About Public Health in the U.S. Territories and Freely Associated States

The U.S. territories and freely associated states are home to unique populations, rich with history and culture. Their customs, geography, and history contribute to their many strengths — but also add nuance and complexity to the public health landscape.

ASTHO works closely with island public health officials to understand, increase awareness about, and champion their needs. The team’s efforts help secure island voices at the table and representation in essential U.S. public health programs.

What Are the U.S. Affiliated Territories and Freely Associated States?

There are eight U.S. territories and freely associated states, consisting of six Pacific islands and two Caribbean territories. The six islands in the Pacific include three territories — Guam, America Samoa, and the Commonwealth of the Northern Mariana Islands (CNMI) — and three freely associated states: the Republic of the Marshall Islands (RMI), the Federated States of Micronesia (FSM), and the Republic of Palau. Meanwhile, Puerto Rico and the U.S. Virgin Islands (USVI) make up the two territories in the Caribbean.

The U.S. territories and freely associated states are often left out of the family picture. However, residents of the territories are U.S. citizens or nationals, and residents of the freely associated states can live, work, and travel in the United States without a visa. Moreover, they have some of the highest per capita rates of U.S. military enlistment. Importantly, these island health systems are also eligible for many domestic health programs, but they may differ from the states (e.g., Medicaid in the territories is capped, and freely associated states do not have Medicaid).

Public Health Challenges in the Islands

Island issues are state issues. Like many states, the U.S. territories and freely associated states have high rates of chronic diseases and must contend with caring for aging populations. That said, there are important differences — such as ineligibility for certain federal programs, available data, existing workforce, and local infrastructure — requiring care in tailoring public health response and prevention strategies.

Given some of these limitations, people from the U.S. territories and freely associated states often travel to the states for health care services and some must move to Hawaii or the continental U.S. Still, they have a dedicated public health and health care workforce, tight-knit communities, and regional partnerships lending to their success addressing certain public health challenges (e.g., COVID-19).

How Is Public Health Unique in the U.S. Territories and Freely Associated States?

Disease, geography, and demographics are unique parts of public health in the U.S. territories and freely associated states.

Disease

Oceans do not protect these areas from the public health challenges that the states contend with, like infectious disease. Infectious disease is one of the main issues across all island jurisdictions, including diseases that the continental U.S. does not often see (e.g., tuberculosis, leprosy, Zika).

In addition, the introduction of canned foods and spam in the Pacific and Caribbean islands have disrupted the indigenous diets of fish and fruit, contributing to a significant chronic disease problem — with the Pacific experiencing some of the highest obesity rates in the world. Chronic diseases are the leading causes of morbidity and mortality across both states and territories. However, the prevalence and incidence of key chronic diseases can be orders of magnitude higher in the territories. For example, an estimated 8.5% of adults in the states have diabetes, while the prevalence is more than four times that (34% in 2018) in American Samoa.

Geography and Demographics

Further, differences in geography and demographics bring novel public health challenges. Most of the U.S. territories and freely associated states are made up of multiple islands, with small island masses, which means delivering public health care might require multiple modes of transportation (e.g., a ferry, boat, ship and/or small plane) and significant costs and staff time to provide services to outlying islands. Many of the Pacific islands are across the international dateline as well, making it difficult to join calls based on stateside working hours.

The geography in territories and freely associated states also leaves them at increased risk for severe weather events (e.g., hurricanes and typhoons) and the resulting immediate and long-term public health impacts. Their tropical climate also raises health risks that are less common in the mainland (e.g., dengue). In addition, many of the territories and freely associated states consist of small population sizes and residents who speak different languages (e.g., Spanish, Haitian, Creole, Marshallese, Filipino, Chuukese, Palauan). Therefore, meaningful, locally-based public health work often looks different than it does in the continental U.S., even if it follows the same principles.

How Does ASTHO Support Public Health in the U.S. Territories and Freely Associated States?

ASTHO’s Island Support team dedicates its time and work to advancing public health in the U.S. territories and freely associated states — working closely with these jurisdictions’ health leaders and their teams to tell their story, serve their needs, and ensure their access to the vital public health programs available to states.

Policy

The team supports island policy priorities, targeting legislative and administrative change:

• The Insular Affairs Committee to ASTHO’s Board of Directors highlights islands’ unique legislative policy needs and engages key stakeholders on Capitol Hill.
• The ASTHO-led Island Areas Workgroup works to address the key administrative challenges affecting health outcomes in the territories and freely associated states through collaboration across health agencies, federal agencies, and partners.

Partnership

The Island Support team also works cross-functionally across the organization and with external regional and national partners to best serve the islands, including:

• Engagement across ASTHO teams to increase awareness of the islands and how to work more effectively with these populations.
• Collaboration with partners to increase awareness of and effectively address islands’ priority public health needs.

Technical Assistance and Capacity Building

In addition, the Island Support team provides health officials from the territories and freely associated states with direct, specialized support for their public health efforts:

• Technical assistance supporting the implementation of new systems, processes, and skills.
• Development of resources (i.e., reports, briefs, etc.) to support health officials in the territories and freely associated states in addressing their priority issues and to advocate to their peers and Congressional leaders.

Get in Touch

Are you a public health leader in the Caribbean or the Pacific looking for assistance? Or perhaps you’re stateside working to include island needs and views in your programs. In any case, if you’d like to connect with ASTHO’s Island Support team, we’d love to hear from you and are here to help.

Email the Island Support team at islandsupport@astho.org.