Overview of State 2019

Geography: American Samoa is a self-governing territory of the United States and consists of a group of seven islands in the southern Pacific Ocean.  It is located about half way between Hawaii and New Zealand south of the equator line. The total land area of American Samoa is approximately 76 square miles (200 square km). The main island of Tutuila, the largest island of the group, covers an area of 55 square miles (143 square km), just a slightly larger than Washington DC.  The center of Tutuila is called Pago Pago, the political, administrative, and commercial center of the Territory of American Samoa.

Aunu`u Island is one mile off the southeast tip of Tutuila (a 15-minute ferry ride), with a land mass of 0.6 square miles and a population of about 300 people.  Sixty miles east of Tutuila is the Manu`a Island group (a 30-minute airplane ride or a 12 hour boat ride from Tutuila) that includes the volcanic islands of Ofu and Olosega, connected by a bridge, and the Island of Ta`u. These islands are sparsely populated, with a total 2010 Census population of 1,400 residents, and each village having a few hundred residents. The Swains Island is a privately-owned coral atoll located 214 miles north of Tutuila with approximately 1.25 square miles of land mass and a population less than 20 (2010 Census). Swains Islanders raise coconuts and grow bananas, taro, breadfruit and papaya, and supplement their diet with fish from outside of Swains' reef. Rose Island (coral atoll) lies 78 miles east of Ta`u with a landmass of 0.1 square miles, is uninhabited and is named a national monument.

Geographically, Pago Pago has one of the best natural deep-water harbors in the South Pacific Ocean, sheltered by shape from rough seas and protected by peripheral mountains from high winds.  American Samoa climate is typically hot, humid and rainy throughout the year, moderated by southeast trade winds.  Maximum rainfall averages about 122 in (3,100mm) per year. Rainy season is also typically hurricane season happening from November to April, while dry season occurs from May to October. Maximum temperatures range from upper 70’s to mid 90’s throughout the year.

Population: According to Department of Commerce in American Samoa, information released projected the 2019 mid-year population was estimated at 58,500 a recorded loss of 1,100 to the resident population due to high outmigration, increased mortality, and declining fertility.  This is also noted in the continuous steady decline of live births annually since 2016.  The mid-2019 population estimate had slightly more females, at 29,746, than males at 28,753. 

American Samoa is divided into four geo-political districts: Western District, Eastern District, Manu`a District, and Swains Island District. The population distribution for these districts show that there are 31,329 residents (56.4%) in the Western District, 23, 030 residents (41.5%) in the Eastern District, 1,143 in the Manu`a District and 17 residents in the Swains Island District (2.1%). The age group of 25-64 years old has the highest number at 26,241; followed by 6-13 years old with 9,976; and topping off the top three is the age group of 14-18 with 6,464.  The age group with the smallest estimated population is infants — less than one-year old at 950, while the age group of 65 and over totals 3,640.

Ethnicity: Of the population, 91.6 percent reported as Pacific Islander are native Samoans, 2.8 percent are Asian, 1.1 percent is Caucasian, 4.2 percent are mixed, and 0.3 percent is of other origin.  Although majority of the population of consistent of native Samoans, more than two-fifths of the population were born outside of the territory, largely in the neighboring independent Samoa Island, with smaller proportions from the United States, other Pacific Islands, and Asia Countries. 

Language:  Most people are bilingual and can speak English and Samoan fluently. Samoan, a language closely related to Hawaiian and other Polynesian languages, is spoken natively by 9 percent of the people as well as the co-official language of the territory.  While 80 percent speak English and Samoan, 2.4 percent speak Tongan, 2 percent speak Asian languages, and 2 percent speak other Pacific Islander languages.   Tokelauan language is also spoken in Swains Island. Literacy is calculated at 97 percent.

There are 9,349 households in American Samoa of which 8,706 (93.1%) are family households and 643 non-family households (householder living alone). Of the family households, 6,596 (70.6%) are married-couple families of which 5,261 are households with children under 18 years of age and 1,398 (15%) are female head of household of which 640 have children less than 18 years of age. Of the total households of all types, 7,598 (81.3%) are households with an individual under 18 years of age.  In addition to the fact that the vast majority of the population of American Samoa is concentrated on one island, Tutuila, the residents of American Samoa are culturally a relatively homogeneous population.

Economic Environment:  Traditionally, the local economy consisted of subsistence farming and fishing. In the 1970’s and 1980’s the influence of the U.S. mainland standard of living took a significant stronghold in local communities. Since then the concept of sustenance living took a downward trend as young American Samoans left for military services, education, and better opportunities on the mainland. Presently, American Samoa has the highest rate of military enlistment of any U.S. state or territory including Pacific Military jurisdictions. With better opportunities came the potential to have enough money to provide for families back on the islands.

For the past 2 decades, major improvement in the cash economy was evidenced by significant increases in exported canned tuna products valuing at over $400 million annually, drawing more migrant families from neighboring islands such as the independent Samoa and Tonga. Tuna fishing and tuna processing plants were the backbone of the private sector, with canned tuna as the primary export. Since then, two Tuna companies have departed the island leaving Start Kist Samoa as the only cannery operating in Tutuila, due to U.S.-International trade agreements and expanded foreign competition, the loss of federal tax incentives, and the dramatic increase in the minimum wage that took effect in American Samoa 2008.

The territory experienced modest economic growth in 2014 and 2015, which was spurred, in part, by a large capital investment by Tri Marine International on the purchase and construction of facilities for processing and packaging locally harvested tuna. The cannery opened early in 2016, under the name Samoa Tuna Processors (STP). Competition from Asian-based canneries immediately put the company in a precarious position and processing operations permanently halted in late-2016. STP laid off at least 400 employees during the closure, which led to hundreds of additional job losses in related and support industries over the following year. Star-Kist Samoa Co., American Samoa’s last remaining tuna processor, also faced setbacks in 2017. Availability of landed fish, along with a number of federally-mandated equipment upgrades, forced the company to temporarily halt operations for five weeks in the fourth quarter of 2017. The shutdown left thousands of employees without salaries to cover basic expenses and cost the local government more than half-a-million dollars in income tax revenues. The combined impact of the cannery closures contributed to a spike in the unemployment rate in the territory in 2017, from 10.5% in 2016 to 14.3%.

The recession may have extended into the following year, if not for a devastating storm that impacted much of American Samoa in February of 2018. By some estimates, Tropical Storm Gita caused as much as $186 million in direct and indirect damages across the territory. At least 50% of all individuals in the territory were faced with significant damage to real and/or personal property during the storm. Food, water, and other basic necessities were in high demand throughout the days and weeks that followed. During that time, automated teller machines were persistently low on cash supplies as the people of the territory scrambled to draw enough to cover immediate repair and replacement costs.

Ongoing disaster relief funding was expected to contribute to modest consumer and government spending increases in American Samoa in 2018 and through to 2019.  Additionally, international relief agencies distributed pre-loaded gift cards to families and individuals that were most affected by the storm. Disaster relief funding is expected to contribute to consumer and government spending in 2018. Once the immediate effects of the tropical storm have diminished, so will many of the economic stimulus benefits.

American Samoa also benefited from recent strength in the broader US economy in 2018, driven primarily by strength in labor markets. With relatively low domestic unemployment rates and consumer inflation, wage growth seems to have finally taken hold in the US during 2018, which appears to have translated to accelerated spending by both households and private businesses.

Combined territorial and federal government spending in American Samoa is expected to have grown by 11.0% in 2018 and is projected to decrease by 2.8% in 2019 as the impact of project grants and disaster relief funds begin to dissipate. Government spending is then expected to increase by 0.8% in 2020, when hundreds of additional workers are hired for the decennial census. Following the completion of the survey, temporary Census employees will fall off of public payrolls and government spending will contract by an estimated 2.1% and 1.3% in 2021 and 2022, respectively.

The accelerated growth in government spending in the early years of this forecast, along with the swell in relief funds to individuals and families, is anticipated to have created as many as 500 jobs in the government and private sectors in 2018, lifting personal income by approximately $10.4 million that year. Personal consumption expenditures are forecast to grow by 1.3% in 2018, 1.4% in 2019, and 0.4% in 2020 before contracting by 1.9% in 2019.

According to the Comprehensive Economic Development Strategy Report for American Samoa 2018-2022, a SWOT analysis identified several strengths and weaknesses that have contributed to the economy of American Samoa.  One noted weakness was the quality of healthcare, stating “The Lyndon B. Johnson Tropical Medical Center (LBJ) is the sole hospital in the territory. As a result, patients frequently experience long delays when seeking medical care. Of those surveyed, 33.3% identified quality of health care a weakness. There are only a small number of private health care practices located in the territory, mainly due to an inability of patients to afford the high cost of unsubsidized health care services. The Department of Health (ASG DOH) does operate five other Public Health Centers, which has helped to alleviate some of the strain on LBJ. The territory has also long struggled with securing and retaining high quality health care practitioners. This is due, in part, to the territory’s remote location, the relatively heavy workload, inadequate funding, and uncompetitive wages.

As noted, American Samoa had about 11,034 housing units in 2015. Of the types of tenure, houses owned free and clear were 74.7 percent, so about 3 in every 4 units. The others were owned with a mortgage (10.2 percent), rented for cash rent (11.1 percent), and occupied without payment of cash rent (4.0 percent). Many families in single-family units had a business on their property – 7.2 percent of all units. Houses continue to get larger, with the median number of rooms increasing to 5.4 with an average of 3.4 bedrooms. Metal roofs continue to predominate (at about 4 in every 5 units), with smaller numbers having poured concrete or wood. Only about 1 in every 4 housing units have access to hot and cold water. But more and more American Samoa families are able to afford appliances. In 2015, these included a Stove (81.2 percent of all housing units), Microwave (58.3 percent), Refrigerator (92.2 percent), Freezer (45.2 percent), Air conditioner (40.1 percent), Television (86.3 percent), and Computer (33.5 percent). However, only about 3 in every 5 units had a vehicle at home.

The 2015 Household Income and Expenditures Survey also collected information on types of income and on regular, annual, and daily expenditures. American Samoa median household income is $22,000 compared to the US median of $52,000. About 42 percent (16,557) of all adults were working at a paid job in 2015. The largest industries in the territory were manufacturing (at 18.1 percent), public administration (17.8 percent), education (17.0 percent), retail trade (8.0 percent), health and social services (7.0) and construction (6.1). Similarly, the largest occupations were production (15.8 percent), office and administrative support (13.2 percent), and education (11.2 percent). About half the workers were in the private sector compared to about 45 percent who worked for the American Samoa Government.

Cultural and Social Environment:  The Samoan culture plays a very significant role in the community and social context.   Traditionally, the family and culture are of utmost importance to the people.   The Samoan family or “aiga” has strong bonds and is a key factor in both service delivery and patient decision-making.   Families make decisions together and often, the family as a group makes health decisions rather than as individuals.

Key members of the Samoan community are family leaders, cultural leaders, and church leaders.  The Samoan cultural leaders are the “matai” or the chief of each respective clan or family.  Land ownership and family dwellings are also tied directly to family, clan and matai titles where the land is communally owned by the family and under the stewardship/authority of the matai.  The matai system provides an extension to the conventional or western idea of families, where any given family or clan includes several households or sections of a village.  Respect and compliance for both the matai and/or family leaders such as parents and grandparents are paramount in Samoan society.   Matai and family leaders are important members of the Samoan cultural and social environment.

Religion: Christianity is the foremost religion in American Samoa.  Churches are embraced as an important component of society.  Church leaders are revered in all social, cultural and professional settings.  Church groups are among the most organized and well attended non-governmental organizations in the community.  Most families and individuals are active participants in a church organization of some fashion. Health promotions and outreach activities are often delivered in religious settings as it reaches majority of people.

Samoans live a communal way of life, participating in activities collectively. In a Samoan village, each ‘aiga’ or family live on family or communal land, often next to each other. Though each family within the family may live in their own housing structure, the family is one – everyone works the same land, cook together, eat at one ‘fale ai’ or family dinner house, pray in one home together and are only separated by night to rest. This continues to be a practice today in many Samoan communities.

These key factors play an important role in health planning.  It is well understood in the health community that any service provided at any level must take into consideration the cultural and social environment of the family.  Many of the services delivered at the community level are designed to be family-friendly, culturally appropriate, or religiously acceptable as most people in American Samoa are active participants in one or all of these groups.

Health Care System:  Under the American Samoa legislative code all residents are entitled to free medical care.  Therefore all health care services are heavily subsidized by government and delivered at little or minimal cost to residents.   Services are administered through the Department of Health and the American Samoa Medical Center Authority (LBJ Hospital). 

The relationship between the sole local hospital and the Department of Health is one of strengths and weaknesses.  The LBJ hospital is assigned to address acute hospital care to the entire island, with support services that enhance diagnostics and treatment to those who seek care from this facility.  DOH serves the community through the community-based health centers spread across the islands, along with preventive programs that are federally funded with local matching requirements for sustainability of services.  These two healthcare entities deliver services in a range that complements one another.  For instance, Community Health Centers provide prenatal care free of charge for all pregnant mothers, with the exception of those with high risk pregnancies who would be referred to the hospital for follow up care throughout their entire pregnancy.  By the 3rd trimester, the pregnant mother will be referred from Community Health Clinics to the LBJ hospital for continued care until after giving birth.  Preventive and primary care services are the sole responsibilities of the Health Department while the LBJ hospital provides acute care.

The American Samoa Medical Center Authority (ASMCA), the only hospital in American Samoa, provides all acute medical services and includes outpatient clinics as well as inpatient hospital care.  The ASMCA provides outpatient care at the Emergency Room, Primary Care Clinic, Pediatric Clinic, Obstetrics and Gynecology Clinic, Surgical Clinic, Medical Clinic, Ear Nose Throat Clinic, Dialysis Clinic, Psychiatry Clinic, Dental Clinic, and the Eye Clinic.  The inpatient services include 128 patient beds in six wards: Labor and Delivery, Nursery, Maternity, Internal Medicine, Surgical, Intensive Care, and Psychiatry. 

The LBJ Tropical Medical Center (LBJ TMC) is a 128-bed general acute care hospital, with an approximate footprint of 150,000 square feet, constructed into six (6) separate linear buildings connected by two primary corridors bisecting each, in a grid pattern. The facility was originally constructed in the mid 1960’s and attained full operation in 1968. The facility is a single-story concrete bent frame, sloped roof and wood framed structure which has undergone a number of minor renovations over the years. The facility is certainly approaching the end of its serviceable life cycle (50 years).

In the last five years, ASMCA has extended its Dialysis Unit to accommodate 32 chairs, providing much needed services to well over 200 patients requiring dialysis.  Most recently, a private-owned dialysis clinic opened its doors to the public. The latest survey reported data that shows 24,623 patients visited the hospital's emergency room. The hospital had a total of 3,937 admissions. Its physicians performed 907 inpatient and 2,521 outpatient surgeries. The ASMCA also provides all laboratory, diagnostic imaging, and pharmacy services for the entire population.   The ASMCA operates as a semi-autonomous agency of the government and is governed by a board of directors whose membership is subject to legislative approval.

The Department of Health is responsible for preventive and outreach services to the community.  The Department of Health delivers primary care services through the Federally Qualified Health Centers (FQHC).   There is one FQHC situated on the West side (heavily populated area) called Tafuna Family Health Center (TFHC).  In 2009, TFHC added two new access points to its services, which included Leone clinic on the western tip of the island, and Amouli clinic on the eastern tip of the island. There are 5 satellite clinics spread geographically throughout the island including one in Ta’u and Ofu of the Manu’a Islands. A newly renovated primary health clinic began its services in mid 2017, located across the LBJ Tropical Medical Center.  This clinic combines services for employment physicals, school athletic clearances, Tuberculosis screenings, RHD echo screening, and Flu shot campaigns.  DOH is continually recruiting additional providers to operate this clinic as only one provider is currently stationed at this site. 

Since the Zika outbreak in 2016, federal funding assistance enabled a satellite pharmacy to open and operate from TFHC, as well as a laboratory to conduct testing for CHC patients.  In the past years, nurses mainly managed Manu’a health clinics, with occasional visits from an available physician.  With continued recruitment of doctors for CHC in the past year, the Manu’a health clinics have been able to entertain a doctor who lives on site and provides services for the Manu’a population.  Also, through the MCH Zika grant, telehealth equipment have been installed in the Ta’u health center, as well as Amouli and Leone health centers, to allow connections during telemedicine and telehealth sessions with US based partners.

The Department of Health is also responsible for infectious and chronic disease surveillance and prevention, community nursing services, environmental health, immunization, Public Health Emergency Preparedness (PHEP), Comprehensive Cancer Control Program (CCCP), HIV and STD screening, early intervention, newborn hearing screening, as well as MCH Program services and the Maternal Infant Early Childhood Home-visiting (MIECHV) Program. 
 

A Medicaid Program exists in American Samoa, operating directly under the Governor’s office.  American Samoa’s Medicaid program was established in 1983. It is a 100% fee-for-service delivery system with one hospital servicing the territory. There are no deductibles or co-payments under the American Samoa Medicaid program, however there are some fees charged by the hospital located in American Samoa. Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $181,307,628 in Medicaid funding to American Samoa.  These monies have allowed the Medicaid program to support an off-island referral process for cases that cannot be addressed in American Samoa.  These cases are directly referred to New Zealand to further care under the sponsorship of the Medicaid program.  Some of these cases include children who require heart valve replacement surgeries due to complications of Rheumatic Heart Disease and babies born with congenital defects.

Eligibility in American Samoa differs from eligibility in the states. American Samoa does not have a TANF or SSI program and does not determine eligibility on an individual basis. Rather, the territory uses a system of presumed eligibility. Each year the percentage of the population below 200% of the poverty level is estimated and, after CMS approval of the estimate, CMS pays expenditures for Medicaid based on that percentage.  There are plans in the very near future to begin individual eligibility enrollment for Medicaid funding.

American Samoa was awarded $16,510,330 million for its Medicaid program in lieu of establishing a health marketplace. American Samoa must exhaust its Affordable Care Act (Section 2005) allotment prior to using these funds.  Moreover, the FQHC’s became eligible for Medicaid reimbursement for services provided through an amendment in February 2017. Due to this eligibility, FQHC’s were able to offer care without a cost to the public.   An additional amendment proposed coverage and reimbursement of emergency and certain other medical services furnished by off-island and out-of-country providers became effective April 1, 2017.

Department of Human and Social Services (DHSS) is the Territory’s Single State Agency for Substance Abuse Prevention and Treatment.  It also serves as the State Mental Health Authority and is the Governor-designated lead agency for Child Welfare Services and Social Services and is the lead agency on underage drinking. This 100% federally funded agency directs four (4) core agencies, including: 1) Social Services; 2) Women, Infants and Children (WIC); 3) Nutrition Assistance Program (Food Stamps); and 4) the Vocational Rehabilitation Division. DHSS provides substance abuse prevention and outpatient counseling to more than 150 families each year, as well as mental health services, 24-hour emergency shelter services and crisis hotline, victims of crime advocacy, crisis intervention, family support services and subsidized child care for low-income working families.

DHSS and DOH often collaborate in efforts that combine the social and health aspect of the community, respectively.  The MCH Title V program partners with DHSS annually for breastfeeding, nutrition, behavioral health, child care, oral health, and surveillance efforts.  DHSS primarily conducts the SBIRT (Screening, Brief Intervention, and Referral to Treatment) tool to identify, reduce, and prevent the use, abuse, and dependence on alcohol and illicit drugs.
 

There is a Veteran’s Affairs Clinic in American Samoa, which caters to veterans and military reservists. The clinic has less than five doctors, and provides outpatient services only during regular business hours five days a week.  The VA clinic also accesses laboratory, pharmacy, dental and radiology services at the ASMCA.   Other private specialized clinics in the community owned by Samoans include services such as Optometry, Primary Care, Sleep Care and Dental operated by an Orthodontist.

Other types of health related entities also exist within the system of care for American Samoa.  These include the following:

• Hope House - the only nursing home-type of setting on island, housing the elderly and children with severe disabilities
• Alliance for Families – providing support services for victims of domestic abuse and violence, shelter for families in difficult situations, and workshops/educational sessions on community-based services
• Intersections – is a 501 c 3 not-for-profit organization that has been creating opportunities for change among children and families since 2002. Intersections provides intervention and prevention services that empower young people to become successful in making positive choices, promote healthy living, and foster social responsibility
•  

It is also necessary to comment on the Department of Youth and Women’s Affairs (DYWA) under the American Samoa Government. DYWA conducts numerous programs throughout the year, targeting adolescents, youth, and women and includes the Department of Health in its efforts.  Such programs address critical issues that improve autonomy and skills that are applicable to life in general for all women, adolescents, and youth.  Through this collaboration, MCH participates to deliver relevant health education and promotion topics that are vital to their development and well-being. 

MCH also works extensively with nonprofit organizations (NGOs) and the business community to reach goals that aim to improve the health of women and children in American Samoa.  Local chapters of organizations such as the Rotary club, the Lions club, and the Shriners provide financial and humanitarian support to assist in health efforts such as vision & hearing, cardiovascular, and Orthopedic needs.  The Intersections Program is a non-profit group that focuses on Adolescent Health and conducts sexual abstinence education and peer mentoring groups.  The Paramount Construction Company has continuously donated financial assistance to support the annual Cardiology clinic for children with Rheumatic Heart Disease for the past five years.  Other locally owned businesses have contributed to Health events that cater to the health of women and children.

MCH intends continuing collaborations with its valuable stakeholders to achieve priorities that improve the health and wellbeing of all women and children in American Samoa