Micronesians Building Healthier Communities During the COVID-19 Pandemic

Abstract

Micronesian communities in Hawai‘i have a long history of mobilizing to address challenges they encounter as the most recent and fastest growing Pacific Islander immigrant population in the state. In particular, community leaders navigate a slew of obstacles specific to systemic racism and health care access. These hurdles have become exacerbated by the COVID-19 pandemic, prompting a range of Micronesian-led responses to the health crisis including strategic adaptations to existing networks and roles to address essential public health functions. These community responses have filled many critical gaps left by the state's delayed response to addressing the disparate impact of COVID-19 on Micronesian communities. This article highlights and encourages engagement with diverse models of collaboration and elevation of Micronesian leadership that has resulted in more productive cooperation with government leaders, agencies, and policymakers. This work offers insight into pathways forward toward healthier Micronesian families and communities.

Introduction

“With a solid foundation of cultural identity and pride, and with both patience and perseverance, we can rise above the racial noise that has brought so much anguish and pain to our [Micronesian] communities here in Hawai‘i and that has broken our confidence in ourselves and our place. Empowered with our culture, our roots, we can then establish strong relationships of trust and mutual respect with our host communities, which may lead to a shared future of true prosperity.”

Peter, Tanaka, and Yamashiro 2018, p. 202¹

Micronesians in Hawai‘i have long organized and led community health efforts, even in the face of systemic racism and fractured relationships. The opening quote from Dr. Joakim Peter, addressing Micronesian responses to the 2009 Medicaid cuts in Hawai‘i, speaks of the “racial noise” of systemic racism and the “broken confidence” of fractured relationships. The COVID-19 pandemic amplified both the needs and the challenges, but also highlighted Micronesian community leadership and opportunities to build enduring bridges with government leaders, agencies, and policymakers. While some connections rose up and thrived at this time—for example, We Are Oceania, a Micronesian-led project of Partners in Development Foundation, received CARES Act funding to provide direct services to Micronesian and other underserved communities²—the community was generally left to care for their own.³ This article highlights lesser-known efforts led by Micronesians, and the ways in which meaningful government actions yielded significant advances. We focus primarily on Micronesians with ties to the Federated States of Micronesian (FSM), the Republic of the Marshall Islands (RMI), and the Republic of Palau (ROP), which are countries that have Compact of Free Association (COFA) agreements with the United States (US). Throughout 2020, COVID-19 data about Micronesians was generally classified within the “Pacific Islander” category and the state's public-facing data still does not report disaggregated data.⁴

Health equity is at the core of public health's mission and essential functions.⁵ However, achieving equity for racial/ethnic minorities in the US requires an understanding of the source of inequalities. Racism is a major driver of unequal treatment of non-white populations in the US. And in Hawai‘i, present-day impacts of colonialism and imperialism interlace with US racism, forming a multilevel, reinforcing system that has impacts across multiple sectors of contemporary society.⁶ Micronesians in Hawai‘i have long faced both personally-mediated racism in the form of inferior and discriminatory treatment, and institutional racism through structural and systemic denials of healthcare.^7–11 In 2020, Micronesian communities in Hawai‘i were not only challenged by the contagion of a disease, but also by navigating the pre-pandemic inequalities and societal prejudices at multiple levels of the social structure.^10,12,13 This worsened structural barriers to health and wellness including: (1) longstanding exclusion from vital social safety nets such as Medicaid and Supplemental Nutrition Assistance Programs;¹¹ (2) language barriers and/or administrative barriers for access to services for which COFA Micronesians are eligible;^14,15 (3) statements from governmental and industry leaders that stigmatize communities;¹⁶ and (4) racist and dehumanizing public and private comments that target Micronesian communities.^10,12,13

Early in the pandemic, Micronesian leaders, many of whom were already providing direct services to their communities and calling for policy and systemic change, predicted that the virus could hit their communities hard.^17,18 Yet Hawai‘i's governmental leaders failed to act.^3,19 At the end of April 2020, higher COVID-19 rates among racial/minority populations were reported across the nation, including among Native Hawaiian and Pacific Islander communities in Hawai‘i.²⁰ By the end of June, the state's partially disaggregated COVID-19 race data showed that Pacific Islanders (largely Micronesians) comprised 23% of COVID-19 cases, despite being only 4% of the state's population.²¹ By mid-August, Pacific Islanders made up 30% of COVID-19 positive cases in Hawai‘i.³ Data published in mid-March of 2021 revealed dramatically worse disparities for this time period; Pacific Islanders actually comprised 55% and 59% of all COVID-19 cases in Hawai‘i in June and July of 2020, respectively.²² Still, gaps in services and support from, and meaningful communication with, state and local leaders remained.²³ In a press statement at the time, the Mayor of the Honolulu City and County reflected, “In some ways, I think we forgot about this community.”³ Despite the inadequate government response, Micronesian communities took the lead on performing essential public health functions throughout the crisis: communicating culturally and linguistically appropriate health information; engaging in informal contact tracing; mobilizing communities and facilitating essential health services; distributing food and emergency resource kits; and redoubling longstanding advocacy work. Eventually, formal connections and official positions were established within government agencies to improve the effectiveness of government responses to COVID-19 in Pacific Islander communities (Table 1).

Table 1.

Examples of How Micronesian Community Organizations Provided Essential Public Health Services During the COVID-19 Pandemic

Core Functions	10 Essential Public Health Servicesa	Actions of Micronesian community leaders and organizations
Assessment	Monitor health status to identify and solve community health problems	Advocated for disaggregation of data on cases of COVID-19 to understand impact and needs on Pacific Islander communities
	Diagnose and investigate health problems and health hazards and root causes	Anticipated needs and facilitated data sharing (e.g., May 9, 2020 virtual meeting hosted by the FSM COVID-19 Task Force) Created and distributed on-line surveys to assess needs among Micronesian families Facilitated COVID-19 testing and contact tracing prior to formalized actions by government agencies
Policy Development	Communicate effectively to inform and educate	Extended existing outreach and education efforts to include information about COVID-19 and provided needed culturally appropriate messaging (via outlets and platforms preferred by community members) Developed webinars directed to Micronesian communities on COVID-19 related topics
	Strengthen, support and mobilize communities and partnerships	Adapted and built on existing partnerships to collaboratively respond to challenges resulting from the pandemic Extended invitations to new partners including government agencies and leaders to increase impact and effectiveness of response
	Create, champion, and implement policies, plans and laws	Continued pre-pandemic advocacy for reinstatement of Medicaid access at the federal and state level Directed focused advocacy and engagement with government leaders and media to specifically address COVID-19 impact on Pacific Islander communities
	Utilize legal and regulatory action	Relayed and reinforced evidenced-based public health messages from the Centers for Disease Control and Prevention, the State of Hawai‘i, and the local government offices on COVID-19 prevention, stay-at-home measures, quarantine rules, etc. to their community networks
Assurance	Enable equitable access	Provided direct support through food drives, distribution of personal protective equipment and supplies for quarantining at home Helped community members access critical services (e.g., rent relief, isolation facilities, testing locations)
	Build a diverse and skilled workforce	Engaged with governmental agencies as liaisons and accepted positions to support efforts at address COVID-19 in Pacific Islander communities
	Improve and innovate through evaluation, research and quality improvement	Engaged in dialog with government leaders and agencies and better positioned to provide feedback on on-going and future initiatives to address COVID-19 response and recovery
	Build and maintain a strong organizational infrastructure for public health	Identified new avenues of establishing, supporting and prioritizing strong relationships between community and government as vital to successfully addressing disparities in COVID-19 and other existing inequities

^a10 essential public health services. Centers for Disease Control and Prevention (Adapted from Sept. 9, 2020 version).

https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html. Accessed June 24, 2021.

Micronesian Responses to COVID-19

This article introduces 4 Micronesian-led responses to the pandemic that represent diverse entry points to Micronesian community engagement. The co-authors participated directly in these efforts, including in leadership roles. These examples reflect the emergence of specific responses to COVID-19, but more broadly illuminate how existing stakeholders and efforts converged and expanded in particular spaces. Given the diversity of the Micronesian community and its long-established record of mobilization, the examples presented here illustrate the range of responses, from broad networks and direct service work to elevated professional roles.

FSM COVID-19 Task Force USA

In early May 2020, Dr. Vidalino Raatior and the Pacific Leadership Assistance Network²⁴ organized 2 virtual meetings of Micronesian community leaders across the US to discuss the gap in information and services addressing the disproportionate impact of the coronavirus on Micronesian populations. The FSM leaders decided to create the FSM COVID-19 Task Force USA²⁵ (FSM Task Force) to focus on the FSM diaspora in the US.

The FSM Task Force has members representing all FSM states, living in 11 US states and territories, and affiliated with dozens of community organizations, educational institutions, and government agencies (Table 2). This broad network serves as a vehicle to facilitate communication and strengthen relationships across many geographic, cultural, and professional affiliations. The Task Force held weekly meetings to provide updates about direct service work of various regions and organizations, and to coordinate projects through committees (Table 2).

Table 2.

Selected Activities of the FSM COVID-19 Task Force USA

Organization	Committees	Leadership	Activities
FSM COVID-19 Task Force USA	Executive Team	John Akapito, Co-Chair Joseph Pangelinan, PhD, Co-Chair Mike Pangelinan, Treasurer FSM Consul General Joe Enlet, Founding Co-Chair Stacy Ruegilin, JD, Founding Co-Chair Raleigh Welly, Secretary Vidalino Raatior, EdD Natalie Nimmer, PhD	Lead coordination
	Data Team	Mike Pangelinan, Co-Leader Kevin Tugruwfaimaw, Co-Leader	Constructed surveys on COVID-19 impact and vaccine attitudes Collected and analyzed survey results Disseminated data
	Communications Team	Cal Tiweyang, Co-Leader Simeon Jacob, Co-Leader	Created culturally and linguistically appropriate information and programs Disseminated surveys Hosted Youth Summit and Panels Virtual Hut Interviews Social Media presence Regional COVID-19 related resource pages
	Education Team	Shanty Asher, JD, Co-Leader Asinech Hellan-Pangelinan, OD, Co-Leader	Hosted virtual programming and information on issues related to parents' and students' concerns about schooling during the pandemic
Marshallese Community Organization of Hawai‘i (MCOH)		Jendrikdrik Paul, President Borden Bolkein, Vice President Kelly Bokin, Secretary Joanne Loeak, Treasurer Ned Anjolok and Cassie Alik, Volunteer Chairs Caster Konou, Constitution Day Chair	Organized food distribution and emergency supports alongside community partners including the RMI Consulate Office, the Marshallese COVID-19 Task Force, We Are Oceania, Pacific Gateway Center, Domestic Violence Action Center, Chef Paul, and Chef Hui Acted as resource navigators for Marshallese community members Provided health messages in Marshallese and English via online social networks Partnered with other organizations to extend reach and support capacity of initiatives directed at Pacific Islanders broadly
Micronesian Ministers & Leaders Uut		Innocenta Sound-Kikku, co-organizer David Derauf, MD, co-organizer Sass Gouland, Pastor and co-organizer Tadasy “Tester” Puas, Pastor and co-founder Bender Sam, Pastor and co-founder Jaffy Poll, Pastor and co-founder	Utilized technology to mobilize community through an approach rooted in cultural traditions and values Organized weekly on-line gatherings to share critical public health information and to address community concerns Hosted guests and community partners including Dept. of Education Superintendent, administrators, and teachers; medical providers; American Civil Liberties Union; Medical-Legal Partnership for Children in Hawai‘i; Office of the Public Defenders; FSM government and FSM Consulate Office officials; Hawai‘i legislators; Department of Health staff; and other service providers.

One of the most significant projects during 2020 was the completion of a COFA citizens' Family Needs Survey²⁶ (Table 1) that gathered responses from 320 Micronesian community households in the US (including approximately 40 families in Hawai‘i). The FSM Task Force evaluated the comprehensive data about the economic and health impact of COVID-19 as well as access to services. In order to best respond to community needs, the FSM Task Force initiated another survey in early 2021 to understand FSM people's perception and acceptance of—and access to—the COVID-19 vaccine.

The FSM Task Force was needed for several reasons: collecting accurate and disaggregated data on the disproportionately high infection rates among the FSM people, creating and disseminating culturally and linguistically appropriate and accurate health and education information to the FSM people, and advocating for the equitable and unbiased perception and treatment of the FSM people (Table 1).

Marshallese Community Organization of Hawai‘i (MCOH)

The Marshallese Community Organization of Hawai‘i (MCOH) was established in late 2019 by Jendrikdrik Paul and other Honolulu-based Marshallese engaging in community service and organizing community sports events. At the beginning of 2020, MCOH received a grant to conduct Census 2020 work. When the pandemic hit Hawai‘i, they quickly pivoted to engage in extensive direct services and community education. This volunteer-driven organization quickly became an essential provider for basic needs (food drives, quarantine supports, mask distributions) and resource navigation for Marshallese-speaking families, including those stranded in Hawai‘i due to the sudden and complete travel restrictions to their home islands (Table 1). All of their services are available in Marshallese and English, and MCOH also established an on-line presence to share vital health education messaging in Marshallese. The MCOH Facebook group currently has over 2,400 members.²⁷

MCOH spent most of 2020 engaging in close collaboration with RMI Consular staff, government officials, churches, and nonprofits, and a wide range of volunteers including Marshallese and non-Marshallese community members. MCOH partnered with numerous organizations to conduct food distributions of food baskets and prepared meals (Table 2). From September through December, they regularly served 300 families on Tuesdays and 400 families on Saturdays, providing essential resources to mostly Micronesian, Pacific Islander, and Filipino communities. MCOH had a regular roster of 27 Marshallese volunteers and engaged as many as 50 volunteers at a single event, such as an event that distributed 1 000 emergency kits. They provided resources to neighbor island communities and assisted hundreds of Marshallese community members to navigate unemployment benefits, housing advocacy, rent relief applications, and other vital services. The MCOH team estimated they fielded up to 50 calls each week for individual help. They reached thousands more through social media messaging.

During 2020, MCOH expanded its capacity by securing non-profit legal status and establishing a formal structure (Table 2). MCOH helped manage CARES Act funding as members of the Pacific Islander sub-group of the Native Hawaiian & Pacific Islander Hawai‘i COVID-19 Response Team.²⁸ This included co-organizing the Pasefika²⁹ virtual concert to share music and health information that was viewed nearly 80 000 times.

Like many other community efforts, MCOH engaged in extensive emergency supports for Marshallese communities, including functions that are the responsibility of the Hawai‘i Department of Health such as contact tracing, quarantine supports, and accessing COVID-19 testing. The pandemic amplified existing problems, and MCOH plans to sustain this work beyond the public health crisis and continue working alongside community, government, and non-profit partners. MCOH's emphasis on nurturing relationships as friends, not just colleagues, illustrates its cultural values and exemplifies moving past harmful narratives and biases that have perpetuated discrimination (Table 1). The Marshallese saying “Kakur wot wor” means “we are stronger together.”

Micronesian Ministers and Leaders Uut

The Micronesian Ministers and Leaders Uut was formed following the circulation of an email from state officials claiming that Micronesian leaders and ministers were “not responsive” to outreach efforts. At the same time, Kōkua Kalihi Valley Comprehensive Family Services (KKV) Executive Director Dr. David Derauf asked Innocenta Sound-Kikku, KKV staff and respected “community aunty,” to convene Micronesian church ministers to address community concerns and disseminate critical public health information and advisories. Ms. Sound-Kikku immediately began efforts with Sass Gouland, Pastor and President of the Micronesian Health Advisory Coalition, that demonstrated how Micronesian communities respond and mobilize when reached out to through respectful and trusted relationships.

The email and resulting exchange served as the catalyst for the establishment of the Micronesian Ministers and Leaders Uut, a weekly virtual meeting that convenes ministers and elders serving Micronesian communities alongside other community members and stakeholders (Table 2). The term uut refers to the meeting houses found in many Micronesian societies where clan dialog on critical issues occurs and important decisions are often made. Drawing from these spaces and traditions in their home islands, Micronesian communities in Hawai‘i and elsewhere have long relied on their elders and church leaders for guidance by forming uut abroad, especially in times of crises and adversity. In Hawai‘i, Sound-Kikku recalls a far-reaching community uut that long predates the current coronavirus pandemic, noting that “we always know that our elders, our ministers and our pastors are our go-to.” Indeed, the current, virtual Micronesian Ministers and Leaders Uut followed a longer standing uut in the Honolulu community, and an even longer tradition of church leaders and community elders being situated at the core of community and mobilization efforts.

The weekly online meeting began as a way to discuss pressing concerns brought on by the COVID-19 pandemic and its impact on Micronesian communities. The organizers also invited guests representing legal, educational, medical, and social services to disseminate information and address questions and concerns from attendees (Table 1). Youth are increasingly attending and given the space and permission by their elders to speak openly on community issues. Participants increasingly dial in from Palau, Guam, Washington, D.C., and everywhere in between.

The uut serves an immediate purpose of providing a space for information sharing, and members have far-reaching impact. For example, Pastor Jaffy Poll posts wide-reaching online sermons and Pastor Sam Bender hosts a weekly radio show called “Voice of Chuuk” where he shares vital information and resources, including health messaging during the pandemic. Pastor Sass Gouland has organized at the state's largest public housing complexes and also serves in a diplomatic capacity with governmental ties to FSM. Just as these ministers and elders have embraced technology and changing social spaces to serve their communities, the broader Micronesian diaspora in the US has followed suit, using social media, the arts, and other platforms to expand and continue conversations that begin in the uut (Table 1).

Elevating Micronesian Leadership

With growing disparities in infection and mortality rates and after several government missteps,³ state and county officials began to meaningfully engage Micronesian communities by September 2020, including appointing Micronesian leaders to government positions. While overdue, these actions were significant to strengthening community relationships and establishing more formal liaison positions between government and Micronesian residents. We next highlight 2 examples of successfully elevating Micronesian leadership.

Tulpe Day is a Kosraean community leader who has worked for the County of Hawai‘i since 2014 as an Immigration Information Specialist, and she was nominated by Governor David Ige to serve on the Language Access Advisory Council.³⁰ Ms. Day is an active member of Micronesians United-Big Island and other groups promoting Micronesian culture, education, and resources. In response to a COVID-19 cluster in Kona—and the outcry after the Department of Health Director Dr. Bruce Anderson singled out the Marshallese community affected¹⁶—Hawai‘i County Mayor Harry Kim asked Ms. Day to identify leaders for a County of Hawai‘i COFA COVID-19 Task Force. This group is tasked with serving as a bridge between members of COFA communities, government agencies, and non-profit organizations.

The County of Hawai‘i COFA COVID-19 Task Force includes Marshallese, Kosraean, Pohnpeian, Chuukese, Yapese, and Palauan community leaders who volunteer their time to support the Department of Health, Civil Defense, and other government efforts. Their work includes education and public health messaging, COVID-19 testing including on-site outreach and contact tracing, and post-testing wrap around services (Table 1). Even before this formal relationship, Ms. Day was leading a Kosrae Big Island COVID-19 Task Force and working with others to address similar needs for Micronesians on Hawai‘i Island. The community did not wait for the government to address these needs. Rather, the increased collaborations and the impact of government and community advocates engaging side-by-side furthered relationships built on trust and respect.

In September of 2020, attorney Shanty Sigrah Asher was hired as the first Pacific Islander Liaison Officer at the Office of Economic Revitalization for the City and County of Honolulu. This role was established by O‘ahu Mayor Kirk Caldwell shortly after a meeting with Micronesian leaders in mid-August. Her role is primarily to engage in outreach and to improve communication between government, community organizations, and community/church leaders, as well as to provide up-to-date COVID-19 resources and information to the Pacific Islander community (Table 1). Like Ms. Day, Ms. Asher brings a wide range of community organizing experience and governmental, non-profit, and grassroots community relationships and expertise.^31,32 In the last 4 months of 2020, she hosted 11 weekly webinars covering topics from COVID-19 updates (testing, quarantine, contact tracing, vaccines) to practical resources for housing, rent relief, unemployment, and scam protections. These webinars and other vital messaging on social media receive thousands of views (Table 1).³³ Her participation at food drives and other events creates opportunities for community members to share concerns with a government representative.

These positions grew out of the government's realization that, in the words of Shanty Sigrah, “they can't do it without us.” Elevating Micronesian leaders within all levels of government programs is a fundamental and effective approach to establishing clear communication, trust, and confidence in the community for public health initiatives (Table 1).

Conclusion

The efforts of the Micronesian community filled the gaps left early in the state's response to the COVID-19 pandemic in addressing health equity. By September, the state made an important pivot and began engaging Micronesian community groups in earnest. The last 4 months of 2020 demonstrated that intentional collaboration, funding grassroots efforts, and hiring Micronesians at all levels of government positions is effective. To the authors' knowledge, there is no study demonstrating the impact of this turn toward greater collaboration with Micronesian community partners. However, there was a decline in the case rates among Pacific Islanders in the following months.²² While serious concerns about testing, hospitalization, deaths, vaccination access, job loss, and other consequences of the pandemic impacting their communities persist, Micronesian leaders maintain hope in the face of loss and uncertainty brought on by the pandemic.

The experience of Micronesian leaders in navigating the challenges of this pandemic exemplified successful strategies for achieving greater equity in health and community well-being. Most prominently, collaborations and relationships must be built on trust and respect. Relationships and connections are fundamental to Pacific peoples' way of understanding, analyzing, and organizing their lives and communities. Relationships cannot be simply transactional. These connections are successful and sustainable only when executed in culturally responsive ways that embrace Micronesian protocols and practices. The increase in collaboration across islander communities and between the government and Micronesian community enhanced the impact of these efforts and amplified the voices of the community.

For continued progress in terms of both addressing the COVID-19 crisis and advancing health equity overall, these relationships must continue to develop beyond the current pandemic. A key requirement is nurturing relationships as friends, not just colleagues, so that policymakers, government leaders, and community members build trust and learn to invest in each other. There can be no return to “normal” when pre-pandemic relationships were marked by neglect and racist narratives. Rather the pathway forward is to work together across communities, organizations, and agencies to rise above the racial noise and achieve the shared vision of healthier Micronesian families and communities.

Abbreviations

COFA

Compact of Free Association

FSM

Federated States of Micronesia

KKV

Kōkua Kalihi Valley Comprehensive Family Services

MCOH

Marshallese Community Organization of Hawai‘i

ROP

Republic of Palau

RMI

Republic of the Marshall Islands

US

United States

Conflict of Interest

None of the authors identify any conflict of interest.