COVID-19 in the Pacific: What We’ve Learned and Where We’re Going

ROBERT JOHNSON:
This is Public Health Review, I'm Robert Johnson.

On this episode: keeping the COVID-19 virus at bay in the Pacific Islands; how public health leaders have managed the pandemic.

JACK NIEDENTHAL:
So we were struggling already with two diseases sweeping through the Pacific. And then we, in January of 2020, we started hearing about this outbreak in Wuhan, and we immediately were like, "Oh my God, we can't do three diseases at once." And so, we really started preparing right away.

HALEY CASH:
I think one of the most important lessons learned is that, again, these border closures were really effective during the early pandemic just because they allowed us the time to be able to prepare for COVID-19 transmission and to get populations vaccinated.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

It comes as no surprise that people in the Pacific Islands are prepared for weather events—that's because storms are a way of life when entire nations are surrounded by a never-ending expanse of ocean waters. But when COVID-19 began to spread like a tidal wave across the globe, there was concern that this storm could be different. Limited healthcare capacity and increased risk factors among many island populations forced public health professionals to recommend drastic measures intended to keep the virus out and people healthy.

Today's guests have been in the eye of the COVID-19 storm from the beginning. Dr. Haley Cash is an epidemiologist working for the Pacific Island Health Officers Association. She's along later to give us her assessment of the last two years and the way forward.

But first, we hear from Jack Niedenthal, secretary of health and human services for the Republic of the Marshall Islands, about the early days of the pandemic and the plan his government developed to hold back the novel coronavirus.

NIEDENTHAL:
So, we were struggling already with two diseases sweeping through the Pacific. And then we, in January of 2020, we started hearing about this outbreak in Wuhan, and we immediately were like, "Oh my God, we can't do three diseases at once." And so, we really started preparing right away. I'm surrounded by some really brilliant, intelligent people, both Marshallese and some—we have Fijians, like I said, and Filipino doctors. So, we got together and we immediately started saying, "We don't want this in here."

And we had one PUI—which was a person under investigation. A man had come from Washington state in early March of 2020, and he had all the symptoms and walked right into our ER. And we thought, we had been told every week, "This is it. This is that. It's coming, it's coming, it's coming." We were making all the preparations and—you have to understand back then, there was no testing and we didn't the capability to test here, and we were really scared.

And so, this guy shows up and we put him in quarantine. We send the test off-island and it comes back after a few—we had to wait a few days even to find out if he was positive or not while he sat quarantine and he had all these contacts. And it came back negative. So we said, "Okay, that's it. We're closing the borders," which was really dramatic. No one else in the Pacific had done something like this. We were the first ones and it was not easy.

We had a long, long meeting with a lot of the relative players here in the Marshall Islands. It took about seven hours to convince people in a room where I was kind of in the center of the room at the time, surrounded by my Ministry of Health colleagues, and it took a long time to convince people. But we did it, and we closed the borders. And everybody around us in Micronesia and the Pacific region were saying, "Wow, you guys are crazy. Closing the borders, that's such a dramatic thing to do. Why would you do that?"

But within two weeks, everyone was doing it out here in the Pacific, because you have an island. It gives you this very unique situation where you can monitor who goes in and who goes out. The goal here was to keep the borders closed until the science caught up with the virus. In other words, we knew there was probably some point going to be really good testing for COVID, and we really knew there was going to be some vaccines at some point; but let's stay closed and stay safe until that happens.

Really radical sort of approach, but we're sitting here two years later living a normal life: we don't have masks, we have gatherings, schools have never closed, kids are given a normal childhood. But we're still, you know, scared that it's going to come. So, we're still on edge here.

JOHNSON:
So, a full closure for how long?

NIEDENTHAL:
Well, full closure—in terms of no one coming here, really nobody coming in—was from March till June of 2020, and at that point we started slowly bringing people in. We really developed our own protocols and our own science for a lot of it that's been very successful until now.

We still are closed—you just can't fly right in here. You have to spend some time in quarantine on both sides, outside and once you get here.

JOHNSON:
What was the initial community reaction to the idea of closing the borders completely?

NIEDENTHAL:
Well, like I said, we had to go to what's called the national disaster committee—which I'm part of, but it's only one vote out of eight. And because it's got all the ministries in it and because this was involving—it began as a state of health emergency, which it still is. It's been—we've been 32 months into a state of health emergency. It's been most of the time I've been secretary of health. There's only been five or six months where we haven't been in a state of health emergency, so it's been pretty brutal.

But we had quite a debate. There was a lot of economic factors—how do you get food in with the ships? So, we developed all these protocols where there be no human-to-human contact that was critical. And so we—the container ships, and we got the flights, and we'd go in and they'd have full PPEs on to deal with the airplanes. Once they started bringing people here, we've just been really, really careful. And that's all the way through Delta and Omicron and the original outbreak. 

We've only had seven border cases—and I would say really four because, as we look back, three of those cases were probably historical, but we didn't have the science at that point to sort that out. So, we've had a few border cases; but outside of that, we've had nothing.

But the reaction to the community at first was quite an uproar. And I can remember the day after we closed the borders, walking into a restaurant and a good friend of mine as I sat down said, "How does it feel to be the most hated man in Majuro?" because a lot of people were angry. But the American Graduate School just sent out a report two weeks ago that said our economy has had little impact from COVID because we managed to keep the economy going and we've never had any lockdowns. So compared to a lot of countries, even then in the Pacific, our economy has done better than most places.

JOHNSON:
What are you doing inside the country to protect the population?

NIEDENTHAL:
Yeah, we've had a massive vaccine campaign. And you have to understand ours is probably one of the most complicated countries in the Pacific because we have 29 outer islands and atolls, and we've got to get to those populations in some of those outer atolls. And an atoll is like a necklace of islands, and people live on all those little islands in the necklace. And so, you've got to get to all of them somehow, and it's very, very complicated logistically.

So, over the past year—we started in December, we got some of the first vaccines. The United States has been fabulous, and I want to say that as a person who—for 30 years, I worked for the people of Bikini and I was basically their battering ram when they'd go to Congress. I fought the United States for 30 years. So, when I compliment the United States after all the nuclear testing and some of the things that have happened out here, it comes with a little bit of pain.

But I'm saying that the United States has been remarkably great to this region—the Freely Associated States, Palau, FSM, the Marshalls, and Guam, and the jurisdictions out here—because we had vaccines before most people in the States could get them. We started vaccinating here—I got my first vaccine December of 2020. My mother who lives in Pennsylvania, is 86 years old at the time, had to wait until April and she had to drive four hours to get it. So, we were vaccinating and anyone who wanted a vaccine—after about a few weeks after we vaccinated our front liners—anyone who wanted a vaccine could walk in and get it in five minutes, regardless of your nationality, or, you know, you had to be 18 and above at that time.

And then, we went on a door-to-door campaign, which is very unusual here when it comes to vaccines, but we went from one end of the atoll to the other. Then, we had this big project that lasted seven months. We went to all the outer islands where they had to get two doses a month apart—that's really complicated, very expensive. We're trying to get the money to do another round where we give boosters—that's going to cost about a million dollars for us.

JOHNSON:
In terms of resources, what would you say turned out to be the most helpful?

NIEDENTHAL:
Well, again, I'm going to toot the United States' horn. They've been so fantastic. First of all, they got us the testing capabilities right away. That was critical for us because we were having to—the second time we had a PUI, a person under investigation, we had to wait eight days to find out if that guy had COVID. Once we got the testing, that was really helpful.

And the second thing—that a lot of people may not think it's a big deal, but it is—we had weekly calls with the U.S. CDC. We've had 104 weekly calls every single week with the CDC. We've got two calls, sometimes three. Information has been tremendous coming out of the CDC. And we have this group call with all these jurisdictions in the Pacific where we share ideas. It's really been tremendous. So, information has been a tremendous help.

And then thirdly, they gave us the vaccines. So, the U.S. has been a great resource.

But I want to say Taiwan has been tremendous, giving us lots of PPEs and coming in and just—they gave us these containers that are like portable labs—they've been a great partner. Australia helped pay for a lot of our outer island activities, which are very expensive in terms of getting the vaccinations out. Japan has been a good partner. So, a lot of people in the Pacific have come together. New Zealand gave us a pretty good chunk of money.

So, we've had a lot of help from the outside and the critical part for us as a nation and the national disaster committee led by Chief Secretary Kano and the Cabinet President Kabua—it's been critical that we all work together.

JOHNSON:
Is there anything about your experience there that could inform or help your colleagues here in the U.S. the next time they face a crisis like this

NIEDENTHAL:
Well, the one thing I see here that I don't see in a lot of places anywhere is a very high level of cooperation between everybody.

I can almost guarantee you if suddenly we had COVID here and we told everyone to wear a mask, they would wear. There wouldn't be all this hemming and hawing about individual rights and things like that. We want to protect our kids. We want to protect our elders, especially. Our culture here, the older people are—and I know they are in every culture—but out here, you don't have nursing homes. You take care of your old people until they're gone and you take care of them very carefully. They're revered. And so, the idea of, you know, if you wear a mask, you're protecting your elders—we're not going to have any problems with that.

And all the different protocols we're going to have to put place so far has been really, really well done. And when I see what happened in the United States, it was really unfortunate.

JOHNSON:
I'm sure everyone there would like things to be fully open again. But if I'm hearing you right, your message right now is we're not there yet.

NIEDENTHAL:
No, and we don't want—like I said, we're so immunocompromised in this population. I just dread the day that I get the call. Every time my phone rings, it's like, "Oh God, is this it?" It doesn't matter who's calling me, you know. When we get that community spread—if, if, I never say when, but I say if, I don't want to jinx it—but if I get that call, it's going to be a different world for us. I'm not looking forward to that, that's for sure.

JOHNSON:
Three U.S. territories and three Freely Associated States make up the Affiliated Pacific Islands. Together, these jurisdictions have worked hard to ride out the pandemic storm, knowing a full scale outbreak could be devastating in their communities.

Dr. Haley Cash is an epidemiologist for the Pacific Island Health Officers Association.

CASH:
Something a bit unique about the USAPI is that they have a very high prevalence of non-communicable disease. And many of these USAPI—as many as three out of every 10 adults—has diabetes. And when we look at those older adults—so those adults 65 and older—about half of those adults have diabetes in many of the USAPI. So overall, just a very high burden of non-communicable disease in this population.

JOHNSON:
How does that figure into the calculation when it comes to trying to control any kind of viral outbreak?

CASH:
Sure. So, with COVID-19 specifically, we know that those non-communicable diseases are risk factors for severe disease and death. So, when we look at our population in the USAPI, that overall they're at a much higher risk for that severe disease and death.

JOHNSON:
How has the course of the pandemic differed there from, say, the way it rolled out here in the continental U.S.?

CASH:
Many of the USAPI closed their borders early on in the pandemic. This was when the U.S. was first starting to report their first cases in many of the states, so a really quick response to close those borders.

Guam is actually the only jurisdiction in the USAPI who's experienced transmission throughout the pandemic. CNMI detected some cases early on in 2020, but was able to close their borders and prevent widespread community transmission until the Omnicon variant showed up. Palau and American Samoa actually prevented any community transmission through use of border closures and strict travel protocols, again until Omicron showed up on island. Whereas FSM and RMI—so, the Federated States of Micronesia and the Marshalls—actually still have not identified any community transmission and their borders remain close. So, quite different situation in the USAPI.

JOHNSON:
The island response to COVID was different from the response here in the U.S. Tell us how.

CASH:
The jurisdictions who do not have any community transmission is because of those border closures, and many of the USAPI were able to close their borders early on. However, they quickly realized that they needed a mechanism to get stranded residents back in country. So, they actually implemented these large scale repatriation efforts to safely be able to get folks back into country.

JOHNSON:
How did closing the borders impact life on the islands?

CASH:
So, as I mentioned, many of the residents unfortunately were stranded off-island and, you know, folks on-island were unable to travel back and forth freely without long quarantines on both ends of travel. However, actually on-island, the benefit is that most folks were able to live fairly normally while the rest of us were locked down. But in the jurisdictions who rely on tourism, there were some substantial economic impacts, unfortunately.

JOHNSON:
Was it hard to sell people on the idea of closing the borders?

CASH:
You know, I think early on there was so much panic around COVID-19 that it was a pretty quick sell. You know, initially these weren't meant to be long-term border closures; but the benefit to closing those borders really allowed all of these jurisdictions who oftentimes have limited clinical capacity to take a step back and properly prepare for their first cases of COVID-19. So, the border closures were a huge asset in the region.

JOHNSON:
Were there any close calls with regard to having enough resources to respond?

CASH:
Fortunately, no close calls. You know, there was some last minute scrambling, but we, you know, through strong partnerships, we were able to leverage resources as needed on a last-minute basis.

JOHNSON:
Tell us about those partnerships. What are you referring to?

CASH:
Sure. So, there are both partnerships on the larger scale with regional and international partners. So many of the support partners met with the jurisdictions over Zoom, at least weekly or sometimes biweekly throughout the pandemic—those calls are still ongoing—just to coordinate responses, share information back and forth, and make sure that the needs are being met from each of the USAPI.

JOHNSON
Who was involved in these partnerships, and what kind of support were they providing?

CASH:
There was technical support, so just sharing best practices, sharing information back and forth. There were some more formal remote trainings done, specifically some clinical trainings. There was also a lot of support around providing resources, such as test kits, making sure that the jurisdictions had adequate vaccines, as well as therapeutics when those came down the pipeline as well.

JOHNSON:
Thinking about vaccines, the vaccination rates, we understand, have been very high on the islands.

CASH:
Yes. Thankfully in most of the jurisdictions, the vaccine coverage is quite high. Again, this is largely due to some really great partnerships on the ground. Many of the jurisdictions found that the best success was with working through local community leaders, as well as traditional leaders, to make sure that the correct information was getting out into the community and that vaccination was encouraged. So, thankfully we did see quite high vaccination coverage across the region.

JOHNSON:
Messaging in the U.S. has been difficult: getting people to buy into the vaccines, finding the right messengers, reaching them, convincing them. How did that process play out in the islands?

CASH:
You know, like everywhere else, vaccine hesitancy was also a challenge in the USAPI. But this is where we really trusted on our health leaders to make sure, you know, the correct education was getting out to folks, and we worked with these individuals to help combat the misinformation that was going around.

In many of the USAPI, they actually ended up leading house-to-house efforts in which local health professionals were really able to take the time to talk to families and individually provide information and answer any questions. So, quite a personal response in many of the jurisdictions.

JOHNSON:
What have been some of the challenges to the response the last two years?

CASH:
I think the biggest challenge has been really the human resource capacity. This continues to be an ongoing challenge. We've seen staff being pulled from various areas of local health departments to assist with COVID-19 efforts, and these folks have been working tirelessly for, you know, two years now.

So, as we move forward to a new phase of the pandemic, we're now faced with the challenge of trying to reenergize a lot of these health programs and efforts while still continuing to maintain adequate COVID-19 response efforts.

JOHNSON:
What have public health professionals learned from this pandemic?

CASH:
I think one of the most important lessons learned is that, again, these border closures were really effective during the early pandemic, just because they allowed us the time to be able to prepare for COVID-19 transmission and to get populations vaccinated. And, you know, this was really critical given the high prevalence of risk factors for severe COVID-19 and death in these USAPI, as well as the limited clinical capacity. So, it allowed us to take that pause and to prepare, which was a huge asset.

Another big lesson learned was that we found vaccination and therapeutics were highly effective tools to help reduce rates of hospitalizations and death.

Just to highlight one of the jurisdictions, Palau was actually able to vaccinate nearly all of their eligible population prior to a widespread community transmission. Then, they were able to administer therapeutics to their high-risk individuals and get vaccine boosters out really quickly to this population. And, you know, by using vaccination and therapeutics in Palau, Palau actually had very low rates of hospitalizations and deaths during their first COVID-19 surge, which happened early this year.

JOHNSON:
You've had an opportunity to experience the pandemic from a very unique point of view. Do you have any recommendations for your public health colleagues based on what you've learned the last two years?

CASH:
Yeah. You know, again, I think that one of the biggest challenges has been trying to maintain other health programs while also responding to COVID-19. So I think, you know, moving forward and thinking about future responses and response planning, you know, it'll be good to think about the lessons learned during COVID-19.

We all had to think outside of the box about how to deliver health programs and deliver health services in a more non-traditional fashion. So, I think it'll be great to think about how we can weave those alternative health delivery systems into future responses to make sure that we can continue to deliver routine healthcare and other health programs while also responding to emergencies, given this long-term pandemic we've all been through.

JOHNSON:
Thanks for listening to Public Health Review.

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For Public Health Review, I'm Robert Johnson. Be well.