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

  1. KauaiFarmMan November 17, 2020 4:24 am Reply

    Nobody cares anymore about our freedoms and rights. Fear has pushed people to abandon our freedom and push for a police state where “security “ outranks our constitutional rights. When Kauai is 90% mainlanders within 5 years because of widespread poverty here caused by our failed leaders draconian restrictions, you’ll all wake up and realize we traded our island and freedom for a not so dangerous threat. It’s absolutely pathetic how people are living in fear and want to make everyone homeless prisoners. Open everything before we have nothing. It’s so sad that no one cares about freedom. I have rights and so do you. Rise up against medical tyranny!

    1. James Z November 18, 2020 12:35 pm Reply

      ‘Nobody cares anymore about our freedoms and rights.’

      That’s not true, as apparently from your opening statement, you do, because you’re somebody. There are lot’s of ‘somebodies’ out there, and thus lots of people (most people?) who care very much about true freedom and rights, but also the responsibilities that go along with them. The ‘fear’ for many of us are called ‘concerns’ for our kupuna, friends, and family members. It’s true that we will have to learn to live with Covid-19 at least into the near future. That takes intelligence, wisdom and discipline, not foolhardiness and a devil-may-care attitude. Medical knowledge is not medical tyranny. You use of extreme language such as ‘Nobody’, ‘fear’, ‘tyranny’, does little to further conversation.

  2. Kyle November 17, 2020 5:44 am Reply

    Great write and spot on. The problem is common sense left the building. We are now in uncharted waters and went from zero to wide spread community transmission within 4 weeks of a failed pre test travel program. Quarantine today could slow this down again but at 10% tourism headed to 60% soon we are on a path to double digit daily Covid numbers . I thought Kauai had limited medical resources ?? Hmmm

    1. Fear Count November 17, 2020 9:54 pm Reply

      Fear is here!

    2. Fear Count November 17, 2020 9:56 pm Reply

      Fear is here! Bland undescribed Numbers take precedence

    3. Fear Count November 17, 2020 10:06 pm Reply

      1.) Fear is here! Bland undescribed Numbers take precedence.

  3. Ricardo November 17, 2020 6:39 am Reply

    Safety is obviously of primary importance, especially with our current obsession over Covid. Dr. Albert has advised multiple layers of “Swiss Cheese” to deal with the complex issues of detecting SARS-CoV-2 when it is contagious & spreading.

    The common Covid test, known as PCR, simply amplifies tiny amounts of genetic material. The questions that we need this test to answer are: 1) is active disease present? And 2) Is that disease contageous, will it spread?

    Unfortunately, PCR is a lousy test because it can’t answer those questions. PCR can’t tell if the genetic material is active or inactive. It also can’t tell if it is contageous or not. So, if you test positive on this lousy test, you could still be perfectly healthy. That doesn’t matter, you have been captured by the “Swiss Cheese.” Now you get to “age” for two weeks in a cheese cellar (isolation), healthy or not.

    But there is a better solution. In Finland they have been training dogs with exceptional smelling ability to detect Covid. The dogs are extremely accurate and reliable, even detecting Covid before it becomes symptomatic.

    Why don’t we just employ some trained dogs and find other uses for Swiss Cheese?

  4. Colin McCleod November 17, 2020 8:38 am Reply

    Great , Phyllis…more of what has not worked & will not work. Virus is as virus does…
    Colin McCleod

    From Tom Woods:

    “But here is some of the collateral damage caused by lockdowns.

    (1) In the UK, cancer authorities have been warning that the lockdowns will wind up leading to as many or more avoidable cancer deaths than COVID deaths there — as many as 60,000, according to one estimate.

    The UK’s Sunday Express – not exactly some obscure dispatch – reports that increased cancer fatalities will result from the redeployment of health resources caused by COVID hysteria. The BBC says the same. In fact, says Richard Sullivan, a professor of cancer and global health at King’s College London and director of its Institute of Cancer Policy:

    The number of deaths due to the disruption of cancer services is likely to outweigh the number of deaths from the coronavirus itself. The cessation and delay of cancer care will cause considerable avoidable suffering. Cancer screening services have stopped, which means we will miss our chance to catch many cancers when they are treatable and curable, such as cervical, bowel and breast. When we do restart normal service delivery after the lockdown is lifted, the backlog of cases will be a huge challenge to the healthcare system.

    According to the Daily Mail on October 6:

    Vital operations were cancelled and patients missed out on potentially life-saving therapy in the spring because tackling Covid-19 became the sole focus of the health service, instead of cancer and other cruel diseases.

    Almost 2.5 million people missed out on cancer screening, referrals or treatment at the height of lockdown, even though the NHS was never overwhelmed — despite fears it would be crippled by the pandemic.

    Experts now fear the number of people dying as a result of delays triggered by the treatment of coronavirus patients could even end up being responsible for as many deaths as the pandemic itself.

    (2) A United Nations report in April warned that economic hardship generated by the radical interruptions of commerce could result in hundreds of thousands of additional child deaths in 2020. The report further warned that 42 million to 66 million children could fall into extreme poverty as a result of the crisis.

    Even The Atlantic had to admit, “When you ask them to stay home, in many cases you’re asking them to starve.”

    And in the UK, The Telegraph says, “The absurd demand that developing countries adopt economically disastrous lockdowns is driving untold misery.”

    (3) The Well Being Trust in Oakland, California, released a study that seeks to determine how many “deaths of despair” (from drug or alcohol abuse or suicide) will occur as a result of the pandemic, including the lockdowns. Their estimate, according to CBS News: about 75,000.

    (4) UNICEF warned of 1.2 million child deaths — “visits to health care centers are declining due to lockdowns, curfews and transport disruptions, and as communities remain fearful of infection.”

    (5) Oxford University’s Sunetra Gupta has pointed to warnings by global authorities that as many as 130 million people are at risk of starvation thanks to the possibility of famine in several dozen places around the world, brought on by lockdown-induced disruptions of supply chains.

    (6) Suicidal ideation is massively on the rise in the United States.

    The federal government’s Substance Abuse and Mental Health Services Administration reports on percentages of people who have considered suicide within the previous 12 months, organized by age.

    People between the ages of 18 and 25 fluctuate between 6.8 percent and 11 percent.

    Now, from the Centers for Disease Control, we find that percentage (for the 18-24 group) has leaped to 25.5 percent — and this survey asks not about the previous 12 months, like the earlier one, but whether they’ve considered suicide just in the past 30 days.

    (7) The CDC estimates 93,814 non-COVID “excess deaths” this year, including 42,427 from cardiovascular conditions, 10,686 from diabetes, and 3646 from cancer, and many of these were caused by the cancellation of “nonessential” care in the midst of the COVID panic.

    Meanwhile, almost no American hospitals were actually “overwhelmed” during 2020, despite what your Facebook friends told you. In April alone, 1.4 million health care workers were furloughed because the hospitals were empty. In May NPR reported on those field hospitals that were assembled to take care of the surge of people who were supposed to appear: “U.S. Field Hospitals Stand Down, Most Without Treating Any COVID-19 Patients.”

    (8) According to The Lancet,( “During lockdown people with dementia or severe mental illness had a higher risk of excess death.” Dementia patients had a 53% greater chance of death because of lockdowns and elderly patients with severe mental illness had a 123% greater chance of death.

    (9) As a direct result of the lockdowns, the New York Times reports that there will be 1.4 million excess tuberculosis deaths, half a million excess HIV deaths, and 385,000 malaria deaths.

    See why “public health” shouldn’t be confused with “the monomaniacal fixation on one virus”?

    Meanwhile, if you look at the charts for country after country and state after state, you will not be able to tell which ones locked down, how hard they locked down, when they lifted their lockdown, whether they had a mask mandate, when they imposed such a mandate, and when and if they lifted that mandate. The charts show zero correlation. Zero.

    For example: for masks, click “If we only wore masks at the beginning this wouldn’t have happened” is hereby refuted.”

  5. nobody November 17, 2020 9:01 am Reply

    If local residents were restricted from travel the numbers make it look like Covid cases would be reduced by over 70%.

    See any large family or community groups of tourists hanging out without masks socializing? Locals have been 100% responsible for Covid community spread on Kauai.

    If we are going to solve the Covid problem we should first identify what exactly is causing the problem.

    Eric Clapton sang, “Before you accuse me, take a look at yourself”.

    That being said, I think we should have a mandatory second test on Kauai for all returning passengers and let them pay for it. Government can’t handle the $1,000,000 a week cost of doing this. If you can’t afford a test, don’t travel. Enough people will pay to keep the economy alive.

  6. Rev Dr Malama November 17, 2020 9:51 am Reply

    Yes Dr. I concur….. the intelligent approach is as you outline and although the governor has Supreme authority over the individual counties with the emergency exemption of due process of some laws, the federal democracy is the rule that must be followed.
    To opt out of treating all travelers with equanimity is a double edged sword that is cutting into the trust and FOUNDATION of the constitution of the United states and the Hawai’ian Kingdom government which is still in existence within the occupation of the Military industrial complex of Hawai’i….
    The Hawai’i Teachers union, Lawyer’s guild, We the Clergy and decades of PhD University Professors have heralded the call for Independence and SOVEREIGNTY against the destruction of our Aina and Moana.
    Please rethink the swiss cheese approach and do the pono action in supporting closing our borders in order to restore the heart, health and sanity to our Constitutional Monarchy….
    The Rightful Hawai’ian Kingdom.
    Read about out 127 years of struggle to support our Queen’s unanswered prayer at:

    Mahalo KE AKUA

  7. Everythingisawesome November 17, 2020 11:38 am Reply

    “the science supporting the requirement for wearing masks”

    It’s wishful thinking. Not science. Science involves observation. Observation reveals that regardless of mask practices implemented in the public at large, a virus spreads at the same rate.

    1. Citation needed November 17, 2020 7:15 pm Reply

      Show your observation data

      1. Everythingisawesome November 18, 2020 8:10 am Reply

        Here’s a good start, or you can observe with your own eyes. I suspect you are the type that won’t let facts, science or observation get in the way of your opinions.

        1. Citation needed November 28, 2020 12:15 pm Reply

          I suspect you are the type of person who doesn’t understand context with respect to data.

      2. Everythingisawesome November 18, 2020 8:35 am Reply

        None of these graphs of infections over time are just somebody’s opinion. It’s real world data.

        Do we judge whether a vacuum cleaner works or not by the size of the motor? The noise it makes? The color of the handle? Whether it picks up marbles off a carpet on QVC? No, we judge it by whether it makes a difference when we push it across the floor. A vacuum that makes a lot of noise but doesn’t leave the floor cleaner than when you started is useless… i.e. it doesn’t “work”.

        Your homework is to look at the graphs and apply the “vacuum cleaner” analogy to whether masks in public “work” to keep people in the general public from getting infected by a virus.

        For extra credit, tell me WHY masking in public doesn’t “work”. I’ll give you a hint…where do “experts”, and the data, does tell us the majority of infection spread occurs?…

        1. Citation needed November 28, 2020 12:18 pm Reply

          Your homework is to come up with a good analogy. The current vacuum cleaner analogy doesn’t reflect well upon the stats the graph shows.

          With your analogy, does the vacuum clearer work if half the people refuse to plug it in? Or if they hold the vacuum several inches away from floor when using it?

  8. Cheez Lueez November 17, 2020 1:41 pm Reply

    Double testing within 14 days still ignores the last minute infection in only a 7 day window of exposure.

    And no one, like the medical authorities at the airport entry to the island regarding, has discussed a positive tested Covid-19 virus person whose test was at least 14 days prior to arrival and the scientific knowledge that they are safe to enter having both immunity and being Non contagious.

    Otherwise why is there the 14 day state and medical mandate for Quarantine? 14 days is the amount to time for virus exposure and infection, met with the person’s natural immune response and completion of personal immunity with over production of natural antibodies for prolonged if not lifetime immunity and becoming NON Contagious as well.

    The study of immunology tells us:

    All the Positive tested people’s immune systems, after 3 to 14 days, develop enough specific bio-identical antibodies to deactivate all of the covid-19 virus in that person’s body.

    In addition our immune systems develop so many antibodies that there are enough antibodies left over to immediately deactivate any new invading covid19 virus trying to re-infect the body, with any amount of re-tries that covid19 virus may try to re-infect that same person. This what is called being Immune.

    When there are NO Active covid19 virus in the body after 14 days of the normal and typical immune system functioning, that person is also no longer Contagious, that is they no longer have covid-19 virus to infect other people with.

    This is why the state demands (only some people now) people need only to Quarantine for 14 days because it is known in science that after 14 days a person will have immunity and will have only deactivated covid19 virus or deactivated particles or fragments of the virus in their body; and can no longer infect or spread the virus to other people. That means the person is not only Immune and Not Contagious, but it also means they are now a part of and contributing to Herd Immunity.

    Herd Immunity means that any people who have already completed the 14 days of the Immune Process will no longer have Active Virus capable of infecting others.

    When enough people in a community like a small town or giant city become Herd Immune, any active virus in any new people coming into the community will find no other person they will be able to infect, because all the people with Herd Immunity.

    Because of this, personal immunity and Herd Immunity, the covid-19 virus will have nowhere to survive or multiply in other people ; and the virus will dwindle or fade away with no new human bodies they are able to infect or invade and not able to survive and multiply. Bringing an end to the Pandemic.

    This is a what happens with Herd Immunity, the virus succumbs and “disappears” because of its own INABILITY to find an available internal welcome environment of another human who does not yet have immunity.

    Humans are recent Vertebrates, Homo Sapiens, there are 40,000 species of vertebrates on earth. Vertebrates have either Fins, Feet, or Feathers, and all have spines and skulls that house and protect their brain, brain stem, and spinal cord. All vertebrates have immune systems to protect themselves from invasive disease virus. Vertebrates have many other body systems as well.

    Vertebrates have been evolving and perfecting Immune Systems for 550 Million years, and for humans, we are homo sapiens, and we’ve been perfecting our collective immune systems since we appeared on earth. Immune Systems, ready, willing, and able to protect us from invading disease virus and other organisms. What greater confidence could we have outside of ourselves and the intelligence that organizes our bodies.

    Clearly, the human specie can, and easily should, have Confidence in our own Immune Systems. Our Immune System(s) have been protecting us 24 hours a day since humans first became a new vertebrate species, and was that a few hundred thousand years ago or even some 1 or more millions ago, who knows, but we, the human race, has always, and obviously survived.

    It has only been since petrochemical pharmaceutical medication and prescription drug companies have had their pseudo science profit motive to sell more and more prescription drugs and over the counter medications that have we had this world wide move to use synthetic, and we must add, carcinogenic cancer causing
    petrochemicals drugs to take when we become sick. The medical profession chose some generations ago to offer medical drugs instead of teaching the return to Health and Wellness.

    The Immune Systems of vertebrates, including the recent addition of humans on earth, have proven their collective ability to protect some of the oldest vertebrates from external disease virus for 550 Million years. Of course with people humans only since we have been on earth.

    However, pseudo scientists, that is scientists who put profit first and ahead of the health of our environment and our precious bodies, are still trying to find a cure for Heart Disease, Stroke, Obesity, Diabetes, too many Cancers, Alzheimer’s, Kidney, Lung, and Liver Failures, and so many others, and have so far failed us other than having thousands of Toxic and sometimes Lethal prescription drugs on the market, distributed by doctors’ prescriptions and sold by drug stores and pharmacists. American doctors prescribe 4.4 billion prescription drugs a year.

    The disastrous shift from letting Nature runs its course as to virus or epidemics and pandemics, to only having prescription drugs, etc., drugs that interfere with the Natural Healing Process has been a work in progress for 100 years + or – of interfering with nature.

    All the medical and pharmaceutical industry has to show for it is that our Nation, the USA, has 80% of all of our people taking 1 or more prescription drugs a day in multiple doses. Some people take 5, 10, and even 15 or more drugs a day. How many do you take, making you less healthy.

    And there are millions of premature deaths, that is, loss of optimal Life Longevity happening to millions of people every year from the diseases these pseudo scientists and doctors profess they are treating, and the people in Blind Faith still believe in them, all the while they are begging us to believe in yet one more vaccine drug for the Covid-19 virus, most of the people are ignorantly living in fear hoping for a miracle vaccine.

    And these professionals are the very people we have been trusting, while they have been failing us with every other disease as well with millions of deaths, and now we trust these same pseudo profit driven scientists and doctors, and their mad quest to sell more drugs and vaccines, while for every other aspect of disease care they provide only drugs, while they ignore almost any approach to educating the people in their own daily personal Health Care of food and activity, etc.

    The word “Physician” means Teacher, and is a piece of paper with prescription drug instructions, or a pill bottle with instructions…an education in Health? NOT !

    80% of the Americans on prescription drugs, and 4.4 Billion drug prescriptions given out to the people per year? This is proof our nation is a sick nation, and no amount of “spin” words can deny this fact.

    It’s a RuiNation of a Nation, accelerated by politicians dicatating that we we do foolish things to hide from a microscopic virus that for the most part travels in the air, like all the other different viruses that comes every year, but a virus none the less.

    Politicians, only the most popular get elected, and few if any with knowledge of actual Health, followings their disease advisers, who depend on lots of diseases to make an upper level living, and why would they want this place disease to go away soon while they making large profits; and telling us we must hide from this viral disease by the futile use of masks and an arbitrary 6’ distancing, and wash your hands all day, and be sure to use the free antibacterial lotion at store fronts so you can kill off all the natural healthy bacteria on your hands and wrists, and upset the delicate bacterial balance on your skin so people can develop new skin diseases, and use more medications and prescription drugs.

    6’ social distancing because of sneeze, cough, or exhale, and these disease scientists think with a porous mask with side, top and bottom air escape openings does not infect the next person, all the while they ignore the smoke filled exhaled breath of a tobacco or vaping person as their toxic fog spreads through a whole room or while standing in line. When you smell cigarette smoke or any other aroma, it is already in your lungs and into your blood stream. And then you’re exposed and develop infection. What about the smells in a large public restroom, mask won’t stop that.

    What a silly immature notion to think 6’ distance saves you from an exhale of a virus infected person who has not had 14 days yet to naturally allow their immune system to deactivate all their recently infected covid19 virus.

    Wait, a negative covid-19 virus person has had no immune response nor have they developed immunity. They are both susceptible and contagious within the first 14 days if they get the virus while negative.

    But Wait, wait, if they are positive for 14 days already they are both immune to the covid19 virus and NON contagious. Which would you rather be + or – ?

    You can run, but you cannot hide from a virus.

    As a community we must all naturally nurture ourselves daily by diet and active lifestyle to naturally allow our Immune Systems to be functionally strong and be able to deactivate all covid-19 virus in our bodies and provide us Immunity and equally and naturally automatic Herd Immunity. And let’s not forget the functional health of our spines and head which house our nervous system which coordinates our immune system to deactivate the infecting virus.

    Exposure, + 14 days to develop immunity, quality nutritious food, no chemicals or sugar additives to the food, including Agriculture chemicals, and an active healthy lifestyle…That will end this national epidemic and worldwide pandemic.

    UNLESS you are elderly with one or more of the end of life diseases and are under medical care with numerous prescription drugs for years and decades, it might be BEST FOR YOUR HEALTH and others to become covid-19 positive, and after 14 days develop personal immunity and become NON CONTAGIOUS and become part of herd Immunity.

    After all before they had prescription drugs, this is how humans recently on earth, and all vertebrates before the humans survived epidemics and pandemics throughout the last 550 Million years of history. It should be easy to have confidence in your immune system.

    Main thing you need to practice Health and Wellness every day in your food intake and lifestyle, and protect and take care prof your Neuro-Spine. Those efforts alone can keep you from sick places like hospitals and doctor offices, and disease testing centers.


  9. Eric Shapiro November 18, 2020 9:43 am Reply

    Lots of good information above. Read, be aware and be safe.
    I think the pre-test, 3 days quarantine and then post-test is a very viable option – and balances risks and rewards fairly safely. I didn’t mind the $150 charges, although I think that there should be a wider range of places to spend the ‘script’ that was given.

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