Pacific Partnerships for Health

Charting a Course for the 21st Century

Committee on Health Care Services in the U.S.-Associated Pacific Basin

Division of Health Care Services and Board on International Health

INSTITUTE OF MEDICINE

Jill C. Feasley Robert S. Lawrence, Editors

NATIONAL ACADEMY PRESS
Washington, D.C.
1998



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i Pacific Partnerships for Health Charting a Course for the 21st Century Committee on Health Care Services in the U.S.-Associated Pacific Basin Division of Health Care Services and Board on International Health INSTITUTE OF MEDICINE Jill C. Feasley Robert S. Lawrence, Editors NATIONAL ACADEMY PRESS Washington, D.C. 1998

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ii NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sci- ences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertain- ing to the health of the public. In this, the Institute acts under both the Academy's 1863 congres- sional charter responsibility to be an adviser to the federal government and its own initiative in iden- tifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Insti- tute of Medicine. Support for this project was provided by the Health Resources and Services Administration, U.S. Department of Health and Human Services, with additional support provided by the Archstone Foundation and the U.S. Department of the Interior. The opinions expressed in this report are those of the Committee on Health Care Services in the U.S.-Associated Pacific Basin and do not necessar- ily reflect the views of the funders. International Standard Book Number: 0-309-05948-8 Additional copies of Pacific Partnerships for Health: Charting a Course for the 21st Century are available for sale from the National Academy Press , 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area) or visit NAP's on-line bookstore at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.nas.edu/iom. Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Insti- tute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover artwork: Women and Children, by Valerie Hunton. Cover design by Francesca Moghari.

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iii Committee On Health Care Services In The U.S.-Associated Pacific Basin Robert S. Lawrence* (Chair), Associate Dean for Professional Education and Programs and Professor of Health Policy, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland Dyanne D. Affonso,* Dean and Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia Carolyne K. Davis,* International Health Care Consultant, Ernst and Young, Washington, D.C. William H.J. Haffner, Professor and Chair, Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland Glen E. Haydon, International Consultant, Des Moines, Iowa Francis X. Hezel, Director, Micronesian Seminar, Chuuk, Federated States of Micronesia Dean T. Jamison,* Professor, Center for Pacific Rim Studies, University of California at Los Angeles, Los Angeles, California (resigned from committee in July 1997) Agnes Manglona McPhetres, President, Northern Marianas College, Saipan, Commonwealth of Northern Marianas Islands Hon. Tosiwo Nakayama, Vice President for Governmental Affairs, Bank of Guam, Chuuk, Federated States of Micronesia Paul W. Nannis, Commissioner of Health, City of Milwaukee Health Department, Milwaukee, Wisconsin Terence A. Rogers, Dean Emeritus, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii David N. Sundwall, President, American Clinical Laboratory Association, Washington, D.C. Study Staff Jill Feasley, Program Officer Annice Hirt, Research Assistant Heather Callahan, Project Assistant Evelyn Simeon, Administrative Assistant Clyde Behney, Deputy Executive Officer Christopher Howson, Director, Board on International Health * Institute of Medicine member.

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iv

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PREFACE v Preface The people of the U.S.-Associated Pacific Basin live half a world away from me and from the health policy makers in Washington, D.C. Yet, we are all linked through decades-old economic, legal, social, and cultural ties and a shared aspiration for better health for our families and children. Members of the committee that the Institute of Medicine convened to carry out the project described in this report are from several parts of the United States, and three members currently live in the region itself. Some of us had relatively little knowledge of the region; others had spent years living and working to improve the overall well-being and health care of people living on the islands of the Pacific Basin. All of us were able to visit at least two of the jurisdictions during our site visits. We were struck by the tremendous differences between the health care services available to most people in the 50 U.S. states compared to those in the Pacific Basin region. Even within the region, the differences were striking: the relative abundance of services and providers in Guam and the Commonwealth of the Northern Mariana Islands compared with the dearth of either in places like Chuuk. Yet, we also saw similarities. The damage and suffering wrought by alcohol and substance abuse, unhealthy diets, and unintended injuries are the same- whether they occur in Milwaukee, Majuro, Guam, or Georgia. On both sides of the Pacific, people at all levels are trying to figure out how to spend health care dollars more wisely. We all struggle with how to make available and provide access to certain basic health care services for the entire population, because we know that some of our vulnerable citizens are falling through the holes in the safety net. We recognize the need to shift our health care focus away from disease treatment and toward disease prevention and health promotion, but we lack the will to reallocate the necessary funds. In many respects, we are not so very different at all.

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PREFACE vi This report charts a course for health care services in the region for the coming years. It calls for a strengthening of community-based primary care, better coordination of efforts between the United States and the island jurisdictions, greater involvement of local communities and individuals in promoting health, and improved education and training for the health care workforce. Change is rarely easy. Some of the recommendations that we have made will require the U.S. government and the island jurisdictions to make very difficult decisions about what is truly important and which activities can no longer be supported. Our report comes at a time, however, when discussions about these decisions have already begun. Some communities are farther along and are better-equipped than others to make these meaningful changes. The committee and I believe that the recommendations contained in this report, if adopted, will make a substantial contribution toward the goal of current health reforms to create healthy islands and island populations for many years to come. Robert Lawrence, M.D. Chair

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ACKNOWLEDGMENTS vii Acknowledgments The committee and staff are indebted to many individuals who provided a great deal of help during the study: our project officers from the Health Resources and Services Administration, Anne Chang and Tom Coughlin, who were aided by Howard Lerner and LuAnn Pengidore; Mary Ellen Kullman Courtright from the Archstone Foundation; and Darla Knoblock from the U.S. Department of the Interior. A special thank you to Roylinne Wada, who diligently provided critical information, data, and analysis throughout the project. We also thank the speakers from our first meeting: Connie Arvis, Tom Bell, Joe Iser, and Greg Dever. We would also like to recognize the many participants in our meeting in Saipan: Father Roger Tenorio, Eliuel Pretrick, Jesse Borja, Victor Yano, Joe Flear, Vita Skilling, Anamarie Akapito, Jimione Samisoni, Wame Baravilala, June Shibuya, Isamu Abraham, Susan Schwartz, Marcus Samo, Elena Scragg, and Joe Villagomez. Jim Johnson, Joe Flear, and Patricia Ruez made presentations at the final committee meeting in August 1997. Before the Saipan meeting in April, the committee and staff visited each jurisdiction and met with literally hundreds of individuals. We have listed many of them below; we regret that we have failed to include each and every person who helped make our stays so worthwhile. American Samoa: Governor Tanese P.F. Sunia, Marie F. Ma'o, Iotamo Saleapaga, Pita Lauvao, Darryl Cunningham, Etenauga Lutu, Rasela Feliciano, Barbara Ueligitone, Patricia Kalasa, Roger Bartels, Salamo Laumoli, Ann Longnecker, Joseph Tufa, Charles McCutcheon, Charles "Mick" McCuddin, Irene Halshem, William Sword, Noa Ma'ae, Siitia Soliai, Matt Tunoa, and Amu Lapati.

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ACKNOWLEDGMENTS viii Chuuk: Kiosi Aniol, Herliep Nowell, Sixto Howard, Shinobu Poll, Enrida Pillias, Andita Meyshine, Joakim Peter, and Governor Ansit Walter. Commonwealth of the Northern Mariana Islands: Isamu Abraham, Josephine Sablon, Greg Calvo, Margaret Aldan, Jon Bruss, Joseph Villagomez, Sr., Joseph Villagomez, Jr., Dr. Sullivan, plus several other teams of staff members of the Department of Public Health, Malua Peter, Heinz Hofschneider, Delores Clark, Gary Bradley, and the irreplacable Bernie Alepuyo. Fiji: Jimione Samisoni, Wame Baravilala, Joseph Tuisuva, May Okihiro, several undergraduate and graduate students (including several PBMOTP graduates) from Micronesia and Samoa, Mike O'Leary, and Pakawan O'Leary. Guam: Dennis Rodriguez, PeterJohn Camacho, Marie Borja, many other staff of Department of Public Health and Social Services, Elena Scraggs, the FHP Medical Group, Peter Leon Guerrero, Don Davis, Mary Mantanane, Tyrone Taitano, many staff at Guam Memorial Hospital, Maureen Fochtman, Ulla- Katarina Craig, Augusta Rengiil, Guam Senators Edwardo Cruz and Lou Leon Guerrero, Laurie Duenas, Vince Leon Guerrero, Mary Sanchez, Helen Ripple, Rosario Nededog, Helen Santos, Bernadette Stern, Elizabeth Gray, Barbara Ashe, and Steve and Arlene Cohen. Hawaii: Sherrel Hammar, Raul Rudoy, Donald Person, Christina Hija, Neal Palafox, Robert Bath, and Gayle Gilbert. Kosrae: Asher Asher, Hitheo Shrew, Josiah Saimon, several administrators of the Health Department, representatives from the Women's Organization and Women's Affairs, Henry Robert, and Kalwin Kephas. Republic of the Marshall Islands: Tom Kijiner, Donald Capelle and staff, Zacharias Zacharias, Marie Lanwi, Tom Jack, Oscar de Brum, Bill Graham, Philip Okney, Jack Jorban, Russell Edwards, Cent Langidrik and staff, Alfred Capelle, Troy Barker, Andrew Kuniyuki, the physician staff of Majuro Hospital, Marita Edwin, Norman Smith, C. Eric Lindborg, the mayor of Kwajalein and two councilmen, and the physicians and primary care team at Ebeye Hospital (with special thanks to Dr. Tallens). Republic of Palau: Masao Ueda, Steve Umetaro, Era Kelulau, Rebecca Bedangel, Ginny Nakamura, Gail Ngirmidol, Regina Mesebeluu, Joanna Polloi, Francisca Blailes, Miriam Chin, Engracia Ongino, Sen. Sandra Pieantozzi, Sen. Santos Olikong, Lucio Ngivaiwet, Gerdence Meyar, Cynthia Malsol, Caleb Otto, Judy Otto, Dr. Ueki, and Francis Matsutaro. Pohnpei: Eliuel Pretrick, Sizue Yoma, Seamo Norman, Greg Dever, Jan Pryor, Susan J. Moses, Dr. Isaac, and Jacob Nena.

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ACKNOWLEDGMENTS ix Yap: John Gilmatam, Matthias Kuor, Mathew Haleyaluw, Andrew Yatilman, David Rutstein, Don Evans, Peter Suwei, Anna Boliy, Stan Gufsag, Bayad Untun, and Joe Haleyalmang. In each jurisdiction, committee members held special meetings with the graduates of the Pacific Basin Medical Officers Training Program. We are extremely grateful to all of them for their willingness to talk about their experiences and were impressed by the dedication each one brought to their duties. Staff members from several embassies and congressional offices also provided invaluable assistance in providing background information and logistical help before and during the site visits. We extend special thanks to Holly Barker, Samson Pretrick, Susan Yakutis, and Rhinehart Silas. Several other individuals also provided valuable background information and keen insight into the issues facing residents of the U.S.-Associated Pacific Basin: Nancy Glass, Mac Marshall, Wes Youngberg, and Ralph Rack. Arranging travel for 13 individuals going to a dozen different islands was truly a logistical nightmare. Our hats go off to Anthony Mavrogiannis and Christina leronimo of National Academy Travel. This project started in 1990 with a planning meeting held in California that highlighted some of the more pressing health issues within the U.S.-Associated Pacific Basin. Polly Harrison, a former IOM staff member, was the program officer for that meeting, and, in the ensuing years, she steadfastly rallied support for this study. Chris Howson, director of IOM's Board on International Health, also provided wise and timely advice once the project actually began. Heather Callahan, project assistant, cheerfully coordinated the complex details of the project—from arranging meetings to making sure that everyone received their reimbursements to formatting the text of the report. A special thank you goes to Annice Hirt, the project's outstanding research assistant, who weathered Typhoon Isa and remained unshaken by an earthquake measuring more than 6 points on the Richter Scale while on her site visit to Guam. More important, throughout the project she showed tremendous dedication to getting the facts right and to researching thoroughly the historical, social, legal, and economic contexts of the health situation in the Pacific Basin. The project and this report have been greatly enriched by her efforts. Finally, the artwork on the front cover is by Valerie Hunton, a renowned artist currently living in Fiji. She was named the Honorary Resident Artist of the PBMOTP in Pohnpei, while her husband was on the faculty there. Her works brighten hospitals and clinics throughout the region as well as the covers of the Pacific Health Dialog. The work on the cover of this book, Women and Children, is from her recently published book, Pacific Journey: A Celebration.

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ACKNOWLEDGMENTS x

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CONTENTS xi Contents SUMMARY 1 1 INTRODUCTION 15 Origins of this Report 16 Study Approach 16 Organization of this Report 17 U.S. Involvement with the Region 17 2 REGIONAL HEALTH AND HEALTH CARE SERVICES 23 OVERVIEW Regional Health Overview 23 Regional Health Care Services Overview 34 Appendix 49 3 CHARTING A COURSE FOR THE 21st CENTURY: A STRATE- 55 GIC PLAN FOR FUTURE HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN Adopt a Viable System of Community-Based Primary Care and 56 Preventive Services Improve Coordination Within and Between the Jurisdictions and 60 the United States Role of the United States 61 Role of the Island Jurisdictions 65 Interface Between the United States and the Island Jurisdictions 65 Increase Community Involvement and Investment in Health Care 67 Promote the Education and Training of the Health Care Workforce 71

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CONTENTS xii BIBLIOGRAPHY 77 APPENDIXES A Committee Biographies 85 B Saipan Workshop Agenda 89 C Organization of Institute of Medicine Site Visits to the Pacific 93 Basin, 1997 D Assessments of Individual Jurisdictions' Health Care Services 95 American Samoa 96 Commonwealth of the Northern Mariana Islands 104 Federated States of Micronesia 110 Chuuk 116 Kosrae 119 Pohnpei 122 Yap 125 Guam (Guahan) 128 Republic of the Marshall Islands 141 Palau (Belau) 149

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TABLES AND FIGURES xiii Tables and Figures TABLES 2.1 Total Population, U.S.-Associated Pacific Basin Jurisdictions 25 and the United States 2.2 Leading Causes of Death (number of deaths), U.S.- 31 Associated Pacific Basin Jurisdictions 2.3 Cost Summary for DHHS Programs and Activities in the 42 U.S.-Associated Pacific Basin Jurisdictions, by Agency, FY 1995 (in thousands) 2.4 Health Resources and Services Administration Budget for 43 Activities in the U.S.-Associated Pacific Basin Jurisdic- tions, FY 1996 2.5 Health Care Workforce in the U.S.-Associated Pacific Basin 46 2.6 Number of Physician Graduates, by Year of Graduation 52 2.7 PBMOTP Budget, FY 1986 to FY 1996 52 2.8 Number of PBMOTP Graduates Currently Working in U.S.- 53 Associated Pacific Basin Jurisdictions 3.1 Total Health Budget Per Capita, U.S.-Associated Pacific 56 Basin Jurisdictions FIGURES 2.1 Population estimates for U.S.-Associated Pacific Basin juris- 26 dictions, selected years, 1950–1997, and projected, 1998– 2010 2.2 Life expectancy at birth, U.S.-Associated Pacific Basin 27 jurisdictions and the United States, 1996 2.3 Number of infant deaths per 1,000 live births, U.S.- 28 Associated Pacific Basin jurisdictions and the United States, 1996

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TABLES AND FIGURES xiv 2.4 Total fertility rate per woman for the U.S.-Associated 28 Pacific Basin jurisdictions and the United States, 1997 2.5 Median ages for populations in the U.S.-Associated Pacific 30 Basin jurisdictions and in the United States 2.6 Percentage of children younger than 2 years of age who are 34 fully immunized, U.S.-Associated Pacific Basin jurisdic- tions, 1996 3.1 Overview of recommended organizational arrangements 61

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xv Pacific Partnerships for Health Charting a Course for the 21st Century

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The Pacific region. SOURCE: Pacific Health Dialog: Pacific Peoples of New Zealand. Journal of Community Health and Clinical Medicine for the Pacific 4(2), 1997. Copyright 1997 by Resource Books Ltd. Reprinted with permission. xvi