Behind closed doors: Yap’s healthcare professionals aren’t resting on their laurels

October 11, 2020

 

 

Colonia, Yap-- Preparing for an emergency is never easy. But for remote islands like Yap that are scattered throughout the Pacific, the Covid-19 pandemic does not compare to the typhoons, droughts and other weather-related disasters that have hit these islands through the decades.

 

Today, those emergencies can be seen developing on digital maps before they hit. Covid-19 slammed into the globe with no warning and it’s now straining much more than the limited health care system and shortages of personnel, supplies and facilities on these far-flung atolls and islands. It’s hitting the already fragile economies, as well.

 

Spread across 1 million square miles of ocean like pebbles tossed from Poseidon’s hand, the Federated States of Micronesia is one of only 10 countries with no Covid-19. The four states that make up FSM closed their borders at the end of March and began planning for the time when they would again open their ports of entry to sea and air arrivals.  

 

In 2018, Yap formed a Health Crisis Task Force to address sudden outbreaks of dengue fever on the state’s main island and 23 inhabited outer islands. John Gilmatam, executive director and CEO of Wa’ab Community Health Centers, was named chairman, a role he continues to perform.

 

Victor Bamog, newly appointed director of the Office of Planning and Budget, was named co-chair. He brings a decade of emergency management to the table, having directed operations for some of the most violent storms to hit the island in the past few years.

 

In March 2020, Gilmatam invited additional representatives from the Department of Health Services and other private and public sectors and non-profit organizations to come together to address the developing pandemic. The hospital’s laboratory manager, Maria Marfel, was appointed the incident commander for Covid-19 and the hospital conference room was turned into the Command Center.

 

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Twice-a-day meetings were initiated seven days a week to identify, categorize and assign a complex hierarchy of preparatory details that had to be addressed with haste and clear thinking. Some of the things they quickly began to work out included:

  • Lay out and implement a plan for preparation, mitigation and containment of the virus if and when it arrives on island;

  • Research and track what other countries are experiencing and doing to control the spread of the virus;

  • Rapidly organize and staff quarantine and isolation sites for the arrival of passengers on the last three flights allowed into Yap during the second half of March before the travel ban was put in effect by President David Panuelo and Congress;

  • Pull together with other task forces from around the Pacific region to stage regular meetings with representatives from the Pacific Island Health Officers Association, the Center for Disease Control and the World Health Organization;

  • Determine and research additional or upgraded equipment required for testing, treating and containing the disease and identify vendors, needed funding and potential grant opportunities;

  • Create a long-range plan, design, site selection and budget requirement for permanent isolation and quarantine facilities and a larger lab to accommodate new testing equipment with greater capacity;

  • Develop protocols and train and assign staff in their implementation;

  • Conduct door-to-door household and business education and research to determine their readiness and sanitary needs;

  • Create port of entry protocols for handling and sanitizing incoming food, supplies and mail to ensure it was free of the virus before being opened;

  • Determine how to deal with bodies arriving for burial and ensure that the virus was not active on the coffins and human remains that were prepared through off-island mortuaries while ensuring the mourners were safe;

  • Design protocols for isolating arriving plane and ship crews from local workers at the ports of entry;

  • Identify staffing needs and scheduling for isolation and quarantine facilities and what to do in the event that frontline workers contract the virus;

  • Determine the quantities of gloves, masks and other protective equipment that will be used every day by frontline staff; and,

  • Work out a plan for how to assess, direct and isolate incoming patients for assessment at the community health centers and the hospital;

  • Obtain and stock enough personal protective equipment (gloves, masks, face shields, gowns, etc.) for frontline workers.

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This was only the beginning. The list grew by the day as statistics from around the world continued to rise at an alarming rate and were updated on the white board in the Command Center every morning.

 

A weekly update was scheduled for Gov. Henry Falan and his Cabinet to keep them informed and answer their questions. A weekly update was also scheduled with the Yap State Legislature. Over the next few months, the updates for the legislature were converted to an “as needed” basis and the weekly meetings with the governor and his Cabinet became biweekly.  The meetings were recorded, transcribed, and filed for future reference.

 

All task force members abruptly found themselves doing their normal jobs while learning how to juggle their new assignments with the imperative for fast action and response.

 

Patients continued to arrive at the community health centers and hospital for treatment of more common ailments.

 

That responsibility would not stop when the virus finally arrived on the island. And everyone agreed it was not “if” but “when.” As news was reported about vaccines and other trial treatments, the hope was palpable that a cure would be found before the travel ban was lifted.

 

When the last three planes brought 145 passengers in late March, the Yap State government shut down, schools were closed, and everyone was told to stay home for anything other than necessary trips for food or medical care until it could be confirmed that none of the arrivals was infected. They were transported to three hastily cleaned and furnished locations – Yap High School, Dinay Middle School and the Matson Sports Complex – to quarantine for 14 days with another 14 days in home quarantine.

 

Two presented Covid-19-like symptoms and were put in isolation at the hospital while specimens were sent to Guam for testing. They all came back negative. But others ignored the requirement to stay home for an additional two weeks, setting in motion a nighttime curfew decree by the governor for the entire island.  

 

A hew and cry went up and people expressed outrage about Yap being turned into a police state. But when the curfew was lifted, DHS received phone calls asking for the curfew to remain in place. The quiet nights were a welcome relief, the callers said.

 

Then, two sailboats arrived without warning in the outer islands. They were told to leave immediately; they were there illegally. But they had already been allowed to disembark and welcomed by the local islanders. Told to leave FSM waters immediately, the island was quarantined because some of the sailors had gone through Guam where Covid-19 was beginning to appear. The supply ship was prevented from dropping off needed supplies on those islands for another two weeks.

 

In the end, the state has remained free of the deadly virus, but the work continues to prepare for its arrival in the future.

 

At the same time, the president, congressional leaders, governors and state legislatures began to deal with the collapsing economy due to the impact on small businesses, halted tourism, and sudden unemployment. Not only were they confronted with the need to create emergency declarations and make hard decisions about whether and when to open the border, the rapid halt also placed a strain on the government’s revenue.

 

Taxes and other income dried up that was normally generated from visitors staying in hotels, eating in restaurants, shopping and paying a departure fee. And, with hundreds of workers laid off, regular spending by residents was impacted, as well.  The domino effect has been catastrophic.

 

But the skeptical question was asked by those who were not directly involved in the preparation why a task force was needed and what they were doing. After all, they said, there’s no Covid-19 on the island so why worry so much.

 

The citizens who were stranded in Guam, Hawaii and the mainland U.S. asked, why not have them get tested and go into quarantine when they arrive? It isn’t that easy, they were told. Although the schools and sports complex had housed those who arrived in late March, the medical staff was stretched to the limit already and the facilities were far from ideal.

 

It was evident that people could not be trusted to stay at home under self-quarantine based on prior experience with the earlier arrivals. And when the hotels were asked to serve as quarantine sites, they refused out of fear of possible infection of their staff and rooms.

 

The task force  advised Falan to remain closed. Not enough was known about the virus, and reports showed that some people were asymptomatic but still spread the disease. Others didn’t present symptoms for nearly a month. Although discussions continue at the national and state levels, no solution has been found to bring them back without putting the rest of the population at risk.

 

It’s one thing to put together plans and quite another to find the funding required to support those plans. Funding and grants and donations were researched.

The Joint Economic Management Committee (JEMCO) of the Compact of Free Association was identified as the first source. The state’s unused roll-over fund of $1.65 million, and another $475,000 that had been designated for the dengue crisis, were approved for Covid-19 use by both JEMCO and the Yap State Legislature.

 

General budgets were drawn up but the often-heard analogy of “learning to fly the plane while building it” best described the situation. The $1.65 million was approved for two years since everyone was looking into a black hole with little to go on to plot out a detailed budget.

 

At the same time, vendors and donation and grant sources were being identified and contacted, but the waiting list of countries asking for help was growing longer by the hour. It was a seller’s marketplace and Yap was not considered as important as other places where the virus was stampeding through the population. In addition, FSM and Yap’s history of paying late meant that many vendors would only accept full payment up front.  

 

Paying half upon ordering and half upon receipt was not acceptable to them. And often there were only one or two vendors manufacturing or selling the needed supplies. This was especially upsetting to the Governor who stepped into the negotiations and resolved to repair Yap’s damaged reputation with his personal guarantee of prompt payment once the supplies had been delivered in good order.

 

Among the equipment and mountain of new supplies that DHS now has in stock, or on order, are one new oxygen plant that will increase the capacity to fill more tanks more quickly; 200 additional oxygen tanks on loan from a local company; one new testing machine that increases the number of tests that can be completed concurrently; thousands of pieces of personal protective equipment made up of masks, gowns, isolation suits, gloves and face shields; several thousand Covid-19 test kits; 35 folding houses with portable showers, toilets and beds for temporary isolation and quarantine use; medicines that treat Covid-19-like symptoms; shipping containers for conversion into offices and other uses at the ports of entry; and much more.

 

Stretched to the limit with meetings every day and both Covid-related and normal work to get done, the task force and DHS have not been able to take the time needed to keep the public informed of the work they’re doing.

 

But in response to questions about where the funding is coming from and how it is being spent, following is an overview of the sources of funding for Covid-19 preparation and containment, what it is earmarked for, and how much remains as of this writing.

 

 

Strides have been made, but there is much more to be done. Falan has told the task force that he will not approve opening the border until they are fully prepared. As has been proven in other countries, frontline health workers are at significant risk of being infected.

 

With so few doctors and nurses and support personnel in Yap, this is a prime concern when dealing with the additional staffing needed for quarantine and isolation of arriving passengers.

 

 

 

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