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In a chapel in Kihei, Maui, a service quickly pivoted from the Book of Jeremiah to an hourlong seminar with controversial medical advice about Covid-19. Pastor Kirk Milhoan said he wanted to have an open conversation about the uptick in coronavirus cases, pulling up a presentation full of graphs and charts for people to “connect the dots.”

Milhoan, who is also a pediatric cardiologist, does not require the use of masks or enforce social distancing guidelines. He also has come under fire for his advocacy of drugs that have not been approved for use in treating Covid.

“I think that we’ve got to read in between the lines on what the CDC says if they’re telling you that every vaccinated person has to wear a mask inside,” he said during a recent sermon that was posted on YouTube.

In a different church seven miles to the north, Pastor Josh Marocco stood on his self-proclaimed soapbox and stressed that the decision on whether to take the Covid vaccine is a personal choice. He equated it with the debate over abortion rights, saying his parishioners should have the same rights to choose what they put in their bodies. Correction: An earlier version of this article attributed the comments to James Marocco, but it was Josh Marocco who said them.

“We’re going to love people,” he said, pacing across the front of the cathedral in a charismatic and assertive fashion as members of the congregation followed his every move. “Whether someone has gotten the vaccination or not, we’re not going to vilify people, right? We’re not going to condemn people.”

Island hopping to West Oahu, Waianae Baptist Church Pastor Michael Brooks sat casually on a stool at the front of his congregation, feeling the trade winds rush through the surrounding open doors as he explained that faith in God can heal the sick and bring miracles.

All three churches are within areas experiencing some of the highest numbers of coronavirus cases. In the past two weeks, Waianae recorded 732, while Kahului and Kihei collectively had 396. Vaccinations also lag. Fewer than 35% of Waianae residents are fully inoculated while Kahului and Kihei vaccination rates fall between 45% and 60%.

Statewide, the vaccination rate is nearing 63%.

They also illustrate some of the key challenges as government and health authorities try to contain the rapid spread of the delta variant with vaccines, safety protocols and crowd size restrictions while balancing concerns about the effects on personal freedoms, vaccine hesitancy or outright rejection and the need to separate church from state.

According to Richard Flory, the executive director of the Center for Religion and Civic Culture at the University of Southern California, the three churches are from different denominations but fall under the broad umbrella of evangelical Christianity. Flory explained that historically, these churches tend to be dominated by white, conservative theologies.

“The history of evangelicalism has a history of opposition to change and to threats,” he said, adding that the church leaders have the power to influence the behavior and decisions of their congregations.

On Aug. 10, Gov. David Ige reimposed restrictions on the sizes of gatherings amid a record number of Covid cases and hospitalizations across the islands. But , leaving them with a variety of individually determined health protocols.

Hawaii reported 938 new Covid cases and five more coronavirus-related deaths on Saturday.

The state Department of Health has detected over 25 different coronavirus clusters in places of worship since November, pointing to the fact that common behaviors at church such as hugging, singing and eating are .

The department, which normally doesn’t provide specific locations for outbreaks, became so concerned in March that it took the rare step of singling out King’s Cathedral in Kahului and accusing it of poorly handling the spread of a cluster of over 50 people.

The also reported in May that a church in the Honolulu neighborhood of Kaimuki tried to hide a Covid outbreak from the DOH after spreading misinformation and conspiracy theories against the vaccines.

The DOH has not reported an outbreak in a place of worship in its weekly cluster report since Aug. 5 even as the state’s positive infection rate has surpassed 8%, but health officials acknowledge the cluster reports present an incomplete picture, especially as the increased use of home testing kits allows people to avoid reporting infections to the state.

Health Department spokesman Brooks Baehr said contact tracers try to get in touch with the person behind every active Covid case in the state, but it’s become increasingly difficult with a limited staff and surge of infections.

On Kauai, District Health Officer Janet Berreman said authorities have been successful at contacting every positive case on the island but acknowledged they depend on people being honest about where they've been in the early days of their infection.

"There's going to be more or less complete data collection, about those things, depending on how successful we are in reaching all the cases," she said.

Milhoan remains unapologetic about mixing his roles as pastor and medical doctor, offering to make free house calls for people who are ill and prescribing the malaria drug hydroxychloroquine and ivermectin, an anti-parasitic mostly used to treat roundworm infection.

"I am treating them with an approved human medicine. And I'm using it within the appropriate dosages," he said in an interview Saturday.

The Food and Drug Administration issued a new warning against using ivermectin to treat or prevent Covid on Aug. 21, noting it's largely intended for livestock. "You are not a horse. You are not a cow," the agency said in a tweet .

DOH Director Dr. Libby Char also of unapproved drugs to treat Covid on Wednesday.

“I want to be clear -- hydroxychloroquine and ivermectin should not be used to treat COVID-19. Taking unprescribed large doses of ivermectin or doses intended for animals can cause serious harm," she said in a statement.

The Hawaii Medical Board also filed complaints against Milhoan and Dr. Lorrin Pang, the state's top medical adviser for Maui County, last week over the issue. The two men are co-founders of The Pono Coalition for Informed Consent, a website that calls the Covid vaccines “experimental” and advocates instead for the use of the controversial drugs.

"I don't necessarily understand why Dr. Pang is coming under so much fire," Milhoan said. "I'm sort of somewhat bewildered because as physicians, we talk about things in conferences all the time that are controversial."

Milhoan added that in the past year, he's seen a lot of newcomers to his church because he does not require the use of masks or follow other .

He acknowledges that the delta variant has made it more difficult to manage the risk of the virus, even forcing him to cancel in-person services on the first weekend of this month.

"Everyone in our pantry got it — all of our volunteers." -- Calvary Chapel Pastor Kirk Milhoan

But, Milhoan said that generally the church's mission must continue, comparing the risk of getting sick to the risk a fireman takes when he saves people in a burning building. Milhoan said over 100 volunteers work in the church's food pantry, helping prepare and serve thousands of meals for people in need.

After collecting a surplus of home-testing kits, he said he also has given about 30 kits to community members who did not want to risk being officially recorded by the DOH. And while Milhoan describes himself as someone that is pro-vaccine with respect to other diseases he said that he is "not thrilled" about this one.

He also said the risk is lower because he and many other church volunteers have natural immunity after contracting the coronavirus.

"Everyone in our pantry got it — all of our volunteers," he said. "There's no reason for me to get a vaccine because my immunity is better than vaccine immunity."

Meanwhile, in King's Cathedral, Marocco preaches about personal choice with regards to the vaccines.

Marocco said the church recently hosted a scientist who "works specifically on vaccinations for Covid" and shared "the good, the bad and the ugly" about the shots.

Marocco refused to identify the scientist because he had not asked for permission to do so.

King's Cathedral now operates like a restaurant — people are asked to mask up when walking through the building but may remove the face coverings once seated.

On the west side of Oahu, Waianae Baptist Church operates similarly with optional mask wearing when seated. Pastor Michael Brooks read a passage from the Book of Mark on a recent Sunday.

It described how Jesus healed a woman who had been bleeding for 12 years.

Brooks paralleled the biblical miracle with the current desire for healing, noting that sometimes it takes years of suffering before miracles occur.

In a follow-up interview Brooks said that initially he did not want to get the vaccine, but he decided to get a shot after months of traveling and spending money on Covid tests. Now, he encourages people to get inoculated if they ask but says he avoids giving medical advice during sermons.

"I just don't see that as my mission," he said. "There's enough people and news folks and everything else talking about it and that's not what I'm here for."

Brooks said that they have not had positive cases in his church and his biggest concern right now is the loss of freedom.

"Free speech seems to be disappearing. You know with the big companies, anything you post online, if they don't like it, they take it down, you know, that scares me more than COVID," he said.

The Rev. Diane Martinson, who presides over the congregation at St. Peter's Episcopal Church in Honolulu, is worried that the news about churches suffering Covid outbreaks and preaching against vaccinations is giving all churches a bad reputation.

"That's not the only voice out there," she said. "The community is wider in scope and that is very true of the Christian community too."

During her services, Martinson projects her voice through her mask to an audience of parishioners also wearing face coverings. The church operates under 50% capacity, requires masks at all times, refrains from singing and strongly encourages the community to "love thy neighbor" by getting the vaccine.

"We're getting confused about what freedom is in this culture. It's not total, 'I can do whatever I want,' it never has been," she said. Martinson said that everyone agrees to a "social compact" when wearing a seat belt in the car for the safety of the community and that following federal Covid guidelines should be looked at in a similar light.

Flory, meanwhile, noted that preachers are able to influence people in a way that can save lives. He said more evangelical leaders have openly supported vaccination amid the recent surge in coronavirus infections.

"They have a lot more power than I think we recognize," he said.