Lessons from the U.S. Pacific Islands in Response to the COVID-19 Pandemic

January 25, 2021 | Karl Ensign

Over the past year, we have become accustomed to a new normal—quarantining, meeting on Zoom, wearing masks in public, and maintaining physical distance in the presence of others. However, as COVID spreads across the United States, with infection rates rising in every state, the U.S. Affiliated Pacific Islands (USAPI) have received media attention for being relatively free of COVID, with the exception of Guam. Recently, the USAPI has again received attention for leading the nation in vaccination rates.

The U.S. Pacific Islands Academy’s unified response to the global pandemic is a groundbreaking story of collaboration, communication, and partnership. The success of public health leaders provides important lessons for preventing, preparing for, and responding to future public health emergencies.

The Pacific Islands Alliance is made up of three territories (American Samoa, the Commonwealth of the Northern Mariana Islands, and Guam) and three freely associated states (the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau). Citizens of the territories are U.S. citizens by birth. However, territories are treated differently than states when it comes to federal funding.

For example, caps were placed on Medicaid reimbursements, which impacted the ability to build an integrated public health and health care system.The three Freely Associated States (FAS) are independent nations that have entered into a free association agreement with the U.S. government that allows citizens to travel to states and other territories without U.S. citizenship and without visa restrictions.

Each of the six jurisdictions has a unique history and culture that dates back to ancient times. As Western exploration began, the islands were referred to as “stepping stones across the Pacific.” This construct was imposed by the dominant culture, and today’s nomenclature “USAPI” reflects the strategic national interests of the United States.

Guam is “where the day begins in America,” with both a naval base and an air base, as well as the Guam National Guard. In fact, the Department of Defense controls one-third of the island’s 212 square miles. Guam and the Commonwealth of the Northern Mariana Islands (CNMI) are both located approximately 2,000 miles from North Korea and less than 3,000 miles from China. As a result, Guam and the CNMI are sometimes collectively referred to as the “Tip of the Spear.”

To say that globalization has been bad for these jurisdictions is a gross understatement. While deadly clashes have occurred, they are minor compared to the devastation caused by infectious diseases upon first contact. It is difficult to estimate the actual impact of the disease on the local population, but the effects are said to be horrific. Through word of mouth, it is widely believed across the islands that there are not enough living to bury the dead.

Today, the Pacific Islands of the United States suffer from both First World and Third World problems. In addition to mosquito and waterborne diseases, the Pacific region faces major population health issues such as imported food and Westernization of diet and lifestyle. The region leads the world in deaths from non-communicable diseases and has some of the highest obesity rates in the world.

In fact, the proportion of people with diabetes in the population is two to four times the national average in the United States. Medical institutions in Guam report that half of the deaths from COVID-19 are among people with diabetes. In the U.S. state of Arkansas, a common destination for citizens of the Republic of the Marshall Islands, the reported COVID-19 death rate for Pacific Islanders is 1,713 per 100,000 people. This is in stark contrast to the statewide average of 11.

However, despite these documented needs, laboratory capacity, health infrastructure, and testing capabilities have been challenging in USAPI. Despite much work on laboratory training and development, it is common for laboratories to send samples to Hawaii and the mainland for analysis. Access to clinical and health care services is limited, especially in FAS jurisdictions and remote outer islands.

Watch The USS Roosevelt Incident As the pandemic spread in Guam and community transmission began, FAS leaders took decisive and drastic actions that most people considered premature and unjustified, effectively closing the border for nearly a year. The territory of American Samoa soon followed suit. While the border between Guam and the Commonwealth of the Northern Mariana Islands remains relatively open, travelers are subject to mandatory quarantine and testing upon arrival.

The widespread fear of contagious diseases from outside the country has allowed the authorities to strictly enforce the new measures. After unloading cargo in the Republic of the Marshall Islands, a United Airlines flight suffered a mechanical failure after landing in Majuro and was unable to take off again.

However, the crew and passengers on board were not allowed to enter the airport facilities or transfer to other facilities on the island. Instead, they were required to spend the night on the plane until the rescue plane arrived the next morning. In Guam, a woman who refused to enter the quarantine area after arriving at the airport was arrested and jailed.

With their borders secured, Pacific jurisdictions assessed their stockpiles of supplies and equipment. As states scramble to acquire testing supplies, personal protective equipment and ventilators, U.S. Pacific island nations are at a distinct disadvantage due to their relatively small populations and remote locations.

ASTHO’s partner organization, the Pacific Island Health Officials Association (PIHOA), stepped up to serve as a distribution point for donated supplies from nonprofit organizations such as the World Health Organization (WHO), UNICEF, the World Bank, and federal agencies (most notably the Office of the Assistant Secretary, the Centers for Disease Control and Prevention, and the Federal Emergency Management Agency), as well as various Asian countries.

Within a few months, all jurisdictions procured ventilators, PPE, stockpiled oxygen, and increased testing capabilities through the Abbott ID and BinaxNOW systems or GeneXpert devices. PIHOA procured and distributed ventilator supplies (such as regulators and tubing) and oxygen delivery supplies (including non-respiratory masks, nasal cannulas, and endotracheal tubes).

Weekly meetings were held in early February 2020 to coordinate procurement and distribution. Organizations representing both the global and domestic response were invited to attend and provide updates on the plans. Over time, three different sets of weekly calls emerged:

1. Jurisdiction-specific calls to collect basic information on testing capacity, border security and quarantine policies, community mitigation measures, supplies and facilities, and vaccine planning and administration convened by PIHOA and CDC.
2. PIHOA convenes a conference call with global and domestic partners.
3. Support calls to involve partners and justice leaders.

These weekly calls have been critical in coordinating and planning for a range of issues, including vaccine programs, coordinating the entry of health care workers, and the subsequent repatriation of citizens stranded outside the jurisdiction. A unique dual quarantine system was developed and coordinated. Hotel facilities in Honolulu were reserved for travelers heading west for the first quarantine, and facilities in Guam were reserved for the second quarantine. Testing was required for both phases before travelers were released. Early on, Guam developed testing capabilities and expanded them to the region, and later the Commonwealth of the Northern Mariana Islands loaned Palau an ultra-low temperature freezer so that the jurisdiction could receive the Pfizer vaccine. Public health leaders from states with relatively large Pacific Island populations were invited and participated in select calls to develop strategies for reaching and engaging these populations in the continental United States.

Recognizing the potential threat posed by COVID, public health leaders in the Pacific took early and decisive action within their respective jurisdictions and worked across jurisdictions and with numerous partners to develop plans and strategies. The foundations that have been established are strong and should be maintained. To help prevent future public health crises, prepare for those that are coming, and respond effectively to future events, we must:

• Establish high-quality public health and health care systems in each jurisdiction that cover all aspects – preventive and public health measures, testing, detection and treatment. The USS Roosevelt’s reliance on Guam demonstrates the global and strategic importance these islands continue to play.
• Develop shared resources at the regional level. With this in mind, the 2021 Department of Defense Authorization Act appropriates $19 million to establish a public health laboratory of sufficient size and technical level to meet the needs of the region.
• Create enhanced data capabilities for surveillance, disease tracking, and situational awareness, and to inform communications between partners and jurisdictions.

You should also consult previous plans that have been developed. These include PIHOA’s Declaration on Non-communicable Diseases 2010Asian Development Bank 2005 Pacific Projectand the National Academy of Sciences 1998 Pacific Health Partnership To name just a few. With these measures in place, USAPI will emerge from current threats stronger than ever.