III.B. Overview of the State

OVERVIEW OF THE STATE OF GUAM

 

The island of Guam lies between 13.2 and 137.7 N and 144.6 and 145.0 E. The island is 30 miles long and 4 to 9 miles wide, giving it an area of 212 square miles, making it the 32nd largest island in the United States. It is the southernmost and largest island in the Marianas and the largest in Micronesia. 

Guam's tropical climate ranges from a mean high temperature of 86 F to a mean low of 76F. The dry season runs from December to June. The remaining months (July to November) constitute the wet season with an average annual rainfall of around 98 inches.

The Northwestern Pacific Ocean region comprises a succession of three tectonic

plates. From the most western, moderately sized Philippine Sea plate to the small crescent-shaped Marianas Plate and the Pacific Plate to the east.

Due to its location on the Marianas plate, Guam occasionally experiences earthquakes. In recent years, earthquakes with epicenters near Guam have had magnitudes ranging from 5.0 to 8.2 (1993). The 1993 earthquake injured 48 people and caused more than $100 million in damages.

Guam is in "Typhoon Alley," the busiest location for tropical cyclones, and it is common for the island to be threatened by tropical storms and possible typhoons during the wet season. The highest risk of a typhoon is during August through December. They can, however, occur year-round.

POPULATION

As of April 1, 2020, Guam’s population was 153,836, representing a decrease of 3.5% from the 2010 Census population of 159,358. Over half of the population (58%) is 25 or older. The estimated median age is 30.4 years. Males slightly outnumber females, with an overall sex ratio of 1.03; however, for those aged 25 years and older, the sex ratio is 1.0. Data on sexual orientation is not available.  

Guam’s population is multiethnic multiracial. Chamorro comprises the largest ethnic group, accounting for

37.2% of the total population.

Filipinos comprise 26.3%, Whites comprise 6.8%, and Other Pacific Islanders comprise 11.5%. Guam's population's ethnic/racial composition has been shifting over time. The proportion of the population consisting of Chamorro has declined from 44.6% in 1980 to 37.2% in 2018.

LOCAL GOVERNMENT

Guam is an organized, unincorporated territory of the United States, which only select parts of the U.S. Constitution apply to its residents. Individuals born in Guam are considered citizens of the United States. Residents of Guam cannot vote in federal elections. Guam's local government is organized into executive, legislative, and judicial branches.

The Legislative Branch consists of a unicameral legislature with 15 Senators for two-year terms, which is led by the Speaker Senator Therese M. Terlaje and has been also the been the Chair for Health during her term in the legislature.  The legislature is empowered and responsible for creating laws to protect the community, ensure the community's health and welfare, and promote Guam's development. Guam's Judicial Branch decides issues of local statutes and interprets how these laws should be applied. The judiciary consists of the Superior Court of Guam and the Supreme Court of Guam. Finally, the island's highest elected officials, Governor Leon Guerrero and our Lt. Governor Tenorio, together manage the executive branch. These officials implement Guam's laws through its departments, bureaus and agencies, and various committees that make up the Government of Guam.

Guam has a non-voting delegate in the U.S. House of Representatives, is the Honorable Michael F.G. San Nicolas. Our delegate is part of the non-voting delegates can perform many functions of a full representative, such as serving on committees, speaking on the U.S. House Floor, introducing bills, and offering amendments. However, they cannot vote while conducting business as the Committee as a whole or on the final passage of legislation.  Delegate San Nicholas has only been a delegate for Guam, for only one-term, but has been involved with many issues related to Guam.  He has worked to secure funding for the payment of War Claims pursuant to the Guam World War II, worked with the Loyalty Recognition Act, to extend coverage for Social Security Supplement Security Income (SSI) to the Territory of Guam, and is advocating to address herbicide exposure for veterans who served in Guam, among other issues.

EMPLOYMENT/UNEMPLOYMENT

The unemployment rate in Guam in December 2021 was 7.2%, a decrease of 0.9% from the September 2021 figure of 8.1% and a reduction of 12.2% from December 2020, but up 3.6% from September 2012 pre-pandemic figure. 

The December 2021 unemployment rate reflected a decrease in the number of persons unemployed since September 2021 due to increased employment and persons no longer looking for work. The number of persons not in the labor force decreased in the latest quarter from 54,190 in September 2021 to 51 950 in December 2021.

The December 2021 Employed Report shows that average weekly hours paid and average weekly earnings have continued their recovery from the pandemic lows. Non-construction employment was up 1,130 since the low in September 2020. Employment numbers began a moderate rebound in December 2020, with the recovery continuing through December 2021. Total employment remains 5,390 jobs below the pre-pandemic employment of 67,580 in December 2019 despite an increase of 2,130 jobs in construction. Private sector employment remains 11% lower than before the pandemic.

EDUCATION

The Majority of the educational need of Guam is provided by an island-wide public school system managed by the Guam Department of Education (GDOE), which is comprised of five high schools (grades nine to twelve), eight middle schools (grades six to eight), and 27 elementary schools (grades one to five) operated by the Government of Guam.

Due to Covid 19 safety concerns, the Guam Education Board approved three models of instruction for the school year. Beginning in January 2021, all three teaching models were anticipated to be offered, and parents may select which models their child would participate in.

1.                 Home Learning Online Instruction – this model of instruction and attendance is 100% online home learning. Students participate in classes online and must have a computer or tablet and reliable internet access.
2.                 Home Learning Hard Copies – This model of instruction and attendance is for students who want to do 100% distance learning but have the equipment to support 100% online work. This would be home learning supported by a paper-based or hard copy-based curriculum.
3.                 Traditional (face to face) – This model of instruction and attendance will be for students who will be participated in traditional face-to-face classes. There would be alternating schedules for students to attend classes on any given school day.

Public school enrollment numbers have decreased over the last two years, and dropout rates have declined. The Annual State of Public Education report for the school year 2020-2021 data confirmed the adverse impact that the pandemic had on education. According to the report, there were noticeable variances in enrollment within grade levels with increases in grades three, 11, and 12. Meanwhile, Head Start through grade two, grade four through 10, and the alternative school showed decreases in enrollment. The estimated enrollment was 26,600.

GDOE officials estimate that the dropout rates have doubled for the current school year. GDOE officials made home visits to track down roughly 864 students who did not attend school in the first few months. GDOE officials stated that 16% of students 18 years old and above did not want to return to school.

CRIME

According to the 2020 Crime in Guam Uniform Crime Report, 6,927 offenses were reported. Of this total, 3,503 arrests were reported for violent and property crimes and other assaults. The total arrest for 2020 is a 5 percent decrease from the 7,231 arrests reported in 2019.

As Guam is a small island, the effects of violent crime are magnified and negatively impact the entire island. The 2020 Uniform Crime Report from the Guam Police Department reports an average of 746 (3-year average beginning with 2018 to 2020) instances of violent crimes each year to the Federal Bureau of Investigation. The violent crimes include murder, rape, robbery, and aggravated assault. In 2020, violent crime decreased by 14.5% compared to 823 in 2019.

From 2016 to 2020, a total of 5,118 individuals are arrested on the island for criminal offenses annually. In 2020, 1,026 juvenile crimes were reported, approximately 384 for violent and other assault offenses. The Department of

Youth Affairs (DYA), a youth correctional facility, is responsible for the care and custody of both status and delinquent offenders. In 2021, the total admissions of youth in custody at DYA was 74, a significant decrease from the 2020 overall admissions of 212 and admissions in 2019 of 360 youth.

Recurring offenses are violations of a court order, beyond control, remand order, and criminal offenses such as family violence, assault, burglary, and underage drinking. Most of the individuals arrested have encountered the criminal justice system, mainly for relatively minor, non-violent offenses, and sometimes from decades in the past. Whether an arrest occurred recently or long ago, individuals with criminal records, particularly recently incarcerated individuals, have a juvenile record and will face serious and complex obstacles to reentry into the community.

The nature and extent of Guam's drug problem have not significantly changed over the years. Record seizures continue to be reported for crystal methamphetamine or “ice” from postal, cargo, and other drug investigations. Crystal methamphetamine continues to be the most commonly abused illegal drug on Guam, and it has been the prominent drug of choice on Guam over the past three decades. Marijuana is another prevalent drug in Guam, in addition to an emerging opioid crisis and a resurgence of cocaine. The prevalence of drugs and the reported rates of drug and alcohol abuse, domestic violence, and gang-related activity negatively contribute to Guam's increasing violent crime problems.

There is a significant disparity between the availability of treatment services for persons with alcohol and drug use disorders and the demand for services. This disparity is also consistent for criminal justice populations with individuals who need substance abuse treatment as part of their justice system supervision but did not receive the treatments due to a lack of resources to implement treatment programs, services, or providers. According to the Department of Corrections’ Casework & Counseling Services Division and Forensic Unit, the average population of local inmates/detainees in 2020 is 701, and statistics continue to show that over 85% of those in Department of Correction (DOC) custody admitted to substance use and abuse before or during the commission of their arrest/crime. This number also represents individuals whose parole or probation status was revoked and incarcerated due to substance use and abuse. The current recidivism rate of the population remains at 67% (18% for parole or probation revocation, 53% for new crimes committed with violence, and 28% for non-violent offenses).

The Healing Hearts Crisis Center (HHCC) is Guam’s only rape crisis center providing comprehensive forensic medical examinations on child and adult sexual assault victims to collect forensic evidence. The center intends to provide survivors of sexual assault with "discrete, immediate, and full medical attention." Collecting forensic evidence is critical to begin the healing process for victims to ensure the successful prosecution of perpetrators of sexual assault on children and adults.

A growing concern in Guam is sexual assault cases involving minors. This is significant as Guam’s only rape crisis center serviced 41 sexual assault victims between the ages of 0 to 15 in 2020. Overall, in 2020 HHCC serviced a total of 74 victims of sexual assault, 66 were female victims, and 8 were male victims, 41 sexual assault victims were between the ages of 0 to 15 years of age, 31 sexual assault victims were between the ages of 16 to 50 years of age, and two unknown who did not state his/or her gender. By 2021, HHCC experienced a slight decrease in the number of victims served compared to the past four years due to the coronavirus pandemic.

HHCC reported a total of 54 victims of sexual assault, with 49 being females and 5 being males. Responding to victims of sexual assault requires a coordinated community effort. Local data continues to show the magnitude of this problem in Guam. According to the Guam Police Department's 2020 Uniform Crime Report, on average, 131 Criminal Sexual Conduct offenses have been reported in the past five years. The Healing Hearts Crisis Center (HHCC) leads Guam's Sexual Assault Response Team (SART), which incorporates governmental and nonprofit agencies that provide services to victims of sexual assault and abuse.

HHCC works closely with the Guam Police Department, Child Protective Services, and advocacy agencies such as Victim Advocates Reaching Out (VARO) to provide a full continuum of care to victims, including the Office of the Attorney General, for the prosecution of perpetrators charged with a sexual assault offense.

These barriers can ultimately contribute to a cycle of incarceration that makes it difficult for even the most well-intentioned individuals to stay on the right path and out of the justice system. Across the country, communities face high recidivism rates for several reasons. Many justices involved individuals return to the community with considerable deficits, such as limited education, few marketable job skills, no stable housing, chronic health issues, substance abuse needs, and fragile support networks.

HIGH COST OF LIVING

The cost of living is the sum required to pay basic prices such as rent, housing, utilities, food, taxes, heating, electricity, and healthcare service in a specific location and time period. The cost of living is frequently used to evaluate the expense of residing from one city to another. Monthly income usually determines the cost of living. If expenditures are greater in a metropolis, such as New York, the income levels must also be greater for individuals to afford to live there. The cost-of-living index measures living expenses in a large city to the average price in a comparable cosmopolitan region. The indicator combines various living costs to create an overall metric that new residents may use as a reference.

The cost of living in Guam is $2164, making it 1.22 times more than the national mean. The cost of living in Guam is high compared to other states, with an overall Cost of Living Index of 83.63, using New York as the base of 100. Employees can make around $2560.52 after taxes. According to the Bank of Guam, the mortgage interest rate is 4.35%.

According to the Guam Chamber of Commerce, the monthly rent for furnished accommodation in Hagåtña or Tumon for 900 sq. feet is around $2,551, whereas the monthly rent for furnished accommodation in a typical area is an average of $1,815. The monthly rent for affordable housing in Guam is 52% more expensive than in the rest of the country. The average monthly rent for a one-bedroom in Hagåtña is between $1,488 and $2,120, 21.5% more than the USA average.

However, the utility cost makes Guam so much more expensive. The United States average utility cost for two people is around $128. Surprisingly, utilities for two people are about $318, making it more than 147% more expensive.

The cost of groceries is very high, especially for consumables, housekeeping supplies, dairies, fresh fruits and veggies, regular food goods, munchies, and carbonated beverages. On average, you can expect to pay 31% more than the average in Guam compared to other cities. Alcohol and tobacco products like beer, liquor, wine, and cigarettes are expensive. On average, a midsize bottle of wine costs $12.75, local beer costs $2.70, imported beer costs $5.50, and a packet of 20 cigarettes costs $11.

Hotel daily room rates, meals, beverages from expensive and inexpensive restaurants, and take-out food and drink are all expensive. It is 3.1% more expensive than an average U.S. state. Moreover, a dinner for two in a nice restaurant can set you back at around $60.

The primary reason for the high cost of living is the "Jones Act." The Merchant Marine Act of 1920, known as the Jones Act, is a federal statute establishing support for the development and maintenance of a merchant marine to support commercial activity and serve as a naval auxiliary in times of war or national emergency (See 46 USC § 50101). It has been a U.S. territory since 1898, when it and Puerto Rico were ceded to the United States as spoils of the Spanish-American War. Before 2016, Guam's exemption from the Jones Act's U.S.-build mandate had not made much difference. The Act applies to four of the seven non-contiguous U.S. jurisdictions, Alaska, Hawaii, Puerto Rico, and [to a limited degree] Guam. American Samoa, the CNMI, and the Virgin Islands are fully exempt from the Jones Act. The Jones Act increases the cost of shipping to Hawaii, Alaska, Puerto Rico, and other non-continental U.S.

lands that rely on imports by restricting the number of vessels that can legally deliver goods.

POVERTY

The definition of Poverty is a condition in which one cannot afford fundamental building blocks such as clean water, nutrition, health care, education, clothing, and shelter. Poverty rates vary significantly according to geography, age, race, and household types. The population groups with the highest poverty rates often have the poorest health status. (Marmont, 2005)

The 2021 Federal Poverty Guidelines designate a family of four with a gross yearly income of $25,750 living in poverty. The annual median salary for a family working at the minimum wage is $19,572. Thus, a family with a head-of household working full-time earning the minimum wage has significantly less income than the federal poverty level. 

In examining the 2010 poverty status of residents in Guam, 22.5% of all individuals on Guam for whom poverty status was determined were considered to be in poverty; of these, 54% were individuals over 18 years of age; 4% were individuals over the age of 65, and 4% were children under the age of 18. When assessing families' poverty status in Guam for the same time period, 41% were married-couple families. Forty-four percent (44%) of families were female-headed households, and 15% were male-headed households living in poverty.

Guam offers cash assistance to low-income persons/families based on rules and standards set by the Division of Public Welfare (DPW), Guam Department of Public Health and Social Services (DPHSS) for some of the most impoverished families. There are two major programs for cash assistance, the Cash Assistance Program (CAP) and Temporary Assistance for Needy Families (TANF).

FOOD SECURITY

Food security is defined as access by all people to enough food for an active, healthy life and is necessary for a family to be healthy and care for its members. Food insecurity occurs whenever the availability of nutritionally adequate and safe foods or acquiring acceptable food is limited or uncertain. Hunger is an unpleasant or painful sensation caused by a recurrent lack of food.

The food insecurity contributes to overweight and obesity, as well as undernutrition. The higher cost of nutritious foods, the stress of living with food insecurity, and physiological adaptations to food restriction help explain why food-insecure families may have a higher risk of overweight and obesity. The Supplemental Nutrition Assistance Program (SNAP) (aka Food Stamps) is a federally funded program that provides a basic safety net to alleviate hunger and malnutrition by permitting low-income households to obtain a more nutritious diet. The amount of SNAP benefits provided is based upon monthly income.

The Guam SNAP income guidelines require that most households meet gross and net income tests. However, if a home has an older adult or someone receiving certain disability payments, they only need to complete the net income test. Laws have been passed to determine the income eligibility standards for SNAP benefits. Gross monthly income limits are set at 130% of the poverty level for the household size. Net monthly income limits are set at 100% of poverty.

MEDICAID PROGRAM

Guam became a territory in 1950, and its Medicaid program was established in 1975. Medicaid is the largest health insurance program in the U.S. and is jointly financed by the federal and local government for low-income and other eligible individuals.

Despite near-identical reliance on the program, territories operate Medicaid program under different rules than the 50 states and D.C., Section 1108 of the Social Security Act established an annual ceiling on federal financial funds to the Medicaid program in the territories.

Unlike the 50 states and D.C., the federal government will match all Medicaid expenditures at that state's appropriate Federal Matching Assistance Percentage (FMAP) rate. In Guam, the FMAP is applied until the Medicaid ceiling funds, and other specific federal funds are exhausted. Historically, territories often exceed the annual cap, after which they must fund their programs using unmatched local funds.

Below are the Allotment Caps for F.Y. 2020, F.Y. 2021, under section 1108(g). For the four territories of American Samoa, CNMI, Guam, and the U.S. Virgin Islands, CMS multiplied the territories' F.Y. 2021 cap by a 2.7% increase for the medical care component.

MEDICAID ALLOTMENT CAPS

	FY 2020	FY 2021	FY 2022
American Samoa	$86,325,000	$85,550,000	$87,860,000
Guam	$130,875,000	$129,712,500	$133,210,000
CNMI	$63,100,000	$62,325,000	$64,010,000
USVI	$128,712,500	$127,937,500	$131,390,000
Puerto Rico	$2,716,188,000	$3,009,063,000	$2,943,000,000

Eligibility rules in Guam's Medicaid program differ from those in the states. Guam is permitted to use a local poverty level established income-based eligibility for Medicaid and is exempt statutorily from requirements to extend poverty-related eligibility to children, pregnant women, and qualified Medicare beneficiaries. Guam currently provides coverage to individuals, including children, with modified adjusted gross income to 133 percent of the Guam poverty level. This is $1,536 per month for a family of four or approximately 61 percent of the federal poverty level, which is $2,500 per month for four in 2021.

Congress provided additional Medicaid funds temporarily. The appropriation package and the Families First Coronavirus Response Act significantly raised each territory's Section 1108 cap. These enhanced funds were set to expire Sept 2021, resulting in a return to the pre-pandemic relief bill amount.

In 1996, citizens from the Freely Associated States (FAS) were removed from the Medicaid program. Their eligibility to the program was restored by H.R. 4821, the "covering our FAS Allies Act" and as a clause in Public Law 118-260, in the Consolidated Appropriation Act of 2021. This went into effect in December 2021. As a result, Guam's Medicaid coverage has expanded to include FAS citizens through a State Plan amendment.

Supplemental Security Income (SSI) is a federal cash assistance program that provides monthly benefits to aged, blind, or disabled individuals (including blind or disabled children) who have limited income or resources (assets). It provides a flat monthly benefit of $794 or $1,191 for a couple. However, while these critical benefits are taken for granted in most American communities, they are not available to otherwise eligible residents of most U.S. territories for no other reason than where they happen to live.

In 2021, an individual with a disability began receiving SSI benefits while living in New York. The following year, the individual moved to his home island of Puerto Rico, unaware that his move made him ineligible to receive SSI benefits. In 2016, the same individual registered to receive Social Security benefits. The Social Security Administration realized that the individual now lived in Puerto Rico and ceased SSI benefits. In 2017, the U.S. Department of Justice sued the individual to recover $28,081 in SSI benefits he received while living in Puerto Rico.

In court, the individual argued that SSI discrimination against residents of the U.S. territories violated the Constitution's guarantee of Equal Protection. The court and a unanimous panel of the U.S. Court of Appeals for the First Circuit agreed, concluding that discrimination against residents of Puerto Rico with aspect to the SSI program fails judicial review under any standard. In March, the Supreme Court rejected the U.S. Department of Justice's request to review the unanimous decision and summon a full review. In late 2021, the federal government filed a brief to the U.S. Supreme Court, arguing that Congress has the authority to withhold SSI benefits from U.S. citizens depending on where they live.

In April 2022, the U.S. Supreme Court issued its decision, holding that the equal protection component of the Fifth

Amendment’s Due Process Clause of the U.S. Constitution does not require Congress to extend Supplemental Security Income (SSI) benefits to residents of Puerto Rico. Residents of Puerto Rico and other territories were excluded from eligibility for SSI benefits when the program was created in 1972.

The Court’s opinion, authored by Justice Kavanaugh, held that Congress’s decision to exempt Puerto Rico’s residents from most federal income and other taxes provides a rational basis for distinguishing residents of Puerto Rico from residents of the States for purposes of federal benefits, including SSI, with concurrences from Justices Thomas and Gorsuch. Justice Sotomayor was the sole dissenter.

MARINE CORPS RELOCATION

The plan is to relocate about 5,000 Marines and dependents from Okinawa to Guam between 2020 and 2025. However, delays to the schedule continue. They were expected to begin arriving around 2025. Construction for the buildup moved forward steadily despite the COVID-19 pandemic. The two major construction sites — the main base in Dededo and a live-fire training range complex at Ritidian — are both quickly nearing completion. Work to clear the area and install utilities, roads, and fences at Marine Corps Base Camp Blaz is 85% complete. Construction for three barracks, the base administration building, and the central fuel station are underway. About 5,000 Marines from Okinawa and elsewhere are scheduled to relocate to a new Marine Corps base in Dededo, Camp Blaz, beginning in 2025. The Marine Corps officially activated the base on Oct. 1, 2020.

Marine Corps Base (MCB) Camp Blaz is a U.S. Marine Corps facility located in the village of Dededo in northwest Guam. MCB Camp Blaz was activated on October 1, 2020, becoming the first new Marine Corps facility since the predecessor of Marine Corps Logistics Base Albany was commissioned on March 1, 1952. The base will house Marines relocated from installations in Okinawa Prefecture, Japan, with the final relocation planned for 2025. [2] Joint Region Marianas is the installation management authority for MCB Camp Blaz, Naval Base Guam, and Andersen Air Force Base.

MCB Camp Blaz is named after Brigadier General Vicente T. "Ben" Blaz. Blaz was the first person of an ethnic minority to reach a general rank in the USMC and the highest-ranking Chamorro ever, and Guam's delegate to Congress from 1985 to 1993.

The main dormitories will be next to Naval Computer and Telecommunications Station Guam, with the final base to house 1,300 permanently stationed Marines and support 3,700 additional Marines on rotating assignments. Base construction includes multiple new ranges, training facilities, schools, housing, and other support facilities. The Department of Defense spent $365 million in FY2020 on relocation expenses, with the total cost expected to be $8 billion, of which the Government of Japan will provide $2.8 billion. The Governor and Legislature of Guam have been engaged with the Guam Military Buildup.

The Ritidian-based Mason Live-Fire Training Range Complex consists of five gun ranges. Four are 75% complete. This year, a construction contract for the complex's fifth, final, and most extensive range will be awarded. The Department of Defense spent $365 million on Marine Corps realignment-related projects on Guam last fiscal year.

 

COMPACTS OF FREE ASSOCIATION

The Freely Associated States, located roughly 2,500 miles southwest of Hawaii, covers a maritime area larger than the continental United States and governs over 1,000 islands and low-lying atolls.

The FAS are sovereign, "insular areas" of the United States that, through bilateral Compacts of Free Association with the United States, receive U.S. economic assistance and grant the United States the prerogatives to operate military bases on their soil and make decisions that affect the U.S. and FAS security.

 

 In 1947, the Marshall Islands, Micronesia, the Northern Mariana Islands, and Palau, under Japanese control during World War II, became part of the U.S.-administered United Nations Trust Territory of the Pacific

Islands. In 1978, the Marshall Islands, Micronesia, and Palau rejected the option of U.S. territorial or commonwealth status and instead chose the status of free association with the United States. The Northern Marianas chose commonwealth status, and nearby Guam, occupied by the United States after the Spanish American War ended in 1898, became a territory in 1950.

The Republic of the Marshall Islands (RMI), Federated States of Micronesia (FSM), and the Republic of Palau signed Compacts of Free Association with the United States in 1982. The RMI and FSM Compacts were approved by plebiscites in the Marshall Islands and Micronesia and by both houses of the U.S. Congress in 1985, becoming effective in 1986. 5 In 1986, Palau and the United States signed a 50-year Compact of Free Association. The U.S. Congress approved the Palau Compact, but it was not ratified in Palau until 1993 (entering into force on October 4, 1994).

Each Compact included economic assistance provisions that would expire after 15 years. The Compacts were conceived to help advance economic development and self-sufficiency among the FAS and to support the national security interests of the FAS and the United States in light of Cold War geopolitical concerns related to the Soviet Union. Although democratic self-government and mutual security goals have largely been achieved, economic development and self-sufficiency have remained elusive, particularly in the Marshall Islands and Micronesia U.S. "insular areas" include possessions or territories, commonwealths, and independent jurisdictions such as sovereign states in free association.

HOMELESSNESS

A safe home and stable housing are essential for everyone. Without a home, applying for a job or building long-term relationships is complicated, reducing social support. Without a home, youth and children suffer from hunger, have reduced mental and physical health, often experience physical and sexual violence, and are more likely to miss school.

 Two trends are primarily responsible for the rise in homelessness over the past 20-25 years: a growing shortage of affordable rental housing and a simultaneous increase in poverty. Problems with definitions and methodology often complicate studies of homelessness. Homelessness may be transitory, and many homeless people are hard to find.

Therefore, it is difficult to determine just how many individuals or families are, in fact, homeless.

 Nationally, about a third of the homeless population is less than age 24. Homeless children are more likely to have health problems, developmental delays, learning disabilities, emotional difficulties, and mental disorders than children with stable housing. According to the U.S. Department of Housing and Urban Development's 2020 Annual Homeless Assessment Report, "Homeless describes a person who lacks a fixed, regular, and adequate nighttime residence."  

In January 2020, the Guam Point in Time Survey identified 790 homeless individuals in shelters, a 9.7% decrease from 2019.[38] Of those surveyed, nine had a mental illness, 15 were victims of domestic violence, and 14 had a substance abuse problem. There were two homeless people under the age of 18. In 2019, there were 58 Chronically Homeless Persons with at least one adult and one child. In 2020, this decreased by 15.5% to 49 individuals.

For 2021, the Guam Homeless Coalition only surveyed the sheltered population of people experiencing homelessness because of the global COVID pandemic. They surveyed 199 people and 66 households.  Since 2004, the DPHSS BFHNS Community Health Nurses have been participating in these Annual Point in Time Homeless Count.  The nursing management provide training prior to the count and the nurses are usually led experts for any health-related issue (clinic visits, home visits, and resource for referrals for Medicaid, SNAP, and medical care.

HEALTH CARE DELIVERY SYSTEM

Guam's health care delivery system is pluralistic and distinguished by public and private sectors for the local civilian population and a military system for delivering medical services to the active military members and their dependents, as well as the military retirees and veterans on Guam.

All the health services customarily found in a community of similar size on the U.S. mainland are available to the island population. One unique problem setting Guam apart from mainland communities is that specialized and tertiary medical services are thousands of miles away, necessitating medical referrals to Japan, the Philippines, Hawaii, or the United States mainland. Guam is situated in the western Pacific. Guam lies about 5,800 miles (12 flight hours) from the U.S. mainland and 3,800 miles (7 flight hours) southwest of its closest U.S. neighbor, Hawaii. While remote from the U.S., Guam is closer to the Asian rim. Tokyo, Taipei, Manila, and Hong Kong are all within three hours of flight time.

Guam has been designated Health

Professional Shortage Area (HPSA) and a Medically Underserved Area (MUA).

Health Professional Shortage Areas (HPSA) are federal designations that apply to areas, population groups, or facilities with unmet health care needs. Designations help prioritize limited federal resources to the areas that need them most. The federal Medically Underserved Area/Population (MUA/P) designation identifies areas or populations needing medical services based on demographic data.

Guam's health care system comprises hospitals, outpatient clinics, and home health care services. The goal of a public health department is to improve every Guam resident's health status and ensure access to quality health care. This includes helping each person live a life free from the threat of communicable disease, tainted food, and dangerous products.  Activities that assist in this mission include regulating health care providers and facilities when appropriate.

TOP TEN CAUSES OF DEATH

Trends in mortality rates due to leading causes of death reflect a society's medical, psychosocial, and economic well-being, and a historical snapshot of such trends can help inform future policies.  For the years 2020 and 2021, COVID -19 was the third leading cause of death.

Top Ten Causes of Death: Guam, 2021
Rank	Cause of Death	N o . o f Deaths	%  of Deaths
1	Diseases of the Heart	395	30.86
2	Malignant neoplasms	212	16.56
3	COVID-19	119	9.30
4	Cerebrovascular diseases	75	5.86
5	Nephritis, nephrotic syndrome, and nephrosis	48	3.75
6	Septicemia	45	3.52
7	Accidents/unintentional injuries	44	3.44
8	Intentional self-harm	24	1.88
8	Certain conditions originating in the perinatal period	24	1.88
8	Influenza and pneumonia	24	1.88
	All Other Causes	253	19.77
	Total Deaths	1,280	100.00

Source: DPHSS OVS

Rank	Cause of Death  2020	N o . o f Deaths	%  of deaths
1.	Diseases of the Heart	342	28.6
2.	Malignant Neoplasms	199	16.6
3.	COVID 19	112	9.4
4.	Cerebrovascular Diseases	73	6.1
5.	Accidents/Unintentional Injuries	45	3.7
6.	Nephritis, nephrotic syndrome, and nephrosis	44	3.6
7.	Septicemia	42	3.5
8.	Intentional Self-Harm	38	3.1
9.	Influenza and Pneumonia	27	2.2
10.	Chronic liver disease and Cirrhosis	23	1.9
10.	Diabetes mellitus	23	1.9
	All Other Causes	221	18.5
Total Deaths		1,192	100

Source: DPHSS OVS

IMPACT of COVID -19

Guam confirmed its first case of the COVID-19 pandemic on March 15, 2020, and the first death on March 22.

The Government of Guam ordered the general lockdown of the island in mid-March. Governor Lou Leon Guerrero announced the implementation of a four-step "Pandemic Condition of Readiness" (PCOR) on April 30, 2020. Travelers to Guam from designated high-risk areas must provide a recent negative COVID-19 test or undergo mandatory quarantine in a government-approved facility.

Guam moved from PCOR 1 to PCOR 2 on May 10, allowing some business activity with restrictions, and then to PCOR 3 on July 20. An outbreak in mid-August was not controlled for several months, resulting in the 7-day rolling test positivity rate to spike above 15% in early October 2020, as well as infections in both the Governor and Lieutenant Governor.

Guam announced a return to the lockdown conditions of PCOR 1 on August 14 to control the outbreak, which was not loosened to PCOR 2 until January 15, 2021. It was further relaxed to PCOR 3 on February 21, 2021. From December 2020 to July 2021, cases stayed very low until a surge in August 2021, primarily due to the delta variant.

Guam COVID-19 Vaccination Update as of December 30, 2021, 129,550 of Guam's eligible population (residents five years and older) is fully vaccinated. This total includes 12,591 residents 12 – 17 years old. Four thousand eight hundred sixty-six residents 5 – 11 years old received their first dose of the Pfizer-BioNTech two-dose series. There were 2,887 residents 5 – 11 years old have completed their two-dose series. An additional 339 residents received their booster shots, and a total of 39,593 booster shots have been administered to eligible residents since September 29, 2021.

Maternal and child health is never static; identifying priorities/needs once every five years does not limit the focus of Title V – significant attention is paid to emerging needs and the flexibility required to pivot and address those needs when necessary quickly. The COVID pandemic highlighted many gaps in services, aggravated disparities, and other issues felt most strongly by vulnerable populations, many of which are common to multiple population groups. Mental/behavioral health has become a significant concern for all domains – affecting children, youth, and women alike as island residents deal with exceptional stress due to the pandemic.

There is also a concern that people have been deferring preventative and essential care during the pandemic. Specific to our MCH populations, we have observed a decrease in attendance of well-child visits. The childhood immunization rate has also decreased during the pandemic, an issue that goes hand-in-hand with the reduction of well-child visits, and it is unclear whether parents will take their children in for their recommended vaccines once the epidemic abates. In addition, the pandemic decreased the number of providers in some areas, and, although most providers are now reopened, increased cleaning requirements and social distancing have reduced the number of children that can be seen in a day.

Many DPHSS staff, including Title V staff, were deployed to assist the COVID-19 pandemic through testing, serving on the outbreak and vaccinations.   The MCH clinics continued to provide services while the DPHSS BFHNS MCH staff were still responding to this COVID-19 Pandemic by providing Community COVID Testing, vaccinating at both in Community Health Centers, and at a local shopping center.  We have participated in 2021 with over 100 community vaccinations with adults, pregnant women, adolescents, and children throughout the island.  From Village Mayors offices, Gyms, schools, parks, beach areas, homeless shelters, home visits in under-served areas, at different GovGuam agencies sites. The mission from the Governor of Guam was to promote, provide and encourage getting all residents on Guam vaccinated with the COVID vaccines.

Essential activities of the DPHSS responded to the pandemic included:

                  Developing COVID-19 data dashboards that present case rates, testing, Intensive Care Units (ICUs) and Acute Hospital beds, testing volume, testing per day, and percent positive rate over seven days,

                  Updating public health partners, including schools, healthcare facilities, colleges and universities, and health emergency preparedness teams with the most up-to-date guidelines

                  Developed public and private partnerships with pharmacies, health care facilities, and community-based organizations to launch mass testing and vaccination sites throughout Guam

                  Launched a communication campaign on the importance of COVID vaccinations

                  Implemented Covid Alert, which uses exposure notification technology to notify users who may have been exposed to an infected person

As we shift from pandemic response to recovery, we are looking at the data to understand how the pandemic has affected Guam's MCH populations, apart from the immediate impact of the disease. Some trends that we are monitoring include increased incidence of domestic violence, disorders of despair (e.g., depression, anxiety, suicide, drug misuse), risky behaviors among adolescents (i.e., unprotected sex, drug use, driving choices), and reduced utilization or uptake of preventive services, childhood immunizations, and developmental screening. These secondary impacts of the pandemic are likely to last for a while, and it will be essential to identify and address them with targeted actions and resources in the years to come.

The MCH clinics continued to provide services while the DPHSS BFHNS MCH staff are still responding to this COVID-19 Pandemic by providing Community COVID Testing, Vaccinating at both in CHCs and shopping malls, and homebound services.  We have been participating in 2021, with >100 community vaccinations with adults, pregnant women, adolescents, and children throughout the island.  From Village Mayors offices, village/school Gyms, village elementary and high schools, malls, parks, beach areas, homeless shelters, home visits in under-served areas, at different GovGuam agencies sites and departments.  The mission from the Governor of Guam was to promote, provide and encourage getting all residents on Guam vaccinated with the COVID vaccines.