The people of the US-affiliated Pacific Islands (USAPIs) face a drastically different level of access to health care and public health services than those residing on the US mainland. Geographic and systemic factors combine to create a unique set of economic and health disparities for these areas. Communicable and other tropical diseases have historically drawn the focus of the islands' curative and public health systems and continue to do so-dengue, chikungunya fever, and Zika virus disease are the latest of such threats. In addition, climate change now presents an increasing threat to infrastructure, food security, and economic development.1 Meanwhile, the entire Pacific region is battling a chronic disease crisis. A "perfect storm" of social, economic, environmental, political, and health complexities poses particular challenges to improving public health practice and ensuring equitable and optimal health for all in the USAPIs.

The USAPIs consist of 3 US territories-American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands (CNMI)-and 3 sovereign nation states holding compacts of free association (COFA) with the United States (also known as the compact nations or freely associated states), which include the Republic of Palau, the Federated States of Micronesia (FSM), and the Republic of the Marshall Islands (RMI). Together with the Caribbean territories of Puerto Rico and the US Virgin Islands, these jurisdictions comprise the US insular areas. These designations came about through various mechanisms over the course of more than a century,2,3 with most Pacific associations commencing after World War II (WWII) in acknowledgment of the significant positioning of the islands to the US military.4 Today, the USAPIs represent a combined population of more than 450 000.5 Those born in the territories are US citizens (or nationals, in the case of American Samoa), and those born in the freely associated states are citizens of their respective nations but may travel freely to the United States for education and employment, access certain US social benefits, and serve in the US military.

The Pacific insular areas rely heavily on US and other foreign aid and face lower incomes and significantly higher poverty rates than the US mainland: per capita gross domestic products (GDP) range from $2205 to $14 100, with Guam's $31 809 granting outlier status and representing a more robust economy than the others. In stark contrast, the US per capita GDP is $53 143.6 Local employment opportunities in the USAPIs are limited, resulting in high rates of military recruitment compared with other US states.7 In 2014, the US Army Recruiting Station in American Samoa was the most productive worldwide.8

Just as the USAPIs experience certain economic similarities, the jurisdictions also share particular geographic and environmental challenges. The region faces geographic remoteness-the islands are between 2500 and 4600 miles from Honolulu, with flight times of up to 20 hours depending on layovers-and the geography and settlement patterns within jurisdictions create additional accessibility hurdles. Dispersed island archipelagos leave some outlying communities with limited to no access to resources and basic infrastructure such as transportation and communication. Many remote island communities live without ready access to even primary care-level health dispensaries, often requiring travel by boat to other nearby islands to access basic medications such as Tylenol (acetaminophen). Both FSM and RMI confront complications with the reliability of basic utilities such as electricity and clean water.9 The region as a whole also contends with increased susceptibility to natural disasters and must devote significant public health resources to preparedness and recovery efforts.6 Climate change exacerbates this issue, creating more frequent severe weather patterns, water shortages made worse by El Nino, and rising sea levels threatening homes and roads. Typhoons and tropical storms have damaged health care facilities on the islands, and recovery is challenging.9 Despite great diversity among and within the USAPI jurisdictions, these structural parallels offer a partial view into the state of the region's public health.

Noncommunicable Diseases: A Public Health Emergency

The most prevalent health concerns in the USAPIs stem from chronic conditions requiring protracted care and significant tertiary intervention. Heart disease, cancer, and diabetes are among the leading causes of morbidity and mortality for all Pacific jurisdictions, and obesity rates are among the highest in the world: Estimated rates of overweight and obesity among adults in some communities are as high as 90%.10,11 In 2010, the Pacific Islands Health Officers' Association (PIHOA) declared a noncommunicable disease (NCD) emergency in the region to acknowledge and begin to collaboratively address the epidemic, and several jurisdictions followed suit by issuing local emergency declarations.12 In some areas, these health concerns are amplified by impoverished living conditions and environmental and behavioral factors. Fresh foods are difficult to access on the islands due to agricultural challenges, geographic remoteness and subsequent transportation costs, and, in some areas, limited refrigeration capabilities. In addition, a post-WWII deviation away from traditional fishing and farming in favor of heavily processed foods and sugar-sweetened beverages continues to influence eating habits today.13

The risk of chronic diseases in the region is compounded by a strained public health infrastructure and an overburdened acute care system. Many of the USAPIs struggle to maintain a full public health and health care workforce due to a number of factors: remote outer islands, a lack of educational opportunities on-island, professionals emigrating for better opportunities and higher salaries ("brain drain"), and underfunded health systems.14 Strikingly, all localities in each of the USAPI jurisdictions are designated as Health Professional Shortage Areas and Medically Underserved Areas/Populations by the US Health Resources and Services Administration.15 Despite a high reliance on US government grants and, in the freely associated states, international donors, the insular areas continue to face significant categorical and programmatic restrictions on aid as well as decreased availability of funds for public health and other services due to disadvantages in US federal funding formulas and ineligibility for certain US federal programs. In addition, successful NCD prevention is obscured by a lack of robust and comprehensive surveillance systems and epidemiological data. There is a lack of large-scale, population-based survey data as well as inconsistent and delayed data capture and analysis by international agencies.10 In health agencies and health care facilities, the collection, storage, retrieval, and use of data are often manual, incomplete, and subject to time lags and inconsistencies. Some jurisdictions lack the informatics and consistent information technology infrastructure to maintain needed registries.14

These human resources challenges and financial hardships severely limit access to primary, secondary, and tertiary health care personnel and facilities. Clinics are often difficult to access from outlying areas and, in many cases, are understaffed and underfunded, and specialty care is frequently limited or unavailable-patients may either wait or travel for care. Residents of the USAPIs must often travel off-island to Honolulu, the Philippines, Taiwan, or the mainland to receive crucial care at great financial burden to both the health care system and the patient and family.9 As chronic disease rates reach overwhelming levels and lead to frequent complications due to the insufficiency of primary and secondary prevention and control efforts, transport for complicated surgical procedures and ongoing services such as dialysis becomes more necessary and inflicts an increasing financial strain.16 Even where complex services are locally available, the cost may prohibit access or limit frequency of care. In Palau, the estimated cost of dialysis per patient per year is just under US $27 000,16 more than 20 times the country's annual per capita expenditure on health.17 Similarly, for residents who remain and seek health care in their communities, testing and diagnosis are challenged by a lack of comprehensive local laboratory services.9,10 Limited access to the islands compounds these systemic issues; transportation for patients, laboratory specimens, and medical supplies is delayed by the inadequate availability of flights into and out of the USAPIs. Some jurisdictions are reached by as few as 2 flights per week, and even scheduled flights can be unreliable due to weather or other concerns. This issue impacts the accessibility and cost of health care at every level.

The lack of specialty health care services and economic opportunities is forcing some USAPI families to leave their islands permanently. Residents of the freely associated states of RMI and FSM, in particular, are emigrating to other USAPI jurisdictions, Hawaii, and parts of the continental United States. Migration rates are expected to increase in the coming years due to the expiration of US financial assistance through the COFA and resulting economic downturn and to the anticipated effects of climate change on the islands.18 Despite the availability of health care services in the areas receiving immigrants and the ease of legal immigration for the USAPI residents, immigrants are frequently ineligible for US entitlements, such as Medicaid and WIC, and must pay for care out of pocket. In addition, shifting the burden of care to these localities places strain on economies unprepared for the heightened need for health care, education, and social services. Immigrants from the compact nations often arrive to find themselves facing unemployment, homelessness, discrimination, and policy discrepancies preventing their access to the health care safety net.18,19

Current Efforts and Potential Solutions

Current efforts on behalf of the USAPIs are aided by the strength and resiliency of island communities, committed local workforces, and national and international organizations with a long-term commitment to improving health in the Pacific. Organizations such as PIHOA, the Association of State and Territorial Health Officials, the National Association of County & City Health Officials, the World Health Organization (WHO), the Pacific Community (SPC), UN agencies, US government agencies, and numerous others are dedicating significant attention and resources to supporting public health systems through partnerships, funding improvement initiatives, and technical assistance. Drawing upon its long history working in the region and a deep understanding of its nuances, PIHOA, through support from the Centers for Disease Control and Prevention, is undertaking a project to improve NCD surveillance and data systems in the region and is dedicating focus toward improving human resources for health through recruitment, retention, and training efforts. These organizations bring diverse expertise and are placing an increasing emphasis on partnerships and coordination-with both local agencies and each other-to the benefit of the USAPI public health systems. Such partnerships, based on a foundation of community perspective, are crucial to the sustainability of systems and health improvement.

Frameworks for modeling and adapting public health interventions offer a structure for programmatic interventions in the region. For instance, WHO developed the Package of Essential NCD Interventions (PEN) for primary health care in low-resource settings.20 On a local level, the USAPI jurisdictions are adapting and implementing interventions in their own communities and focusing attention on addressing the NCD epidemic. PIHOA has documented more than 308 promising practices undertaken by jurisdictions to address chronic disease rates across the USAPIs. In CNMI, for example, the commonwealth's Non-Communicable Disease Bureau has implemented an obesity campaign adapted from Michelle Obama's Let's Move! initiative. FSM has worked with WHO to develop a culturally adapted version of the Health Promoting Schools Program, an evidence-based gardening program to promote nutrition and physical activity.21 These adaptations illustrate the successful synchronization of thoughtful frameworks with existing programs to improve health outcomes.

The health care and public health systems in the USAPIs benefit from an immensely dedicated public health workforce and a committed governmental public health leadership. Multiple factors on the islands create the possibility of swift and efficient systems-level innovation, including small population sizes, closely integrated communities, strong churches, traditional leadership structures, and the unified provision of public health and health care services. These factors, together with the "policy nimbleness" of the islands, make them ideal proving grounds for innovative health policy and care delivery models. Recently, for example, the Guam Department of Public Health and Social Services quickly and successfully implemented a Salt Reduction Initiative through which food establishments committed to removing salt shakers from tables in restaurants.22 In RMI, the Health Promotion and Disease Prevention Program's Legislator Luncheons led to banning the sale of betel nuts,23 a widely used stimulant and known carcinogen.24 These encouraging community initiatives and the robust network of regional support are crucial to maintaining and improving the health status of the region, and the international public health community should continue to build on these efforts.

Addressing the issues outlined here will undoubtedly require a multifaceted approach. As the COFA between the United States and the freely associated states near expiration and as Congress considers how to support migrants from the compact nations and the states and territories that receive them, abundant opportunities to implement health equity in all policies are emerging. Public health entities in the USAPIs are severely limited by the outside funding they receive. The US public health enterprise, for its part, bears the responsibility of considering the impact of these challenges on the achievement of health equity. Interventions must operate with an understanding of the local context and build upon the immense local strengths and successes. Sustainable improvement will require thoughtful and continued investment in infrastructure, systems strengthening, and workforce development, as well as creativity in developing long-term solutions whereby local health systems and communities are empowered and sufficiently supported to implement and sustain such efforts. As partners in the mission of securing health for all, it is critical that we maintain awareness and embrace opportunities to address public health and access to care in the USAPIs.

REFERENCES