Close ports of entry

Ishmael Togamae, Sheldon Riklon, Kamal Gunawardane, and Seiji Yamada are physicians who have practiced in Micronesia.

By ISHMAEL TOGAMAE, MD, SHELDON RIKLON, MD, KAMAL GUNAWARDANE, MD, and SEIJI YAMADA, MD, MPH
Special to the Saipan Tribune

Author’s Note: Here we use the name of the virus, “SARS-CoV-2,” instead of saying “COVID-19,” the name of the disease involving fever, cough, and shortness of breath.

An emergency doctor met with the governor’s Cabinet of a Pacific Island jurisdiction to present about the coronavirus pandemic. He noted that there is only one ventilator for the entire country. The doctor asked the parliamentarians whom among them they would choose to be on the ventilator in the event that the coronavirus reaches their islands. The Cabinet members, many of whom have diabetes and hypertension, were all silent. A few days later the head of state declared a state of emergency. All ports of entry, particularly the airports, are now closed.

SARS-CoV-2 is very contagious. Because it has to come from somewhere, the first people on-island to become infected have some connection to travel. They’re visitors. Or they’re locals who went somewhere else. Or they’re locals who had close contact with visitors. A single case, though, of a person with no connection to travel represents many more people with SARS-CoV-2. A single case represents widespread community transmission.

SARS-CoV-2 is very wily. Some patients will die. Some will feel completely well but can spread it to others. All 3,300 people in the small northern Italian town of Vo Euganeo were tested. Only 3% were positive, but of that 3%, half had no symptoms at all. Of the 531 infected individuals evacuated from the Diamond Princess cruise ship, 255 (48%) were asymptomatic at the time of specimen collection. Of 12 Japanese nationals evacuated from Wuhan who tested positive, five (42%) had no symptoms. Among those that get sick with COVID-19 disease, the infected person is contagious for two days before the onset of symptoms, and transmissibility peaks before or with the onset of symptoms. Some 44% of transmission occurs before the infected person develops symptoms.

Some might say, “It doesn’t matter if we don’t identify the minimally symptomatic people, because everybody who is sick is supposed to be isolating.” This doesn’t take into account the need for people to make a living. That person with minor symptoms is going to keep serving at the restaurant, cashiering at the store, or working at the hospital. The public health authorities need to know about every single person infected with SARS-CoV-2.
The point of the two-week quarantine is that those who are going to be sick will get sick within two weeks. If everybody perfectly socially distanced from everybody else for two weeks, no new people would get infected. But obviously, social distancing isn’t going to be perfect, because we Pacific Islanders have collectivist cultures that engage in most daily activities as a group, a family, a community. So we then have to lock down for another two weeks, and then another two weeks.

So we need to know who in particular (i.e., the individual infected with SARS-CoV-2) needs to stay away from everybody else. We can identify those individuals only by testing.

Maybe your remote Pacific Island jurisdiction hasn’t had SARS-CoV-2 introduced yet. In this day and age, perhaps that’s not likely. But if you don’t get too many visitors from outside, maybe you’re lucky. If your people are still able to live off of the land and aren’t completely dependent on canned food and toilet paper—last month was the time to close the ports of entry, the seaports, but especially the airports. The Marshall Islands shut them down on March 8; Pohnpei shut them down on March 21; Chuuk shut them down on March 29. The Marshall Islands are following every precaution, including putting 19 Marshallese students returning from Chuuk under a mandatory 14-day quarantine, to keep SARS-CoV-2 out of the country. Just lock it down now; the tighter the better. Congratulations to those who already bravely and decisively took that step. You are making history in an exemplary manner at this critical time for the whole world.

If your economy was dependent on tourism from all over Asia, you probably already have community transmission. As Dr. Anthony Fauci says, now you have to focus on mitigation with social distancing measures. You will still want to test as widely as your resources will allow for the coronavirus, and eventually get back to containment.

During the Great Influenza of 1918-1919, American Samoa closed itself off and did well. Western Samoa, now Independent Samoa, did not close itself off and lost a quarter of its population. If your island ends up being the American Samoa or Tasmania of today’s pandemic, you will owe it to the foresight of your leaders.