vantage point they're in. And for me, for epidemiology, it's looking at how it spread to certain populations and all the demographics associated with risk.

PH: Sure, and at the time that covid arrived here in Hawaiʻi, what positions did you hold as they relate to microbiology and public health?

TL: Yeah, so in Hawaiʻi, really, in March, middle of March, I was teaching a couple of courses. I was an assistant. I am an assistant professor of epidemiology in the Thompson School of Social Work and Public Health. And I was teaching global health and public health biology and pathophysiology during that spring semester. I just vividly remember the last lecture before spring break and saying this could be our last class in person and it ended up being the last class in person for the semester.

PH: And then can you talk a little bit about with covid-19, when did you first become aware of covid-19 and when were you concerned that it could pose a threat to Hawaiʻi?

TL: I was first made aware around in January when it was starting to make its way into the national and international media. First China and then when it made its rounds to South Korea, Japan, Taiwan, and then also through Europe. At the time, the United States... There were no cases that were identified, though covid was already circulating within our country and obviously Hawaiʻi as well. So that's kind of when I was tipped off. In terms of being concerned, I became more and more concerned once I saw Europe really starting to kick off their first wave, and that's when I knew that it was a very potent virus because it quickly went from the Asias across the continent to European continent. So that's when I knew we were in some trouble.

PH: And then as a professor at the onset of the pandemic, of course, everything moved virtually. But can you talk a little bit about how you used your platform there just to kind of educate your students about covid-19 and the threats it posed to them?

TL: Yeah, definitely. So I actually gave a lecture to my global health course prior to going virtual because I wanted them to know everything that we knew at the time. So I gave a lecture in person and then, as the rest of the semester progressed, I would continue to update them. And one of my lectures I always have like a hot topics for global health. And I always led with a couple major news stories and covid obviously dominated that, and I share that with my other public health biology course as well. And then some of the other things that I was doing with the university, I was asked to put together a video interview with someone else in the history department at UH. So I did a quick 20 minute video, really comparing or looking at Korea, Japan and their successes and what we could potentially learn in the initial response for Hawaiʻi. So that was kind of what I was doing on the academic side.

PH: Can you talk just a little bit about some of the challenges you faced as a professor moving online and maybe also on the flip side challenges that you noticed students facing as well?

TL: Yeah, I would say, thankfully, the platforms that I was currently using, the students are very familiar with in terms of Laulima. I had all the assignments there, all the announcements, so nothing really changed in terms of how I communicated and how they turn in assignments. What was difficult for one of my classes for a global health course was it's a slightly larger class, about 40 or 50, and I really like to be engaging with them. And I found it very difficult to execute that type of lecture style virtually. Zoom was almost impossible because of limitations with my students. A lot of them, you know, we have to remember that they might not have Internet access or high speed internet access at home or even a laptop. You know, some some of them rely on the computer labs at school and then obviously with campus shut down that was an issue. And the other thing that I realized was a lot of students had to pick up the slack financially because their parents were immunocompromised or at risk, and they couldn't go out. So they had to work an extra job or two. And, you know, that impacted their ability to be in class per se in terms of a set time. So the way I mitigated that was to just make everything asynchronous so that they could still keep up. And really what I tried to do was just be overly transparent, send 10 different announcements to make sure they didn't miss a thing. And that was the best way. And I held Zoom office hours. They could always reach me via email. So that was really what I saw and how I tried to get around some of the challenges that my students faced.

PH: Yeah, it's great to hear about the ways you tried to accommodate. You were already involved, I guess, as an epidemiologist in terms of teaching epidemiology and public health. But can you talk about when and how you first became involved in directly fighting this pandemic?

TL: Yeah, for sure. So, Hawaiʻi is so small, as you know, and the coconut wireless is a real thing. One of my colleagues, she connected me with a physician who's faculty at JABSOM, who works at a community clinic. And she had some questions about covid on the epi side and contact tracing, so I was answering that. Then about a week later, she connected me with a fellow academic and professor at JABSOM, who was tapped to be the lead coordinator, so basically within HiEMA, the Hawaiʻi Emergency Management Agency, you have different emergency support functions. There's 20 of them, and one of them is health and public health. And that's the number 8. So he was tasked to lead that. and then because of the coconut wireless, he called me, and he asked if I would be willing to support from a modeling epidemiology capacity. It so happened he was prior public health service, and he knew that I was a reservist in the Army. And I told him I would be honored to support. And the fastest way to get me was to be activated as an Army officer to support the state. So that whole process of Hawaiʻi Emergency Management Agency working through big FEMA, there's this whole process where the request went up and then DOD activated me to support the state. So I was on active duty orders from April through July and early July as the lead forecaster and modeler for ESF8 and HiEMA, which ultimately meant that I was doing work to inform policymakers, including the governor and the mayors.

PH: And I guess I'm curious, working for the state and through HiEMA, what was the basis of your forecasting models when data was still evolving on covid-19 and the pandemic was ever-changing?

TL: Oh, yeah. So the big reason why I was asked to come on was there was a lot of uncertainty within the state around early April in terms of, are we going to surge? And was that surge of cases going to result in an overwhelming of our hospitalization capacity in the state? And there was no way to do that except for forecasting. And the state did not have any organic capacity to model like other departments of health and other institutions on the mainland were doing. And the models that were available for Hawaiʻi were so wildly inaccurate because of how different Hawaiʻi was that we really couldn't trust it. So really they brought me on to try to refine a lot of these modelings to really impact decision making for the state. Modeling is something that's not really present in most departments of health. But I think moving forward it will be. But that's why I was brought on.

PH: Do you feel like from your own work and also the work of your colleagues Hawaiʻi is now better prepared and equipped in terms of modeling should a future pandemic come around.

TL: 100% in terms of, we know we have the capacity and the skill sets and the personnel because of the work that we've accomplished already. Even through this current surge that we're experiencing, as you said, it's August 21st, we've been having triple digit cases for the past three and a half weeks, almost over three, four hundred a day. So a lot of our modeling we've been getting on from the public and Hawaiʻi News Now, KHON, Civil Beat, and its made its way to some of the policy makers to at least bring awareness about potential impacts, specifically with our surge in cases. Once again, the topic of hospital capacity is a very sensitive issue for Hawaiʻi. Because we're an island, we can't just bring a bunch of nurses or bring a bunch of medical stuff across the country. We have to fly and that takes time and planning. And so really we are able to utilize our modeling to help inform but also help educate the public in terms of truly understanding the severity of the disease that's circulating across our islands. One thing that I will say that is still lacking is long-term funding for improving the modeling capacity and improving surveillance and just understanding how this modeling and surveillance can fit into the overarching strategy for future responses and how that might sit in our Department of Health. Because it's clear that one, covid is not going away anytime soon, two, with global warming, with increases in urbanization and industrialization and globalization, it's only a matter of time before we are hit with another pandemic, definitely within our lifetime.

PH: Yeah, and you talked briefly there about your role educating and advising both the public and also state leaders. Can you talk a little bit about how you advised state leaders and maybe some of the challenges that came along with that?

TL: Totally. So, you know, I look at them no differently than I looked at my students because they're experts in policy and in government, not so much in the science and in epidemiology. So first thing I had to do was really just in a very easily understood manner explain the epidemiology of covid and what the terms mean so that they're not getting mixed up differences between quarantine and isolation. What exactly is R0? What does that mean? How does that number impact our calculations and potential response? And then once once we did that and there was definitely a team that did that, it was then with the models helping them understand the so what to the models. They don't like that it was nuanced and it was complicated, but we had to help them understand that everything with this responses is in a gray area. There is very little that is black and white, especially when it comes to modeling. And there are always caveats and assumptions and helping them understand the usefulness of the models and what it can be used for, but also what it should be used for. The purpose of the model shouldn't be to say, "well, you were off by 20 cases yesterday." That's not the point. The point is to help policymakers understand what are the impacts of certain mitigation measures on the epi curve. And that's kind of what we try to utilize them all. Of course, if you did X, Y and Z, this is what we project the future trajectory to be, tt's going to decrease or increase or have no impact. And I think we ultimately succeeded. At this point, they understand what the models were, but definitely in the beginning they were not quite understanding it. And that's of no fault of their own. It was just a completely different field and they had to get spun up on it relatively quickly.

PH: Yeah, and I understand you influenced or informed some really pivotal decisions. Can you talk about just some of those policy decisions that you've helped influence at the state level?

TL: Yeah, so the very first one, I remember the first day, not even the first day that I was brought on I was on a three hour long Zoom call at night from 7 to 10 PM because we needed to get a decision to Major General Hara, director Hara, in terms of does he need to stand up the Convention Center for overflow capacity? And he was making that question based on a national model for Hawaiʻi from the University of Washington's Institute of Health and Metrics (IHME). They were showing us the surge in two weeks, and we needed to be prepared. So what I did with with Dr. Hankins who was the lead of ESF8 and a couple other health experts, we sat down. We took a very crude model. We applied Hawaiʻi's population and some assumptions. And we said with what we understand about the epidemiology of disease transmission of covid in Hawaiʻi, we weren't going to hit a surge in the next two weeks. And and we did not. And that was something that I had to... Then once we knew what the data showed and what the modeling predicted, then we presented that to Major General Hara. And based on that decision, we shared that with the governor and the mayors, and they didn't stand it up. And history will show that we didn't hit a surge or any major surge until the end of summer. We had a slight peak, but that was nothing compared to what we're experiencing today and last fall. So that was one pivotal impact that we had.

TL: The other major one that I had and the team had when I was there in HiEMA and ESF8. It was close to the end of June when there was talk about reopening up travel, the economy with what is now known as the Safe Travels program because the case counts are so low and some days there was zero new cases. But what I was looking at was Hawaiʻi is never in a bubble. We are never in a vacuum. What was going on internationally? What was going on nationally? What were the historical trends? We know that Europe, Asia will get the major wave first then it will go to Europe then it will go to the continent of the United States, and eventually make its way to Hawaiʻi. At the time, Europe and then parts of the mainland were experiencing that second surge. And I knew it was a matter of time, and by opening up without having a strong, safe travels plan in place, we're just asking for a real big surge without being prepared. So our models had constantly refined from April to June, with more time, with more manpower, we were able to better refine it. And we were able to factor in impacts of travel and accounting for age and also all sorts of metrics that we weren't able to earlier on the response. And what we were showing was even a reasonable worst case scenario and a most likely scenario, we would reach ICU capacity within a couple of months if we opened up based on what was going on in the mainland. And so Dr. Anderson, the then director of health, was in a meeting with me and Dr. Hankins, and I share the modeling and he completely agreed with this assessment because he's an epidemiologist, and he understands the nuances. And because of that, he got us a meeting the next day with the leadership and we presented the same findings and in their own meetings, then I guess they deliberated, and they made the decision not to open up. And if you look back historically, we didn't open up, yet, Hawaiʻi really experienced our first true surge and our first true wave in August and September. So what I use as an education lesson is what would Hawaiʻi experience if we had opened up and we had that surge? It most likely would have been at least two, if not three times greater in magnitude than if we didn't, then if we just kept things out of school and had less than 10,000 less than 5,000 travelers a day. So that would be the second biggest impact. I would say the biggest impact, because I think we truly mitigated a big surge just by not opening up and saved a lot of lives.

PH: Yeah, you played a really crucial role there. Just with your work as an epidemiologist and informing at the state level, I mean, you talked about at the beginning the pandemic being on that Zoom call at night and also being a professor at the university. Were there any past life experiences that prepared you for the demands of being the lead forecaster on covid-19 and also pulling double duty as a professor?

TL: Nothing prepared me for this specific situation. I would say that my experiences of going to the doctoral degree and still being a teaching assistant and holding other responsibilities, I think just the ability to multitask but also compartmentalize and prioritize really played a role. And what I will also say is being a professor and having the ability to take complex ideas and break it down into a very sizable and easily understandable chunks made a big difference in the effectiveness of how we message the epi and the science to policy leaders, to others across the health community. So they could truly understand in a quick manner the severity of the epi and things that were changing across across the spectrum of time. I would say it was just a collective of preparedness. And I would say that also being an officer in the Army as well, in terms of knowing when to lead from the front and knowing how to support by just doing good work and giving the messaging up to people in higher positions of authority and knowing the true chain of command, because in this response, chain of command is definitely a thing and definitely something to be respected.

PH: Yeah, definitely. Looking at your work with HiEMA, and even as covid-19 evolves rapidly, could you maybe just give us a snapshot of what a typical day or maybe not so typical day might look like as an epidemiological forecaster?

TL: Yeah, definitely. The first month was Monday through Friday, I got into Diamond Head around 7:00, 7:15, 7:20 AM. and didn't leave until about 5 PM. And it was nonstop meetings and or work. And I would get home. I would try to work out a little bit, have some family time, but it was very hard to shut off my brain because I would try to stay on top of what was going on in the community because a lot of what I was doing was so focused on the response. I still needed to have a situational awareness of what people were thinking, what was on the news, how people were perceiving the virus because that all impacted the messaging, because nothing with the response is in a silo. So really, there was no true break from COVID and the response from covid for a long time. And also we would have meetings on Saturday mornings, and I would just listen mainly to the other members of the ESF8, people in charge of hospitalization and long term care and PPE. But I would always need to be there because what I forecasted impacted everybody's response, so if they had questions, I would be able to answer it. So that was basically my typical week, Monday through Friday in Diamond Head, Saturday mornings on a call trying to balance as much as possible with family and exercise. But that was really what my life looked like. And not really going out because obviously things were close, and I was trying to lead a good example. Because if I'm not living what I'm preaching, then I can't expect people to follow the same rules.

PH: Yeah, absolutely. And you talked briefly there about messaging to the public. Can you talk about how you convinced lawmakers to make covid-19 data more readily available and why that was so important to you?

TL: Yeah, I think the the way that I did that was, one I try to work with my colleagues in the Department of Health, and create synergy, break down data silos within my power. And if not, then I would say, "hey..." To provide some clarity before I say what I'm going to say next, in terms of the hierarchy, because Department of Health was there, their authority for the response was taken away from them because of the emergency. And now HiEMA running the response at least last year. The lead of ESF8, Dr. Hankins, was actually in charge of the entire health response. And I sat directly under him as a lead forecaster modeler. And then you had different heads of DOHs and subcategories. So I technically sat, in terms of the hierarchy of the response, above the state epidemiologists. So because of how important the modeling was and the credit that I built up with the policymakers, if there were things that I needed to inform and refine the modeling that I couldn't get, I would just simply work through the chain and say, "hey, I really need this. I've tried getting it through my own channels. It's not working. So can you help me get the information that we need?" I think over time I realized I didn't have to use that tactic because we all realize that we're on the same team. We need to support each other when we can. I think if you look at today, the data dashboards on Department of Health's website is night and day with the data that's provided to the public. And even there's a lot more sharing of information inside channels between myself and some of my colleagues at DOH for a lot of reasons. But definitely the data flows have increased tremendously.

PH: Now, in terms of getting that data out to the public, were there any challenges or strategies that you followed to ensure data was presented clearly and accurately and not misinterpreted or misrepresented?

TL: Yeah. So with all of my direct work and my team's work, I would be very upfront and say, "here are the caveats to the modeling. Here is what we're trying to do. Here is we can't do it." So they understood that. We're not trying to predict the exact number of cases. We're saying, "hey, here's our best guess, we're only going out two weeks because that's how comfortable we feel." Anything beyond that is like trying to predict if there's going to be a hurricane in six months and trying to use metaphors and analogies that people in Hawaiʻi are used to in hurricanes were perfect. The other thing, to speak to data and the limited data environment, in the beginning, I was on Civil Beat panels with some of my colleagues and fielding questions from the community and be like,"hey, why aren't you talking about this? Are you incorporating these types of data?" And we're saying, "hey, you know, you are all spot on. These are great comments. Unfortunately, we don't have access to that because we are still external partners. The people who get this data are within Department of Health," and having them understand who truly has the ability to share the data. And once they understood that, then their frustrations... Really, they still were frustrated, but they better understood where the data was housed. And then I think everybody can see when there was public pressure, eventually, more data was made available.

PH: Yeah, and you talked earlier about how that data or some of the modeling was partly based off of what was taking place on the mainland and Europe. But I'm curious, were there any other prior public health crises such as Ebola or the Spanish flu or any others that kind of helped influence your modeling and predictions for covid-19?

TL: Initially, no, because so much has changed historically. I mean, I would say now in the past six months, we try to look for corrollaries between the impact of the 1918 pandemic locally in Hawaiʻi, and we can glean many trends in terms of education and higher risk populations. But really, in the initial response, even though the data environment was scarce, we couldn't really turn to historical references to inform us. But what we did turn to was looking at what were the countries that were successful before Hawaiʻi in January, February, March, April, in succeeding and really limiting the spread of cases? And, you know, I looked at South Korea, Taiwan, Japan, New Zealand, Australia, and what did they do and what lessons can we learn from a public health response measure? And they had really all robust contact tracing, isolation, quarantine capacity, testing capacity, things that history has shown that we were not very prepared as a state and as a country for compared to some of these other nations.

PH: Yeah, definitely, and here, especially in Hawaiʻi, can you talk about some of the impacts that you observed covid-19 had on Native Hawaiians and other underserved Pacific communities directly?

TL: Yeah, I mean, unfortunately, there was a tremendous impact, both covid direct and covid indirect impacts. If you look at the data there, one of the the leading ethnicities that were negatively impacted by covid in terms of covid cases, ICUs, hospitalizations. And there's a whole host of reasons. We know that at least last year and even more so this year, if you have comorbidities, diabetes, obesity, hypertension, heart disease, you're at greater risk for getting covid and then going to the hospital and potentially expiring as well. And we know that certain demographics, certain ethnicities are at high risk for those comorbidities. One of the leaders is Native Hawaiians, Pacific Islanders. And so it's not surprising that they were one of the hardest hit by covid directly because of these parallel public health issues and health issues that impacted them that are due to just socioeconomic and other social, behavioral and institutional standards. So I was not surprised there. And then the secondary impact, their access to care for things other than covid were impacted because the hospitals were shut down, and they didn't have the means to see their PCP or maybe get virtual consuls because of social disparities and economic disparities as well. So what negatively impacted their ability to deal with covid also are the same regions with regards to negatively impacting their non-covid associated health outcomes as well. And it's unfortunate. It's something that public health leaders and social justice advocates have been trying to improve upon. But it really exacerbated and highlighted the inequities of health and access to health for Native Hawaiians and Pacific Islanders in the state.

PH: Yeah, thank you, Dr. Lee. As an epidemiologist like yourself, do you think that data and just the increased awareness of public health that has been brought forth by covid-19 can better protect these communities in the future? And if so, how?

TL: Yeah, I would hope that it does. However, what I know is that having data, having great data isn't enough. The most important thing when it comes to public health and public health education is gaining trust. And there are so many great organizations across the state who have already established trust and will continue to utilize that trust to educate. But I think we're obviously not there, and we need to first and foremost create more and more trust across all health sectors, across all health leaders, so that when they see people on the TV that they don't recognize who haven't been in the community, they'll still realize that, hey, this health leader does have my best interests in mind, even though I don't have that trust. I think we're working towards that. We're not quite there. And only then will data truly have an impact because like we're seeing with vaccine hesitancy, you can throw all the data out there. I can cite all the statistics that I want. But if I don't have the trust of someone who's vaccine hesitant, that is not going to make a lick of difference. So truly, especially in Hawaiʻi, where our island community is so small and and trust is such a valuable commodity, that is where we first need to start.

PH: Yeah, absolutely. Getting into where we are presently with the pandemic, could you talk a little about what factors the state should potentially consider in reopening, especially with the more contagious Delta variant that we're experiencing now?

TL: Yeah, I think you're seeing that we're pretty much fully open. And I know a couple of weeks ago, the governor had an executive order which reduced capacity for high risk environments like bars and restaurants to 50%. But in terms of travel, they haven't made any adjustments to the Safe Travels program. They haven't limited types of social gatherings, so I am surprised that nothing's happened. I think that purely relying on the vaccination rate and people getting vaccines is not enough, ovbiously, as the data is showing, and something needs to be done. Multiple things need to be done. I think increase education efforts and community outreach, along with helping out my colleagues in the hospitals, at least in the short-term to make sure that the ICU and the ICU wards are not going to be overrun. We have enough capacity. We have enough personnel because what I'm concerned about is to going into two years of this response, our health care workers are reaching a mental breaking point. And I think that's something that a lot of people who are hesitant to get the vaccine or are vaccine averse are not considering that if they were to get covid, they'll still be treated, but they're directly responsible for the mental health of the health care workers. That's something I'm concerned about because what we're seeing, it's not the the actual beds, it's not the actual ventilators, it's the personnel that's the limiting factor with regard to moving forward with the response.

PH: Yeah, I'm glad you highlighted that. I know this pandemic is certainly not over yet, but just with what you've experienced and your forecasting and modeling over the course of the pandemic, are there any key lessons that you think future policymakers should take away from this experience?

TL: Yeah, there's a few perks. One is preparedness, and not preparedness in the sense of having enough stocks of PPE, but really doing a deep dive of policy because we know that speed really has a potential for reducing loss of life. And having policies created to cut a lot of the red tape in the bureaucracy for something like this in the future will be key. I mean, if you look at South Korea and Taiwan with their experiences with SARS and Mers, which was a similar type of resperatory virus, they created policies to reduce the red tape in terms of private companies developing and producing PCR tests so that they're not waiting on one or two major manufacturers to get it out. They could just quickly have emergency use authorization to produce these tests because we know how effective quickly testing and then subsequent contact tracing, isolation, quarantine is for a disease that we don't yet have a vaccine for. So that's one thing looking at refining the policy and the policy response is big moving forward because the bureaucracy and red tape really can slow things down. So that's one thing. The second thing is having the support from policymakers for funding for long term surveillance of future infectious diseases that are going on that are potentially popping up across the Pacific and the Asia Pacific. Because of where we are in the region, we are positioned as... you know, UH is the only R1 Research Institute in the Pacific. So we are primed to be the leaders of surveillance for this entire region. And then we can support our partners and our ʻohana in the South Pacific, in Oceania because they don't have half the capacity in terms of funding and research and more importantly, health care personnel and epidemiology capacity to mount the response that we could in the state. So really doing the Pacific a service by having long-term support for surveillance and modeling will go a long way. So those two things and finally, a big indirect impact that will have long-term ramifications is building public health capacity in terms of investing in our students and investing in jobs in the public sector for our future graduates of the public health program and of nursing and social work so that we have sufficient local high quality personnel who are supporting our state, and that's a long term effort. I mean, look at how many contact tracers we need that we are still struggling to get and epidemiologists that we're struggling to get and social workers and mental health workers and nurses. Covid has really brought to light the disparities and the lack of capacity that we have in the state, and a lot of it is driven by cost of living and the wages that are not sufficient to keep our very bright graduates of UH Manoa and everybody across the UH systems on island. So they're going to the mainland to seek better compensation. But we need to make it sustainable to keep our talent locally to better serve our community in the future. So that's a very long-term thing, which will have dramatic positive impacts in the future if we're able to execute.

PH: Yeah. Thank you, Dr. Lee. I think those are all excellent takeaways. As we kind of wrap up the interview, just going more personally, you've already talked a little bit about how covid-19 and just some of the challenges of your work impacted your family. But can you talk maybe about how the experience has changed, how you think about your family and friends and community at large?

TL: Yeah, definitely. So I had a major life change. Halfway through the pandemic my wife and I were pregnant, and we have a beautiful four month baby girl. And so that definitely changed personally, how I looked and did my own risk calculations for living my daily life. I no longer could just worry about myself and my wife. I had to worry about someone whose immune system is not yet developed, even with the vaccines. And so what I did on the daily basis was dictated not by me, but by the impacts I would have on my daughter. So that was a big thing. The other thing was just realizing the importance of balance because I'm going on two years on this response and direct response with covid and really bringing to light the importance of mental health. Not just for me, but for my family members and for everybody in the community that, hey, you know, mental health is such a silent killer in terms of, it just chips away at you until one day it comes to a head and it's oftentimes too late. So just checking in, making sure there's balance. And as a public health professional, that's always been something on the forefront of having healthy eating, getting out, getting a good exercise, balance, not being in front of a screen all day. All of these things are protective, not just against coivd, but against most chronic diseases as well. And with covid we're seeing a strong connection between infectious and chronic diseases. Just improving our overall health has done wonders and trying to educate the public as the best of my ability I think was a result of covid and bringing more self-awareness to overall aspects of health.

PH: In terms of the community that we live in here in Hawaiʻi, are there any positive or negative aspects of living on an island, specifically, here in Hawaiʻi during the pandemic that you observed?

TL: Yeah, I think you see more so than the majority of the states, you saw collectiveness to at least in the beginning, to wear a mask, to go through these restrictions together because they put the common good in front of their own personal needs. And I think a large part of that is the island culture, the sense of family and belonging to the state, but also, we pull a strong Asian and Southeast Asian sense of duty to community first. And Native Hawaiians and Pacific Islanders are no different. So we, more so than most states, had that mindset of, OK, we'll suffer for a little bit, but it's going to benefit the community. Obviously, now we're seeing more friction and more breaking point. But we're still better off than most when it comes to the response because of how unique our island community and sense of belonging is.

PH: Yeah, well, in closing, is there anything else that you would like to add to this conversation, Dr. Lee? Any final thoughts you want to leave with?

TL: No, I just hope that in the future, people take the time to listen to me and to everybody else that you and your team have taken the time to interview and to archive because we can learn from the past. We just have to take the time to want to do that and to recognize that there are trends that will always inform others. And if you don't learn from history, it's going to repeat itself. And hopefully we can. And hopefully the next generation will take some of the rough lessons that we had to go through and avoid them in the future. So that's really what I hope for whoever watches this or listens to it.

PH: Absolutely. Well, thank you so much, Dr. Lee for taking the time out of your Saturday morning to contribute to this oral history project. I think that will conclude our interview, so I'll stop recording.