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INTRODUCTION 15 1 Introduction Covering an expanse of ocean larger than the continental United States, the U.S.-Associated Pacific Basin consists of six island jurisdictions. Three are U.S. flag territories: American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), and Guam. The other threeâFederated States of Micronesia (FSM), Republic of the Marshall Islands (RMI), and Republic of Palauâare independent countries but are also freely associated with the United States. This report examines one aspect of U.S. involvement: its role in the region's health care delivery systems. The health care delivery systems of the different jurisdictions in the region reflect the challenges and strengths unique to the islands. The health status of the island inhabitants naturally varies within and among the jurisdictions. In general, however, almost all health indicators for these islanders are worse than those for mainland Americans. This is most notably so in the freely associated states. The systems must deal with health conditions typical of those of both developing countries (e.g., malnutrition, tuberculosis, dental caries, dengue fever, and cholera) and developed countries (e.g., diabetes, heart disease, and cancer). In the delivery of health care services numerous challenges must be overcome. These include: administrative structures that emphasize hospital-based acute care; the long distances that must be covered to provide care to people in remote areas; dependence on foreign aid; inadequate fiscal and personnel management systems; poorly maintained and equipped health care facilities; the enormous costs involved with sending patients off-island for tertiary or specialized care; and shortages of adequately trained health care personnel. In many cases, the island jurisdictions are also contending with significant social change brought about by incredible population growth, rapid economic development, and a shift away from a way of life based on communal
INTRODUCTION 16 farming and fishing to one that is market and consumer oriented. Attempts to address these health conditions and challenges come at a time when U.S. federal government aid to the region has begun to decrease, a trend that is likely to continue. These challenges are also embedded in the islands' many strengths and resources: cultures that remain vibrant even after years of foreign occupation and influence, strong familial ties and roles for women, highly developed and organized communities, traditional health practices, and powerful religious beliefs. ORIGINS OF THIS REPORT The Institute of Medicine (IOM) was asked by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services to examine these issues and suggest possible approaches to improve the health care situation. Specifically, IOM was to: 1. collect and examine all readily available information on the status of health service programs in the Pacific Basin, including the recently concluded Pacific Basin Medical Officers' Training Program (described in Chapter 2 and Appendix D); 2. develop assumptions about benchmarks to be used to assess needs and services in those jurisdictions (discussed in Chapter 3); 3. assess the accomplishments, adequacy, and shortcomings of health services programs and related health interventions compared to the baseline assumptions (described in Chapter 2 and Appendix D); and 4. develop a strategic plan to address the problems and inadequacies, and reinforce the successes, in health services (described in Chapter 3). Additional financial support for this project was provided by the Office of Insular Affairs of the U.S. Department of the Interior and the Archstone Foundation. STUDY APPROACH To undertake the requested study, IOM's Division of Health Care Services and Board on International Health convened a 12-member study committee, with experts in primary health care, education, international health, mental health, and public health (see Appendix A for a complete list of committee members and their brief biographies). The committee met three times between January and August 1997. The committee's second meeting occurred in April 1997 on Saipan, CNMI, in conjunction with a workshop with health officers from the region (see Appendix B for the workshop agenda and a list of
INTRODUCTION 17 participants). Immediately before the Saipan workshop, teams of committee members visited all the jurisdictions (see Appendix C for more details).1 Committee and staff reviewed the literature on health care services in the region and met with the jurisdictions' key congressional and diplomatic representatives in Washington, D.C. Grant applications and reports on federal grants were also reviewed. Two papers were commissioned: one examined the social and cultural implications of health care delivery in the region, and the other provided updated health data for the region. At its third and final meeting in August 1997, the committee reviewed a draft manuscript and discussed final conclusions and recommendations. ORGANIZATION OF THIS REPORT This document constitutes the committee's final and formal report. It is divided into three main chapters. This chapter provides background on the IOM's study and U.S. involvement with the region's health care. Chapter 2 presents an overview of the region's health and health care services, including a chapter appendix that describes the Pacific Basin Medical Officers' Training Program. Finally, Chapter 3 contains the key recommendations for a plan for future health initiatives in the region. General background information and assessments of each of the six jurisdiction's health care delivery systems can be found in Appendix D. U.S. INVOLVEMENT WITH THE REGION The ties that bind these Pacific islands to the United States have been forged largely within the past centuryâfrom ties through trade and religious missions to ties with the United States as the United Nations-approved trust administrator and the preeminent funder of much of the region's economic activity and its social and health services. As the twentieth century ends, these ties continue to change. Yet, the United States still has a variety of important military, economic, and health interests in the region. Historical Overview Archaeological data suggest that the islands of the U.S.-Associated Pacific Basin might have been inhabited as far back as 3000 B.C. Contact with the Western world, however, began in 1521, when the Spanish explorer, Ferdinand Magellan, landed in the Mariana Islands. Since that time, the islands have 1 The site visit to RMI took place in July 1997.
INTRODUCTION 18 experienced successive waves of foreign occupation and domination: Spanish, German, Japanese, and, most recently, American. Spain remained in control of all the islands except the Marshall Islands and American Samoa until 1898. That is when, shortly after the Spanish-American War, the United States acquired Guam. Germany, through a series of diplomatic maneuvers, purchased many of the remaining islands from Spain. German interest in the region was primarily economic; the interest of the United States was decidedly economic as well, although missionaries had begun working in the region as early as the mid-1850s. In the South Pacific, American Samoa was officially claimed as a U.S. territory in 1900. Fourteen years later, Japan took control of the German-associated Micronesian islands at the start of World War I; its rule continued until the end of World War II. During its occupation, thousands of Japanese citizens immigrated to the islands and helped to develop an extensive infrastructure of roads, schools, and hospitals. After World War II, the United States reclaimed control over Guam. The United States also took administrative control over all the other Micronesian islands: first through a military administration and later through the United Nations' Trust Territory of the Pacific Islands (TTPI), administered through the U.S. Department of the Interior (DOI). A substantial military presence built up during the Cold War because of the islands' strategic position near Asia and for weapons testing, training maneuvers for the Central Intelligence Agency (CIA), and military staging for the Korean and Vietnam conflicts. Current Political Status of the U.S.-Associated Pacific Basin Jurisdictions The political status of most of the U.S.-Associated Pacific Basin jurisdictions has changed greatly over the past 20 years. Currently, the three flag territories (American Samoa, CNMI, and Guam) are officially part of the United States. The three freely associated states (FSM, RMI, and Palau) are independent countries that have chosen to be associated with the United States through Compacts of Free Association. The Flag Territories Guam, CNMI, and American Samoa maintain close ties to the United States either as unincorporated territories (Guam and American Samoa) or through a commonwealth covenant (CNMI). All citizens of the flag territories are U.S. citizens. A commonwealth differs from a territory in that the commonwealth can control its own immigration, customs, and tax policies. An unincorporated territory means that not all provisions of the U.S. Constitution apply to the territory. All three flag territories have locally elected legislatures and governors.
INTRODUCTION 19 The Freely Associated States The FSM, RMI, and Palau marked their political independence by signing Compacts of Free Association with the United States. Each Compact provides for development assistance and cedes full authority and responsibility for the jurisdiction's defense to the United States. The Compacts also allow citizens of the freely associated states to immigrate to the United States and any of its territories and possessions. FSM and RMI signed 15-year Compacts that will expire in 2001. Renegotiation of the Compacts is allowed, however, and FSM and RMI have apparently chosen to pursue this option (U.S. State Department, 1996). Palau signed a 50-year Compact that will expire in 2044. U.S. Military Interests in the Region The United States has had a military presence in the region that can be traced back to 1898, when the United States acquired Guam after the Spanish-American War. From 1946 to 1958, the U.S. Department of Defense performed nuclear weapons testing in the Marshall Islands (U.S. State Department, 1994). Saipan was the CIA's training ground for Chinese Nationalists in preparation for a possible assault on Communist China (Hezel, 1995). In the aftermath of the Cold War, a strong military presence remains a priority for the United States and its partners in Asia. The United States is obligated to protect Japan, Taiwan, andâ through the Compactsâthe freely associated states from external threats. In addition, the U.S. presence in the Pacific Basin is considered a source of strength in Asian affairs and protects trade routes. The islands continue to hold a significant geographic importance in the Pacific, particularly as China develops its economic and military power. The United States military has unlimited access to the waterways of all the jurisdictions, as well as the authority to turn away vessels from other nations (Bank of Hawaii, 1996). The past and current instability on the Korean Peninsula has required the presence of U.S. troops in South Korea, but they are supplemented by the troops in the Pacific Basin. This is particularly important because U.S. bases in the Philippines have closed and the number of U.S. forces in Okinawa, Japan, may decrease. U.S. Economic Interests in the Region Today, more than 40 federal agenciesâfrom DOI to the U.S. Postal Serviceâare involved with all six jurisdictions in various ways. The United States also has an interest in the millions of dollars that it has and will continue to provide the region. The three flag territories are officially part of the United States and are therefore eligible for federal economic aid and programs, much like any of the 50 states. Likewise, the United States still remains heavily
INTRODUCTION 20 involved with providing financial support to the freely associated states, and each of the Compacts calls on the United States to promote greater economic self- sufficiency for each of the jurisdictions. Currently, more U.S. dollars are spent per capita on freely associated states than any other foreign country (Arvis, 1997). Of the millions of dollars spent on the islands, however, a large amount is returned when islanders import U.S. goods (Diaz, 1997). Consumer goods and conveniences, such as SpamÂ® and beer (albeit not the most healthy of trade items) represent major commodities in Pacific trade with the United States (DOI, 1996). Although the region imports far more than it exports, it does export some commoditiesâranging from tuna canned in American Samoa, to garments made in CNMI, to gourmet pepper grown in Pohnpei. Copra (dried coconut meat) is still produced in many of the region's outer islands. Tourism is the economic mainstay for many of the islands and this industry is growing throughout the region (DOI, 1996). U.S. Interests in the Region's Health Care Systems As the Compacts were being negotiated in the early 1980s, all parties agreed that the United States should remain involved with the region's health care. Today several federal agencies provide health-related services and funding to the region, including several agencies of the U.S. Department of Health and Human Services (DHHS), U.S. Department of Energy, and DOI. For example, in fiscal year 1996, DHHS provided approximately $70 million to the region (see Chapter 2 for more detailed figures) (HRSA, 1996). DOI gave funds to improve the jurisdiction's infrastructure, including some of its health care facilities, and provided technical assistance in a range of areas related to health care. Additionally, all Compact and Covenant funds for the islands are administered through DOI. The benefits of improved health in the Pacific flow not only to islanders but also to populations on the U.S. mainland and other countries as well (IOM, 1997a). In an age of nearly instant access to every corner of the globe, no one is immune to the threat of infectious diseases. This is of special concern in the Pacific, where poor environmental and sanitary conditions and high degrees of mobility make island populations much more vulnerable than the populations in industrialized nations. As the Pacific Basin jurisdictions grow in population and attempt to modernize, problems persist with basic sanitation and environmental health. In the FSM and the RMI, respiratory and waterborne illnesses are a major concern (Hezel, 1997). The Centers for Disease Control and Prevention (CDC) advises travelers to the regionâparticularly in the remote outer islandsâto take precautions against measles, hepatitis B, parasites, and cholera (CDC, 1996). Although infectious diseases remain an important public health concern, few places in the region can quickly collect and analyze data on these communicable diseases (Diaz, 1997).
INTRODUCTION 21 The Compacts of Free Association permit the free movement of people between the freely associated states, flag territories, Hawaii, and the mainland United States. As Diaz (1997) points out, ''At any given moment, an epidemic can break out in the Pacific that might remain undetected until a laboratory result returns from Hawaii several days later. By then, the highly transient population might have carried the disease to the population centers or a tourist might have carried it back to Hawaii or the U.S. mainland" (p. 121). Recently, an outbreak of measles on Guam spread to Chuuk, despite a campaign to prevent the spread of the disease by Guamanian health officials. In 1991, dengue fever spread from Palau to Yap and then Guam before the epidemic was detected (Diaz, 1997). The United States has also benefited from health research conducted in the islands. By documenting the health status and treating the Marshallese islanders and the U.S. military personnel exposed to radiation during nuclear weapons tests during the 1940s and 1950s, for example, the United States has learned a great deal about radiation and its effects on human health (Howard et al., 1995). In Guam, research on the neurodegenerative syndromes Lytico and Bodig has yielded valuable information and basic science now being used by scientists to better understand Alzheimer's disease and other forms of dementia (Sacks, 1996).