Dr. Frank Underwood, who came to the Marshall Islands as a TB physician in 2018, currently serves as the Marshall Islands’ public health director. He assumed the position during the initial stages of the Covid-19 pandemic in 2020 based on his experience in communicable disease control. Prior to coming to the Marshall Islands, He served as the national TB control officer in Fiji.
This is the first of a series of expositions of public health challenges in the region. We begin our discussion with Dr. Underwood about the lessons learned from our Covid-19 response.
Dr. Underwood: During the early days, the most important decision that we made as health officials was the closure of our borders.
Our Ministry of Health leadership made our determinations based on the vulnerabilities that the RMI faced and the potential impact of massive mortality. We saw how the pandemic unfolded for our citizens living in the U.S. Covid-19 was a new disease that people's immune systems had yet to contend with, so the border closures throughout the Pacific were important.
I came into the role as a National Disaster Committee health advisor to assist the secretary of health, who was a sitting member of the NDC.
Those early days were chaotic. A lot of emotions and public panic to contend with for MOH. However, our goals were clear: close the borders to ensure that the citizens of the RMI were protected in order to build our ministry's capacity to respond to an outbreak.
This was before there were Covid-19 rapid tests and vaccines available. We established close relationships with the CDC via weekly regional calls and relied on their coordination for the Northern Pacific. Through this relationship, and with our international partners, we managed to secure resources that we desperately needed such as testing capabilities, ventilators, PPEs, etc.
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One of the issues that regional governments had to contend with was the impact of border closures. How do you ensure that people don't starve? We had to make sure the flow of goods and services continued. Additionally, many of our citizens, including medical personnel, were off-island when the borders closed and wanted to come back.
One of my major roles was the designing of protocols to ensure cargo could come off supply ships safely, to ensure exported cargo was able to leave the country, and how to service fuel and fishing vessels coming into port. The Marshallese economy is heavily dependent on the tuna industry. Our view was that if the tuna industry was affected in terms of revenue for the government, this would also heavily impact the government’s health spending.
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I had to develop protocols for the quarantine facilities both for our own incoming citizens and for the U.S. military base on Kwajalein along with protocols for unusual events such as search and rescue missions. Most of these protocols were tailor-made according to the informational ––and often complicated––variables at play.
Much of the early Covid-19 information was based on other infectious respiratory diseases like the contagious staph infection, MRSA. Even as time passed, we experienced informational lags regarding Covid-19 characteristics as the dominant variants changed.
The world’s scientific community ––amazingly–– began collaborating all their efforts into solving the unknowns of the virus. Traditionally, we relied on the WHO or CDC to help formulate public health responses based on the evidence. But for us, we knew they catered to different audiences. For example, it is widely known in the case of the World Health Organization, it's a solution that fits “most” countries.
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We saw a lot of political involvement in the decisions CDC was making. This made us feel vulnerable here in the Pacific. We had to ensure that whatever evidence we used as a basis for recommendations was as sound as possible for us.
Our protocols here in the RMI probably appeared overly restrictive. Yes, we inconvenienced some people, but in the end, because of our conservative approach, we believe we saved hundreds of lives, especially during the early stages of the pandemic.
Pacific Island Times: When the vaccines arrived in our region in late December of 2020, we had one of the earliest opportunities to begin vaccinating. What did MOH do to convince our citizens to accept the idea that these vaccines would work?
Underwood: We never “mandated” the vaccine in the Marshall Islands. We “educated,”; we selected various community leaders and our own MOH leadership to be vaccinated as part of the initial rollout. We believed that if we gave people accurate information, and showed them evidence, they would make the right decisions for themselves and their families.
A large portion of our population already had Covid-19 comorbidities, and some were already suffering from serious diseases. So we knew we had to deal with any vaccine issues with transparency and accountability.
In the RMI, we had the added complication of vaccinating our neighboring islands, which turned out to be a time-consuming and expensive process. This is why we had to keep informing our government that we weren’t ready to lessen quarantine days. We felt that until the neighboring islands had been fully
vaccinated, the disease would pose a huge risk for those living in isolated areas.
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PIT: Overall, our success in the RMI was directly tied to an overwhelming amount of cooperation and collaboration between different entities. What we saw in many countries was public health locked in pandemic policy struggles with politicians and the government.
Dr. Underwood: For us here in the North Pacific, what we suffered at one stage was the impact of the vaccine politics in the U.S. In the Marshall Islands, listening to differing opinions is important. There had to be MOH coordination with NDC, the Cabinet, our traditional and religious leaders and the community-at-large. It was dealt with in a democratic way, but that made the process both time-consuming and strenuous.
In August of 2022, we became the next to the last country in the world to experience community spread of Covid-19. Our successful prevention measures had given us time to perform numerous full-scale and tabletop exercises. We had our supplies stored, organized and ready for the setup of test-to-treat centers. We had high vaccination rates and we were the only country in the world that had the opportunity to vaccinate all age groups before we had community spread of Covid-19. We had numerous forms of testing capabilities, and we had the therapeutics and tremendous regional cooperation.
Dr. Underwood: Yes, and for future public health emergencies, it's best practice and most critical that governments should —during a response— mirror the advice of the health agencies coordinating those efforts with expertise to ensure that all elements of government become a well-synchronized part of that same response.
Jack Niedenthal is the former secretary of Health & Human Services for the Marshall Islands, where he has lived and worked for 42 years. Niedenthal is the author of “For the Good of Mankind, An Oral History of the People of Bikini.” Send feedback to jackniedenthal@gmail.com
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