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Pacific Partnerships for Health: Charting a New Course (1998)

Chapter: 2 Regional Health and Health Care Services Overview

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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"2 Regional Health and Health Care Services Overview." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 23 2 Regional Health and Health Care Services Overview Healthy islands should be places where: children are nurtured in body and mind; environments invite learning and leisure; people work and age with dignity; ecological balance is a source of pride. —Yanuca Island Declaration on Health in the Pacific in the Twenty-First Century (WHO, 1995) The Yanuca Island Declaration represents the collective health goals of all Pacific Basin jurisdictions. How close the islands actually come to achieving this vision varies considerably. This report focuses primarily on the health care delivery systems in the six jurisdictions of the U.S.-Associated Pacific Basin. This chapter begins with a brief overview of some of the region's key health status indicators. They are a reflection, in part, of how effectively health care services are being provided. The second section of this chapter provides an overview of the region's health care services. (Specific information on the health care services in each jurisdiction is provided in Appendix D.) The chapter concludes with an appendix describing the recently concluded Pacific Basin Medical Officers Training Program (PBMOTP) based in Pohnpei, FSM, which trained 70 islanders as physicians. REGIONAL HEALTH OVERVIEW Within the past century, the region as a whole and the U.S.-Associated areas in particular have experienced both demographic and epidemiological transitions. The demographic transition means that people are living longer (e.g., they have longer life expectancies and the infant mortality rate is lower). The epidemiological transition means that people tend to die from noncommunicable diseases (e.g., heart disease and cancer) rather than infectious diseases (e.g., influenza and tuberculosis). Guam and the Commonwealth of the Northern Mariana Islands (CNMI) appear to have already completed these transitions. Importantly, however, many of the jurisdictions (particularly in the freely associated states) appear to be experiencing both transitions at roughly the same time and must therefore confront the challenges of simultaneously

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 24 providing health care to older individuals with chronic conditions as well as to younger individuals fighting acute infectious diseases. Demographic Characteristics of the Region Population Roughly half a million people (454,118) live in the six jurisdictions of the U.S.-Associated Pacific Basin (American Samoa, CNMI, Guam, Federated States of Micronesia [FSM], Republic of the Marshall Islands [RMI], and the Republic of Palau [Palau]) (see Table 2.1). Although the islands cover an area of the Pacific Ocean that is larger in size than the continental United States, most people live on a handful of densely populated islands. Currently, Guam, with 155,225 people has the largest population of the six jurisdictions; Palau, with only 17,225 people, has the smallest population (PIHOA, 1997). (For more information on population for each of the jurisdictions, see Appendix D.) Overall, the region has experienced a high rate of population growth since 1950 (the approximate start of U.S. involvement and administration in all jurisdictions), and that growth is projected to continue to increase rapidly over the next few years (see Figure 2.1). The increase in the total population and projected population growth result from several factors: higher life expectancy (see Figure 2.2); lower infant mortality (see Figure 2.3); and, in some jurisdictions such as CNMI and Guam, high rates of immigration. One change typical of a completed demographic transition is a decline in fertility rates and a resulting increase in the median age. As indicated in Figures 2.4 and 2.5 respectively, however, several of the jurisdictions have not completed their demographic transition because they continue to have high fertility rates and low median ages. In RMI, for example, the median age is 16.2 years. This means that half of the population of RMI is under the age of 16. This could have a tremendous impact on growth rates as more and more women reach childbearing age. Migration is another factor that has contributed to population changes in the jurisdictions, as well as in the Pacific region in general. In search of better economic opportunities, Pacific islanders have migrated to Australia, New Zealand, and the United States, including its territories.2 High rates of 2 According to the 1990 U.S. census, 56,153 Micronesians (49,345 Guamanians and 6,808 "other Micronesian") were residing in the United States (Bureau of the Census, 1990). The census also shows that Samoans numbered 62,964 in 1990. Although not counted in the census, numbers of citizens from the freely associated states living in American Samoa, CNMI, Guam, and Hawaii have been estimated to assess the impact of the Compacts of Free Association on Hawaii and U.S. territories. For a discussion of these population estimates, see Appendix D, under either CNMI or Guam.

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 25 immigration—from other Pacific island countries and Southeast Asia—have contributed to significant population increases in some places such as CNMI and Guam. On islands with fewer economic opportunities, large numbers of citizens emigrating out have helped to lower population growth (East-West Center, 1996). For example, an average of about one percent of the FSM population emigrates each year since the Compacts went into effect in 1986, significantly contributing to declining growth rates in that jurisdiction (Hezel, 1997) (See also Appendix D, CNMI and Guam assessments, Compact impact descriptions.) TABLE 2.1 Total Population, U.S.-Associated Pacific Basin Jurisdictions and the United States, 1997 Jurisdiction Total Population American Samoa 58,070 CNMI 58,846 Guam 155,225 FSM 105,506 Chuuk 53,319 Kosrae 7,317 Pohnpei 33,692 Yap 11,178 RMI 59,246 Palau 17,225 TOTAL, Pacific Basin jurisdictions 454,118 TOTAL, United States 260,372,174 NOTES: Total population is the total number of people residing in the jurisdiction. Official estimates for American Samoa, Guam, and Palau are according to the Bureau of the Census 1990 reports. The population for CNMI is from the 1995 mid-decade census. The population for the RMI is from 1996 and that for FSM is from the 1994 FSM national census. Total U.S. population is from July 1, 1994, official estimate based on the 1990 U.S. Census. It includes the resident population living in the 50 U.S. states and the District of Columbia. SOURCES: Population figures for the six jurisdictions are from PIHOA (1997); the U.S. population is from the Bureau of the Census (1997a).

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 26 FIGURE 2.1 Population estimates for U.S.-Associated Pacific Basin jurisdictions, selected years, 1950–1997, and projected, 1998–2010. SOURCE: Bureau of the Census (1997b). NOTE: Projections are based on average annual growth rates for each jurisdiction. NOTE: Assumptions for estimates and projections are based on fertility, mortality, and migration assumptions that may differ somewhat from those provided by PIHOA, 1997. For more information, please see Bureau of the Census, International Population Center (URL www.census.gov/ipc). Ethnicity Ethnically, most of the population in the North Pacific (CNMI, Guam, Palau, FSM, and RMI) is considered Micronesian. In the South Pacific (American Samoa), the population is almost entirely Polynesian. (More precise breakdowns of each jurisdiction's ethnicity are given in the jurisdiction's individual assessment found in Appendix D.) This general homogeneity of the overall population masks considerable diversity of culture and language—even within the same jurisdiction. For example, in FSM, eight major indigenous languages are spoken and no two states have the same native language (Hezel, 1997). English is spoken throughout the region, but for most people it is a second language. Economy Economic conditions vary tremendously throughout the region. In general, residents of the flag territories enjoy a higher standard of living than residents in

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 27 the freely associated states. For example, in 1994 the per capita gross island product for Guam was $20,640, but in the FSM it was only $2,000 (Bank of Hawaii, 1995a; Bank of Hawaii, 1995b). Economic conditions and characteristics are described in more detail in the individual jurisdictional assessments given in Appendix D. Epidemiological Characteristics of the Region The health status of the islanders naturally varies within and among the jurisdictions. In general, however, almost all health indicators for islanders are worse than those for mainland Americans. This is most notably so in the freely associated states. The health care systems must deal with health conditions typical of those of both developed countries (e.g., diabetes, heart disease, and cancer) and developing countries (e.g., malnutrition, tuberculosis, dengue fever, and cholera). Key health promotion and disease prevention indicators are of concern as well. FIGURE 2.2 Life expectancy at birth, U.S.-Associated Pacific Basin jurisdictions and the United States, 1996. SOURCES: Ages for the six jurisdictions are from PIHOA (1997); age for the United States is from NCHS (1997) and represents preliminary 1996 data. NOTES: Life expectancy at birth is defined as the number of years that a person at birth is expected to live under the mortality pattern prevalent in the community or country. Data for the six jurisdictions are from their respective most recent censuses or population surveys: Palau, 1996; Guam and American Samoa, 1990 censuses; CNMI. mid- decade census; FSM, 1994 census; and RMI, 1994 survey.

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 28 FIGURE 2.3 Number of infant deaths per 1,000 live births, U.S.-Associated Pacific Basin jurisdictions and the United States, 1996. SOURCES: PIHOA (1997); the U.S. rate is from NCHS (1997) and represents preliminary 1996 data; the goal for infant mortality rate set in Healthy People 2000 (USDHHS, 1996) is 7 per 1,000 live births. NOTES: An infant is considered to be a child between the ages of birth and 1 year. RMI reported 63.0 infant deaths per 1,000 live births in 1994 FIGURE 2.4 Total fertility rate per woman for U.S.-Associated Pacific Basin jurisdictions and the United States, 1997. SOURCES: For CNMI, PIHOA (1997); for all others, Bureau of the Census (1997b). NOTE: RMI reported a rate of 5.7 from its mid-decade 1995 census.

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 29 Mortality The leading causes of death in the region (see Table 2.2) are very similar to those of developed countries, with heart disease and diseases of the circulatory system leading the list in all jurisdictions except FSM and RMI. Tobacco use and abuse is very prevalent throughout the region and has been linked to many of the leading causes of death (Marshall, 1991). Accidents, especially those involving motor vehicles, are also a leading cause of death; possible reasons include the densely populated areas where most people live as well as the abuse of alcohol and other substances. Disease Prevalence The focus of this report is on the health care delivery system rather than health status. As such, the committee did not make a special effort to collect data on disease rates and prevalence although such information can indicate how well the health care delivery system is working. Unfortunately, such data are not readily or consistently available from all jurisdictions. It is important to note that Pacific Islanders have not generally been included in most Healthy People 2000 objectives (in fact Epstein reports that out of the hundreds of Healthy People 2000 objectives, only eight address Asian Americans and Pacific Islanders directly and none address the U.S.-Associated Pacific Basin jurisdictions [1997]). The overall disease trends point to an increase in the prevalence of noncommunicable diseases and a decrease in communicable and infectious disease. The following list is meant to provide a brief overview of some of the more pressing health concerns in the islands. It is by no means comprehensive. Diabetes Just after World War II, a naval survey of the islands found no cases of diabetes (Flear, 1997b). Today, however, diabetes is a major health concern in each of the jurisdictions. The dramatic increase is associated with many factors, most importantly increased use of fatty or salty imported food, increased consumption of alcohol, and decreased physical activity (Brewis et al., 1996). Diabetic patients contribute to the high demand for dialysis, and the effects of uncontrolled diabetes are major reasons for off-island referrals. In Guam the prevalence of middle-age-onset diabetes is seven times that in the United States. It accounted for about 5.1 percent of all deaths on Guam between 1983 and 1992 (GHPDA, 1996). In RMI, 30 percent of the population over 15 years of age suffers from diabetes (Diaz, 1997).

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 30 FIGURE 2.5 Median ages for populations in the U.S.-Associated Pacific Basin jurisdictions and in the United States. SOURCE: U.S. Department of the Interior, Office of Insular Affairs (1996). NOTES: Data for the six jurisdictions are based on: 1990 Census reports for the areas, American Samoa census, 1995; CNMI census, 1995: FSM census, 1994; Guam census, 1995; RMI census, 1988; and Palau census, 1994. Median age for the United States is from the Bureau of the Census, Current Population Survey, 1995. Cancer With the exception of FSM, all jurisdictions list cancer as one of the top three causes of death. On Guam, a recent study of death certificates showed between 1971–1995 lung cancer was responsible for a little over one-third of all recorded cancer deaths (Haddock, 1997). In RMI, one survey of Nuclear Claims Tribunal records found that lung and cervical cancers accounted for over two- thirds of cancer incidences in that population between 1985 and 1994. Those cancers, and others, occurred at rates significantly higher than in the United States. Cervical cancer was 5.8 times higher in Marshallese females than in U.S. females. (Palafox, Johnson, Katz, et al., in press). Some evidence has linked certain oral cancers and betel nut chewing, a widespread practice in the Marianas, Yap, and Palau. However, this link is not well-established since studies have not taken into account other risk factors such as the use of tobacco, which is commonly chewed with betel nut (Haddock, 1997; Haddock, et al., 1981; Marshall, 1987, 1991). Tuberculosis Tuberculosis (TB) is a problem within all the jurisdictions. FSM had 171 registered cases of TB in 1994, with an incidence rate of 163/100,000 (FSM, 1996). Guam, CNMI, and Palau have also noted increases in the numbers of cases of TB and attribute these increases in large part to the arrival of large numbers of foreign contract workers from Southeast Asia, who are more likely to have and spread the disease. Guam, for example, has a TB incidence rate seven times the U.S. rate (Diaz, 1997). They have also encountered drug-resistant TB, and reoccurrence of the disease in older people who were treated in their earlier years.

TABLE 2.2 Leading Causes of Death (number of deaths), U.S.-Associated Pacific Basin Jurisdictions American Samoa, 1995 CNMI, 1991 Guam, 1995 FSM, 1994 RMI, 1996 Palau, 1996 Heart diseases (50) Circulatory (36) Heart diseases (175) Circulatory (86) Sepsis and septic shock (29) Circulatory (43) Cancer (32) Accidents (25) Cancer (100) Respiratory (53) Renal failure and disease (16) Accidents (28) Cerebrovascular (18) Cancer (16) Accidents (28)* Endocrine, nutrition (52) Cancer (16) Cancer (11) NOTES: Data for the six jurisdictions are from their respective most recent censuses or population surveys: Palau, 1996; Guam and American Samoa, 1990 censuses; CNMI: mid-decade census; FSM: 1994 census; and RMI: 1994 survey. Circulatory: diseases of the circulatory system; cancer: malignant neoplasms; cerebrovascular: cerebrovascular diseases. Except as noted for Guam, accidents include deaths due to accidents, homicides, suicides, and other deaths associated with alcohol and drug abuse. * Accidents for Guam do not include motor vehicle accidents, which are the fifth leading cause of death. SOURCE: PIHOA (1997). REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 31

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 32 Sexually Transmitted Diseases Great concern about sexually transmitted diseases exists throughout the region because the population, particularly the younger population, is considered quite sexually active, many people often have multiple partners, and people do not take appropriate precautions against the transmission of sexually transmitted diseases. By mid-1995, Guam reported 70 cases of acquired immune deficiency syndrome and human immunodeficiency virus infection, the third highest rate in the entire Pacific region. Rates in other U.S.-Associated jurisdictions are lower, but data collection and surveillance are not considered to be completely reliable (Sarda and Harrison, 1995). Leprosy Leprosy, or Hansen's disease, continues to be a major public health problem in FSM. The World Health Organization (WHO) considers leprosy to be epidemic in FSM. In 1996 WHO and the FSM Department of Health launched a massive program of leprosy screening and treatment in FSM, financed through a donation from a private Japanese foundation (FSM, 1996). Lytico-Bodig Disproportionate numbers of people in Guam are affected by disease syndromes known as Lytico and Bodig. These neurodegenerative syndromes appear to affect only people born before World War II (Sacks, 1997). On site visits, we were told there are currently 220 confirmed cases. Although the number has been dropping steadily as people with the disease die, the age of onset appears to be increasing. The National Institutes of Health has supported research of these diseases since 1952 and the latest project began in 1997 as a consortium between the University of California at San Diego and University of Guam. Thyroid Disease In RMI, high rates of thyroid abnormalities are seen as an effect of exposure to radiation from nuclear weapons testing. These abnormalities seem to be slightly greater in exposed populations, and their descendants, than for other populations. Incidences of thyroid cancer also seem to be at higher rates for those closer to testing areas (e.g., Takahashi, Trott, Fujimori, et al., 1997; Palafox, Johnson, Katz, et al., in press). Disease Prevention and Health Promotion Immunization Rates As indicated in Figure 2.6, immunization rates for most jurisdictions come close to or actually surpass those for the United States. This results from concerted efforts to improve immunization rates and the availability of funds specially dedicated to immunization. Nutrition As noted in the earlier discussion on diabetes, poor nutrition has resulted in several major health problems throughout the region. Vitamin A deficiency, a preventable disease that can lead to night blindness, is widespread in FSM, particularly among young children. In fact, FSM has one of the highest

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 33 rates of vitamin A deficiency in the world (Pryor et al., 1994). Malnutrition is considered the leading cause of death of Marshallese children; in 1989 it accounted for 17 percent of deaths in children under five years of age (Republic of the Marshall Islands, 1988). Obesity is of great concern to all jurisdictions, especially because it is a key determinant of many other noncommunicable diseases and health disorders such as diabetes, coronary heart disease, and strokes. WHO recently reported that the highest rates of obesity in the world were found in the Pacific among Melanesians, Micronesians, and Polynesians (WHO, 1997). Tobacco Use Of great concern throughout the jurisdictions is widespread tobacco use, and its contribution toward prevalent chronic diseases, such as heart disease and cancer. As the region began to modernize, demand for cigarettes, and other imported items, grew. Today, smoking is more prevalent in the entire Pacific region than in developed countries, and even more common than in many third-world countries. For example, surveys conducted in the 1980s found that one-half of males in American Samoa, and 53 percent of males in Weno, Chuuk were smokers, compared to a little less than one-third of men in developed countries like the United States and Australia. Higher smoking rates were also found in the more urbanized areas. Although cigarette smoking is more prevalent in the Pacific than in developed nations, the surveys also found that Pacific men smoke fewer cigarettes per day than in industrialized countries. Cigarette smoking among Pacific women is much less prevalent than for men (Marshall, 1991). In the CNMI, it is estimated that 18 percent of the total cost of hospital days in 1994 for Chamorro and Carolinian patients was attributable to smoking. This does not take into account the additional costs for outpatient visits, medications, or off- island referral (e.g., anyone with lung cancer was sent off-island for treatment) (Bruss, 1995). Alcohol and Substance Abuse Average consumption of alcohol in FSM is an astounding two six-packs or 12 drinks per drinking day (i.e., those days on which a person drinks), according to a recent survey (Micronesian Seminar, 1997). Binge drinking is a common practice throughout the freely associated states, most notably on days when government workers receive their paychecks (Marshall, 1979). So, while alcohol may not necessarily be drunk every day, on those days that it is, it is drunk to excess. The total amount of alcohol consumed yearly in FSM (with a total population of 105,506) is the equivalent of almost 1 million cases of beer. The survey estimated that FSM has 11,000 problem drinkers, the overwhelming majority of whom were male, and most between the ages of 30 and 44. CNMI and Guam are both experiencing a rise in drug abuse and related violent outbreaks. The use of ''ice" (also known as methamphetamine, a stimulant) is rising, and is often used in combination with alcohol and other drugs. In 1993, arrests for marijuana and methamphetamine were responsible for 22.2 percent of all drug arrests (GHPDA, 1996). On site visits we were told

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 34 some methamphetamine use has already spread to Palau and there are concerns the country may suffer a similar ice epidemic. Hard drug use (excluding marijuana) does not appear to be a problem in the freely associated states at this time; a recent survey found only one current user of hard drugs in FSM (Micronesian Seminar, 1997). Suicide Suicide has become one of the leading causes of death in many of the jurisdictions. In FSM, suicide has been a significant problem since the early 1970s. In recent years the annual rate was 30 per 100,000 people, and these were mostly young men. Alcohol use was involved with 45 percent of these deaths (Micronesian Seminar, 1997). The suicide rate in Guam, although lower than in FSM, is still higher than the United States. In 1994, the United States had a suicide rate of 11.6 per 100,000 (USDHHS, 1996). FIGURE 2.6 Percentage of children younger than 2 years of age who are fully immunized, U.S.-Associated Pacific Basin jurisdictions, 1996. SOURCES: Rates for the six jurisdictions are from PIHOA (1997); the rate for the United States was obtained from USDHHS (1996) and is for children 19–35 months who have received the completed set of immunizations; the goal for immunization rates set in Healthy People 2000 (USDHHS, 1996) is 90 percent. NOTE: "Fully, and completed, immunizations" are defined according to WHO and the Advisory Committee on Immunization Practices. REGIONAL HEALTH CARE SERVICES OVERVIEW The health care delivery systems in the Pacific Basin reflect the challenges and strengths unique to the region and the undeniable influence of the nations that have occupied the islands since the turn of the century. In the delivery of health care services numerous challenges must be overcome. These include administrative structures that emphasize acute hospital-based care, the long distances that must be covered to provide care to people in remote areas,

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 35 dependence on foreign aid, inadequate fiscal and personnel management systems, poorly maintained and equipped health care facilities, the enormous costs involved with sending patients for off-island tertiary care, and shortages of adequately trained health care personnel. Structure of the Health Care Delivery System All jurisdictions have planning documents espousing the importance of preventive and primary care, but a review of actual service delivery and budget decisions shows a heavy bias toward hospital-based acute care. This misallocation is often shown as an inverted pyramid in which a small base represents the funding for public health and prevention services, an equally narrow middle represents funding for primary care, and toppling over the entire health care delivery structure, the tremendous uppermost section represents funding for hospital-based acute care and off-island referrals (World Bank, 1994). With the notable exception of Guam with its relatively well-established network of private clinics, almost all health care practitioners in the region work out of each jurisdiction's central hospital. In the early 1970s, a move was made to decentralize the delivery of health care services. Ambitious training programs were established to train mid-level practitioners, or medexes, who were to go to the outer islands where they in turn would train and supervise the even more peripherally located health assistants in newly opened dispensaries. Unfortunately, this decentralization movement was short-lived. Most of the specially trained medexes were brought back into the district hospitals to fill in for doctors who were in short supply. Similar movements to decentralize the health care delivery system have been tried in the ensuing decades, but have been thwarted repeatedly primarily because of staffing shortages and budget cutbacks. It is hoped with the recent addition of 70 PBMOTP graduates within the freely associated states and American Samoa who have been specifically trained in community health that future efforts at decentralization will meet with greater success. The Institute of Medicine (IOM) defines primary care as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (IOM, 1996). The systems of health care in a few places in the region begin to approach this ideal. Developments in some communities are encouraging, such as the primary care team described in the assessment of RMI in Appendix D. Most public health care programs rely almost exclusively on U.S. federal funds. Most of that funding, in turn, is rather categorical and may not necessarily focus on the most pressing needs of the individual jurisdictions. The

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 36 committee is gravely concerned, however, that these programs would simply ceases to exist should the United States discontinue its funding. Administration Money aimed at improving health has not always been well spent; instances of mismanagement and poor oversight of government funds have been documented in most of the jurisdictions. One frequently mentioned problem on the committee's site visits was the "black hole" of the general government fund. All the jurisdictions pool revenue from all sources into these general funds. Health care expenses—along with all the government's other expenses—are paid out of these huge funds. The directors of health in each jurisdiction have little to no control over how the money in these funds is spent. It was also reported that it is burdensome for the jurisdictions to apply for, carry out, and report on multiple categorical funding programs. The amount of paperwork required to receive funding from the myriad U.S. grant programs, including those sponsored by the Health Resources and Services Administration (HRSA), creates problems for many of the island jurisdictions, which have limited staff for such tasks. One person may be in charge of applications and reporting requirements for more than 20 different grant programs. Additionally, in several jurisdictions the level of interaction between the individuals who apply for a grant or develop performance indicators and those who actually provide services appeared to be minimal. The purposes of collecting data and setting goals, it seemed, were only to receive funding; they were not seen as methods of improving health care services. Many people interviewed during the site visits expressed the desire for greater flexibility in the way in which grant funds are administered and used so that federal programs can be adapted to better address local needs. At the same time, they also desired being held more accountable for how money was spent and expressed the need for more technical assistance in applying for and reporting on federal grants. Coordination Efforts to achieve better coordination and accountability have been initiated. The Pacific Island Health Officers Association (PIHOA) has been a forum for jurisdictional collaboration. Its membership includes the primary public health officer (who is typically a political appointee) from each of the six jurisdictions. It is administratively headquartered at the University of Hawaii in Honolulu. The aim of this group is to "promote functional and cost-effective solutions to common health service problems, and to collectively achieve improved health status for all island residents" (PIHOA, 1996, p. 1). In addition, PIHOA officially represents the collective health interests of the region; it

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 37 focuses its efforts on objectives and programs that benefit all of its member states. For example, with financial support from the Centers for Disease Control and Prevention (CDC), PIHOA recently recruited and hired a physician-level regional epidemiologist who will complete an epidemiological needs assessment and develop working surveillance systems and a reporting structure for the entire region. There is also nascent, but still minimal, coordination among and within different agencies within the U.S. Department of Health and Human Services (HHS). For example, in 1995, the Office of Pacific Health and Human Services was established to improve coordination among HHS agencies including the Office of Public Health and Science, HRSA, CDC, and the Substance Abuse and Mental Health Services Administration (SAMHSA). Similar coordination efforts have been initiated within individual HHS agencies; HRSA has set up an Intra- Agency Workgroup on the Pacific Basin, for example. Coordination among other federal agencies that serve the region is rather uncommon. This may change as the Compacts of Free Association are renegotiated (e.g., individuals from the Departments of Interior, Energy, Health and Human Services, and State have begun to meet as part of a task force to prepare for Compact renegotiation). Data Management Health care data for the Pacific Basin population come from a variety of sources. These include: vital statistics (birth and death certificates), inpatient information (hospital discharge data), outpatient clinic data, public health clinic information (with special information regarding rates of, for example, Hansen's disease, sexually transmitted diseases, tuberculosis, immunizations, and prenatal care), dispensary data, incidences of notifiable (reportable) diseases, and special data sources (e.g., dental clinics, disabled children's services, and laboratories). A number of organizations require and make use of this data including each jurisdiction's own health departments and local government, several U.S. agencies, WHO, and the South Pacific Commission (SPC). Several problems surrounding these health status data exist, however. They include (1) difficulties in collecting data, especially when births and deaths occur outside the hospital; (2) data overload from too many forms and the collection of more data than can or are being used, (3) lack of data consistency when outside groups or funders request new or slightly altered information; and (4) problems with computerization and automation because of insufficiently trained data personnel, lack of appropriate hardware and software, and unreliable power supplies (O'Leary, 1995).

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 38 Health Care Facilities The state of the health care facilities throughout the region varies considerably. Relatively new and well-maintained hospitals can be found in Saipan, Guam, and Palau. The hospitals in FSM, RMI, and American Samoa are older and are generally in need of much greater repair or rebuilding. Although the majority of health care is provided through the main hospitals, each jurisdiction has a system of primary care sites, often referred to as dispensaries, that provide health care to residents in more remote areas and outer islands. These sites often are not well maintained, are staffed by inadequately trained individuals, and usually provide only very limited services. Planning and budgeting for maintenance for all health care facilities and equipment are lacking throughout the region. Residents are often reluctant to go to these health care facilities because they believe they will often have to wait for long periods before being seen, the equipment and medicine they need may not be available, and the health care professionals may not diagnose or treat the ailments correctly (Flear, 1997b). Use of Military Health Facilities Although the Compacts direct the secretary of defense to make military facilities available to citizens of the freely associated states, those facilities do not normally treat the patients, except in emergencies. The Naval Hospital on Guam, for example, coordinates with the Guam government in emergency situations such as car accidents when the Naval Hospital is the closest hospital or under emergency conditions that threaten to overload Guam Memorial Hospital emergency rooms, such as the recent crash of a South Korean passenger jet. Tripler Army Medical Center in Honolulu has also been used for medical referrals from the region and is leading many of the region's telemedicine efforts. These facilities can continue to play a key role in the region's health care. Community Involvement with Health Care Delivery The community and community involvement have formed the bedrock on which Pacific societies have survived and flourished for centuries. In general, however, over the past 50 years communities in the U.S.-Associated Pacific islands have not been actively involved in the formal provision of health care (which has been primarily through hospitals funded by the United States. in each jurisdiction's main population center). Additionally, the link between health and personal responsibility has not been well cultivated. On the site visits, many islanders noted that the expectation that the United States would take care of health problems, particularly by sending people off-island for diagnosis and treatment, continues to be considered by many islanders as an entitlement. Indeed, many islanders—particularly in the flag territories—have lived or have

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 39 relatives who live in the United States and, having experienced the health care there, feel they should receive similar services at home. Traditional health beliefs and practices are thought to have existed throughout the islands for centuries and even today continue to be used either independently from or as a complement to the formal health care delivery systems (Flear, 1997). While many islanders have come to expect and even demand western-style medicine, with its biomedical model and theories about how germs and genetic information are transmitted, many others continue to view illness as being "caused by supernatural transgressions, ancestral transgressions, imbalance of Yin and Yang, or cold or hot forces in the body and other causes not included in the repertoire of western medicine" (Lin-Fu, 1994, p. 296). In some instances western-style medicine is tried only if traditional methods fail. On the site visits, committee members were told that traditional practitioners such as fao faos in American Samoa and surhanos in Guam continue to provide important health care services to many islanders. Presently, it appears that traditional and western-style practitioners rarely interact or consult one another regarding a patient's treatment (for more details on traditional health practices and beliefs please refer to the assessments in Appendix D). Nevertheless, some jurisdictions have engendered a good deal of community involvement with health care delivery. For example, volunteers in CNMI have raised more than $750,000 over the past 10 years to buy needed equipment for the Commonwealth Health Center and to support a variety of community health education programs. Guam has several health-related nonprofit organizations such as the American Cancer Society. In Pohnpei, a group of community volunteers banded together and within 2 weeks renovated a building being used as a dispensary (Flear, 1997a). In American Samoa, local businessmen helped to support a fund that bought medicated cream to treat children with scabies. The Red Cross is active in several jurisdictions including Chuuk and American Samoa. The committee draws particular attention to the role of women and women's groups in achieving improved health. Examples of past contributions of women in the region show promise for their continued involvement and for improved results in the future. Two examples are noteworthy. The Youth to Youth in Health program in RMI, which empowers adolescents to improve their health, was founded, implemented, and managed by female leadership and staff (Youth to Youth in Health, 1996). Women also volunteered critical language interpretation and organizational services at a successful dispensary in Pohnpei (Ruze, 1997). Similarly, church leaders and heads of community organizations have the potential to provide prevention and treatment services. For example, SAMHSA is now setting up a training program for government employees who will theoretically train the members of community organizations to reach people with substance abuse problems in the villages. This strategy is particularly w well- adapted to the situations in FSM and RMI.

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 40 Off-Island Care A legitimate need for medical care for tertiary needs and specialized services not available on an island will always exist. This means travel from one island to another within the same jurisdiction and travel to another country. Such referrals consume much of the total health care budget but benefit only a small number of individuals, often for marginal gains. This is especially notable when terminally ill patients are referred off-island. Off-island care decreases the funding available for care of the general population and for efforts to enhance on-island service capabilities. Off-island referrals also foster a sense of dependency on outside agencies and tend to undermine the public's confidence in on-island providers and facilities. Reportedly, many referrals for off-island care have been given on the basis of political or familial favors rather than clinical necessity. The problems associated with these referrals are also universally recognized by each of the jurisdictions. Some efforts at cost-saving have been implemented, such as sending people to the Philippines and other countries for treatment, which is less expensive than treatment in the United States. (More detailed information on each jurisdiction's off-island care program is provided in Appendix D.) Financial Resources With the exception of Guam, health care services in the region are almost exclusively publicly financed. The U.S. government, in turn, provides the majority of funding for that financing, either directly, as in the case of American Samoa, or indirectly, through Compact and Covenant funding, as in the case of the freely associated states and CMNI. Private health insurance provides most of Guam's health care finances, although it should be noted that government employees are a large part of the market and provide a major source of revenue for the private sector. Today several federal agencies provide health-related services and funding to the region. The two most important health-related funders are DHHS and the U.S. Department of the Interior (DOI). For example, as indicated in Table 2.3, in fiscal year 1996 DHHS agencies provided approximately $70 million to the region (HRSA, 1996). Of that total amount, HRSA spent $7,314,840 through five different operating divisions (see Table 2.4). DOI provided funds to improve the jurisdiction's infrastructure, including some of its health care facilities, and technical assistance on health-related matters. Other U.S. agencies providing health-related funding include the Departments of Energy (DOE), Agriculture, Commerce, Education, and Defense. DOE conducts research on and provides financing for the health care needs of those individuals who were exposed to radiation during nuclear weapons testing in RMI. The Department of Agriculture provides child nutrition programs and food stamps to needy citizens and families in the flag territories and administers several agricultural and forestry programs aimed at improving agriculture throughout the region. The Department of Commerce is responsible for conducting the census in the region and has prepared special reports estimating the impact of the Compacts

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 41 of Free Association in Guam and CNMI. Commerce also operates the National Oceanic and Atmospheric Administration, which has been involved in a number of water and shoreline conservation projects. The Department of Education works in the flag territories to improve basic and secondary education, including for children with special needs. The Department also provides U.S. federal scholarship and grant funds for students throughout the region pursuing higher education. The Department of Defense has military installations with medical facilities in Guam and RMI. Tripler Army Medical Center in Hawaii also sends some medical consultation teams to the region and accepts some patients for specialized tertiary care when they are referred from the jurisdictions. Several civilian action teams also provide some health care services in the region. Workforce The 3,142-member health care workforce in the U.S.-Associated Pacific Basin comprises several types of health care professionals including physicians, dentists, mid-level practitioners, nurses, and other allied health professionals. Table 2.5 provides a detailed numeric description of the region's current health care workforce. Although these professionals may have the same title as health care professionals in the United States, their skill levels and the roles they perform can be quite different from their U.S. counterparts. The reliance on expatriate physicians, nurses, and dentists is found in every jurisdiction except Palau and Kosrae (for more detail on each jurisdiction's workforce see Appendix D). Physicians The physician workforce includes individuals with M.D. degrees (if trained according to U.S. standards), M.B.B.S. degrees (the British equivalent to the M.D.), and M.O. degrees (if they are medical officers [typically trained in Fiji or the PBMOTP]). Almost all physicians with M.D.s or M.B.B.S.s are expatriate workers brought in on contract.3 Some have advanced or specialized skills such as in anthesesiology or cardiology, others act as general internists. The ranks of physicians have grown significantly in recent years as a direct result of the training of 70 new indigenous medical officers through PBMOTP described in the appendix to this chapter. Medical officers from the PBMOTP have received five years of formal medical school and clinical experience in Pohnpei and have undergone a two-year internship in their own jurisdiction. They were trained to act as independent practitioners. In their formal training, they were taught the skills to do some types of surgery such as the surgical repair of coral cuts and fish bites, but they were not trained to do more major surgery such as cesarean sections, open chest surgery, or tumor removal. 3 In late 1997, two National Health Service Corps volunteers were working in the region: one in Palau and one in Yap.

TABLE 2.3 Cost Summary for DHHS Programs and Activities in the U.S.-Associated Pacific Basin Jurisdictions, by Agency, FY 1996 (in thousands) Flag Territories Freely Associated States DHHS Agency American Samoa CNMI Guam FSM RMI Palau Multijurisdiction Total Administration on Aging $1,219 $516 $1,987 $0 $0 $277 $0 $4,000 Administration for Children and 4,014 2,920 13,925 3,034 1,932 1,762 0 27,587 Families Centers for Disease Control and 762 1,336 2,332 1,276 717 805 0 7,228 Prevention Health Care Financing 3,181 1,896 15,193 NA NA NA 0 20,271 Administrationa Health Resources and Services 610 629 1,227 781 575 845 2,648 7,315 Administrationb National Institutes of Health 0 0 600 0 0 0 0 600 Office of the Assistant Secretary 143 72 168 141 67 44 110 745 for Health Substance Abuse and Mental 431 451 888 566 246 116 0 2,699 Health Services Administration TOTAL $10,360 $7,820 $36,320 $5,798 $3,537 $3,849 $2,758 $70,445 REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW aHealth Care Financing Costs are Medicaid and Medicare. These programs are not available to the Freely Associated States, and are therefore marked "NA." b Multijurisdictional funds for HRSA are from the Bureau of Health Professions. These funds go directly to the University of Hawaii. In FY 1996, $1.2 million funded the PBMOTP and the remainder funded financial assistance, loans, scholarships, and traineeships for students and health care professionals. SOURCE: USDHHS (1997). 42

TABLE 2.4 Health Resources and Services Administration Budget for Activities in the U.S.-Associated Pacific Basin Jurisdictions, FY 1996 Flag Territories Freely Associated States Bureau Total Funding America Samoa CNMI Guam FSM RMI Palau Bureau of Health Professions* $2,647,805 NA NA NA NA NA NA Bureau of Health Resources Development Ryan White Title II Grant 5,790 0 0 5,790 0 0 0 Bureau of Primary Health Care Community Health Center Program 975,944 0 0 183,470 142,362 238,479 411,633 Maternal and Child Health Bureau MCH Block Grants 2,708,813 510,027 481,693 787,710 538,363 238,011 153,009 EMS for Children Block Grants 47,986 0 47,986 0 0 0 0 Special Health Services Demonstrations 748,128 100,000 99,764 250,000 100,000 98,364 100,000 Office of Rural Health Policy Rural Health Outreach Grants 180,374 0 0 0 0 0 180,374 TOTAL $7,314,840 $610,027 $629,443 $1,226,970 $780,725 $574,854 $845,016 REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW NOTES: MCH = Maternal and Child Health; EMS = Emergency Medical Services. * Bureau of Health Professions funds go directly to the University of Hawaii. In FY 1996, $1.2 million funded the PBMOTP, and the remainder funded financial assistance, loans, scholarships, and traineeships for students and health care professionals. SOURCE: HRSA (1996). 43

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 44 Dental Professionals Of particular concern is the dearth of dentists and other dental health practitioners, particularly in the freely associated states. While 70 dentists are in practice in Guam, only 35 other dentists or dental officers serve all the other jurisdictions. The overall U.S. ratio of dentists to population stands at approximately one dentist to 1,785 persons. In Guam, that ratio is one dentist per 2,218 persons. The rest of the region's ratio ranges from one dentist per 4,306 people in Palau to one dentist per 14,811 people in RMI. Many of the current dental practitioners are expatriates, including one National Health Service Corps dentist in RMI, or are nearing retirement (PIHOA, 1997). Shortages of dentists, dental officers, dental therapists, dental nurses, and dental aides and technicians are already being experienced in all the freely associated states. Mid-Level Practitioners The Pacific Basin workforce makes use of several types of mid-level practitioners unique to the region. Individuals licensed as physician's assistants and advanced practice nurse practitioners do work in the region, but only in Guam and CNMI. In the early 1970s, several groups of Micronesian health professionals began to be trained as ''medexes," the rough equivalent of a physician's assistant in the United States. Several of these medexes are still practicing today. These individuals typically came with nursing backgrounds and received 2 additional years of specialized training (4 years if they did not have a nursing background). Medexes are trained to be independent community-level practitioners in areas where they are physically separated from higher-skilled physicians. They cover the spectrum of health care services, including disease prevention and health promotion and are able to train and supervise health assistants. Nurses Nurses play an important role in the region's health care delivery system. Yet in nearly every jurisdiction, officials reported having a nursing shortage. While most nurses practicing in the flag territories are licensed and practice at the U.S.-equivalent of a registered nurse (R.N.), most nurses in the freely associated states are graduate nurses, meaning they have completed a 2-year, college-level nurse training program. Most nurses in the region practice in the hospital setting. Many potential explanations exist to explain the nursing shortages. Some nurses move to other jurisdictions in search of better pay and benefits. Because most nurses are women and most physicians and administrators are men, some

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 45 nurses have quit or relocated when traditional gender roles and expectations have collided with their professional aspirations and training (for example, traditionally most men have come to expect unquestioning obedience from women. This is especially problematic when even the most highly trained and competent female nurse questions a male doctor's decision.) Health Assistants Health assistants are individuals trained to staff the outlying dispensaries and non-acute care clinics. They have been trained to respond to most basic first-aid needs, dispense "over-the-counter" medications, and be the link to the central hospital when more serious situations arise. Most are connected to the hospital via shortwave radio. The need for continuing education of health assistants was noted repeatedly on the committee's site visits. Health Care Workforce Education and Training Currently, primary and secondary education throughout most of the region does not adequately provide students the skills that they need to participate in the health care workforce. For example, the reading levels of high school graduates in FSM hover around the fourth-and fifth-grade levels and math and science scores are equally poor (Hezel et al., 1997). Almost all of the students entering the Pacific Basin Medical Officers Training Program (PBMOTP) had to take special remedial classes in English, math, and science to come up to speed in these areas. In American Samoa, similar remediation efforts are provided to nursing students. The John A. Burns School of Medicine at the University of Hawaii has established the Imi Ho'ola program with the specific aim to improve the academic performance of promising students from the U.S.-Associated Pacific Basin jurisdictions. The program provides remedial coursework to pre-medical students and special support once these students enter medical school. Students from Guam and CNMI—jurisdictions considered to have some of the best educational systems in the region—have participated in the Imi Ho'ola program. Some special programs to improve the performance of students who want to go on for secondary education do exist. For example, the "2 + 2" program in CNMI targets high school students interested in pursuing careers in education and links them with mentors and special courses.

TABLE 2.5 Health Care Workforce in the U.S.-Associated Pacific Basin Federated States of Micronesia Position American CNMI Chuuk Kosrae Pohnpei Yap Total Guam RMI Palau Total Samoa Physicians MO 9 1 19 7 17 11 49 0 6 16 81 MBBS 0 0 0 1 2 5 11 0 1 3 15 MD 4 26 4 1 7 1 10 311 19 12 382 Ophthalmologist 0 1 0 0 1 0 1 10 1 0 13 Dental Professionals DDS 8 2 5 1 4 0 10 70 4 3 97 DO 2 1 1 2 1 4 0 0 1 8 Dental therapist 1 1 1 0 0 2 0 0 0 3 Dental nurse 0 7 3 3 10 10 26 0 4 6 43 Dental hygienist 0 1 0 0 0 0 0 21 0 0 22 Dental aides 0 14 11 1 9 0 21 221 8 0 264 REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW Dental lab. tech. 0 0 0 0 0 0 0 0 0 2 2 Mid-level practitioners Medex 0 0 5 0 4 0 9 0 9 0 18 Physician assistant 0 11 0 0 0 0 0 23 1 2 37 46

Nurses RN 31 139 55 1 63 1 120 648 1 10 949 GN 23 0 0 34 0 12 46 0 79 53 201 LPN 97 9 99 3 49 12 163 164 0 50 483 Aides 12 22 0 0 0 3 3 0 44 0 81 Health assistants 0 0 88 3 15 3 105 0 56 28 189 Allied health workers Lab. tech. 20 14 3 6 2 7 18 13 16 7 88 Pharm. tech. 9 17 2 1 2 1 6 57 6 8 103 Rad. tech. 9 14 2 1 2 30 8 5 6 42 TOTAL 225 279 294 64 184 70 612 1,538 260 207 3,121 NOTES: The CNMI data were provided to PIHOA by the CNMI Department of Public Health, but are different from data provided to the IOM committee earlier by the CNMI Department of Public Health. MO = Medical Officer, MBBS = Bachelor of Medicine and Surgery (British equivalent of U.S. MD), MD = Doctor of Medicine, RN = Registered Nurse, GN = Graduate Nurse, LPN = Licensed Practical Nurse, DDS = Doctor of Dental Science; DO = Dental Officer, Dental lab tech. = dental laboratory technician, Lab. tech. = laboratory technologist or technician, Pharm. tech. = pharmacist or pharmacy technician, Rad. tech. = radiology technologist or technician. SOURCE: PIHOA (1997). REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 47

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 48 If students do make the grade academically, the financial inability to pay for medical and health education at secondary and graduate institutions of higher education has been a stumbling block to many Pacific Island students. Some federal financial aid programs are available to students. Additionally, in the past students from former trust territories (i.e., CNMI and the freely associated states) were allowed to receive in-state tuition at the University of Hawaii, but this special allowance has been threatened because of recent state budget cuts in Hawaii. Some private scholarship programs exclude Pacific Islanders. For example, the Association of American Medical Colleges, through its Minority Medical Education Program, offers medical scholarships to minority students from underserved areas. Although the program reaches out to native Alaskan and Hawaiian youth, students in the U.S.-Associated Pacific Basin are not currently eligible. The Yanuca Island Declaration designated both the Fiji School of Medicine and the University of Papua New Guinea as regional centers for postgraduate medical education (WHO, 1995). The DOI, first in cooperation with the PBMOTP and currently with the Pacific Basin Medical Association, has established formal ties with the Fiji School of Medicine to provide postgraduate education to Micronesian medical officers. Several PBMOTP graduates are training there, and many others hope to do so once they have completed their required 2-year internship in their host countries. The Fiji School of Medicine was chosen because the political and social situations in Papua New Guinea are viewed as unstable. Although continuing medical education is already required for licensure in some of the jurisdictions, it is not a requirement throughout the region. (See individual assessments in Appendix D for more information on licensing requirements.) Technology and Equipment The availability of supplies and medicines is also a problem throughout the Pacific Basin, even for the "better" facilities. Shortages of critical supplies were noted in American Samoa, Chuuk, Guam, Pohnpei, RMI, and Palau. Because of budget constraints and other factors, supplies are not routinely or consistently ordered in advance—a process that sometimes requires up to 11 signatures! Generally, the order amount can be altered (typically, lowered) throughout this chain of approval. Thus, with a 3-month lead time from order to actual delivery, an order for X-ray film that started out as 30 cases may actually arrive 90 days later as 6 cases. When the need for such supplies arises, they must then be filled through expensive air freight emergency orders or by emergency referrals to Guam or Honolulu. Some suppliers simply refuse to work with certain jurisdictions because their accounts are so far in arrears. In the past, these bills were routinely paid by the U.S. government or were simply written off by the suppliers.

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 49 The equipment and technological capacity for distance education exists. PEACESAT, based at the University of Hawaii, provides all the Pacific Basin jurisdictions with basic satellite and communication services, including Internet access. It is, however, routinely criticized as being hard to use, out of date, and hard to maintain. Technical support from the University of Hawaii was described as minimal. Some people have had difficulty scheduling necessary time slots to use the system. The University of Guam (UOG), through the College of Nursing and Health Science, provides distance education via PEACESAT to help nurses in Micronesia earn advanced credits towards a BSN degree. UOG is also investigating other satellite technology for this purpose. Northern Marianas College has recently invested in satellite technology of its own and is already offering several of its Saipan-based classes to students on the island of Tinian. APPENDIX Pacific Basin Medical Officers Training Program In the early 1980s many of the physicians in Micronesia (primarily RMI, FSM, and Palau) were nearing retirement. With few students from the region in medical school and even fewer of those who did finish their medical training returning home to practice medicine, a potentially devastating physician shortage seemed imminent (Pretrick, 1997). Officials from the affected jurisdictions worked together with the John A. Burns School of Medicine at the University of Hawaii to create a response. The solution—the formation of a regional medical officers training program based in Pohnpei—received a commitment of 10 years of funding from the U.S. Department of Health and Human Services' Health Resources and Services Administration. The Pacific Basin Medical Officers Training Program (PBMOTP) enrolled its first class of students in 1986. Overview of PBMOTP Student Recruitment and Retention With the exceptions of Guam and CNMI, each jurisdiction sent students to PBMOTP. Recommendations for students to be enrolled in the program were solicited through admission boards established in each country (and all four states of the FSM). The department of health within each jurisdiction administered and oversaw these boards. PBMOTP provided students with room and board, transportation, books, and a small stipend for living expenses (some of which could be sent directly to the students' spouses back home). Students were also given time off twice a year for home visits.

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 50 Over the 10-year span of the PBMOTP, 170 students were accepted into the program; 58 percent (99 students) did not complete the training. Several reasons explain this dropout rate. The vast majority (about 80 students) dropped out early for academic reasons, including trouble communicating in English. Problems with alcohol abuse, stealing, and other behavioral problems resulted in some students being asked to leave, particularly in the early years of the program. Separation from families and the resulting depression and loneliness also led some students to drop out. Nevertheless, some of the students who dropped out of the program are currently providing health care in the region as either health assistants (12 individuals) or medexes (10 individuals). In the later years of the program, several factors brought about increased retention rates. The admissions board nominated better-qualified individuals. The program hired top-quality faculty, many of whom were Pacific Islanders with good credentials and who served as positive role models (as did the medical officers who had already been graduated from the program). The faculty also developed a screening test for English as a second language, which quickly and accurately predicted a student's ability to perform academically using English. Students who did not score well on the screening test were encouraged to reconsider their decision to participate in the program. Others were required to take a survival skills program for the first 6 months of the program that provided remedial courses in English, math, and science. The program's recruitment and retention of women is particularly noteworthy. Special efforts were made to recruit capable women to the program because they were so underrepresented in the professional workforce. The program did make some special recruitment trips to the jurisdictions but recruitment was a continuing process during PBMOTP Advisory Board meetings and other regional health training activities and conferences. During the clinical workshops for the Micronesia Otitis Media Training Project (funded by HRSA) and the PBMOTP's on-site clinical rotation in Chuuk during 1990–1991, bright women were noted and then actively encouraged to apply to the program. Directors of Health were informally encouraged by PBMOTP faculty to find and recruit able women. Additionally, over the course of the program, six well- respected female physicians and three nurse midwives worked as program faculty. They acted as professional role models and as confidants and advocates to female students, bringing attention (formally and informally) to sexual harassment and abuse within the program. Female PBMOTP students also had a higher retention rate than that of the men. In the last graduating class, more men than women were initially admitted, but by graduation women outnumbered the men (and women took all the top academic prizes). About half of the female PBMOTP students were married and about two-thirds of all the female students were mothers. In fact, six students had babies while in the program and they all went on to complete the program. While at the PBMOTP, most female students were separated from their families and most were able to handle the separation quite well.

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 51 Curriculum In about 1990 the PBMOTP teaching approach changed from being teacher-centered to being "problem-based." This switch placed more of an emphasis on community health training, rather than hospital training, and moved away from a focus on classroom lectures to student research. About half of the program was academic and the other half consisted of supervised clinical experience. Students were required to conduct self-directed research projects and to staff several "clinics without walls" located in several communities near the school. This change is credited with invigorating the program and seemed to work well at motivating students to become more actively involved with their education: to think critically and to solve problems. This problem-based type of approach is now being implemented in a variety of educational institutions throughout the Pacific, including the Fiji Schools of Medicine and Dentistry and the University of Guam School of Nursing. Career Ladder Program PBMOTP also provided students with a graduated career ladder. During years 1 to 3, students engaged in self-directed learning with a focus on using clinical skills in community health settings. The students assisted in public health and community medicine clinics throughout Pohnpei (thereby fulfilling some service needs in Pohnpei State). After the first year, students became health assistants. Upon completion of the third year, students were certified as assistant medical officers (AMO) and licensed as medexes. During years 4 and 5, students focused on inpatient medicine, primary care, mental health, and more projects in the community. During this time, students also returned to their home jurisdiction for a 4-week clinical inpatient internship at their local hospital. Returning home also helped students reconnect with their communities and allowed them to spend time with their families. Upon successful completion of the 5-year program and a final qualifying examination process, students became medical officers and received a diploma in Community Health, Medicine, and Surgery from the John A. Burns School of Medicine at the University of Hawaii at Manoa. Once they completed a 2-year internship with the respective department of health, the graduates took a registration examination, and if they passed, they became fully licensed medical officers. Results PBMOTP fulfilled its mission to provide a locally trained physician workforce and to eradicate the chronic physician shortage of the 1980s. Over the course of the 10-year program, 70 students graduated and are now practicing in the region (see Table 2.6). Half of these graduates are women (Head, 1997). The total

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 52 cost of the program tallied almost $15,000,000 (see data in Table 2.7). This money had the secondary effect of providing health care for the local communities. The founders of PBMOTP instituted several policies to address concerns about medical officers leaving the islands once they had completed training. For example, the medical officer license granted to PBMOTP graduates is recognized only in FSM, RMI, and Palau. Students who graduated were guaranteed jobs with their home governments at a salary considered quite good for the region (although not as high as those for expatriate contract workers). To date, all graduates have remained in the region (although some have married classmates and moved to islands other than the jurisdiction that sponsored their training) (see Table 2.8). However, as Compact funding decreases, governments in the region are reducing costs. Whether a medical officer continues to practice is up to his or her government's ability and willingness to support them. TABLE 2.6 Number of Physician Graduates, by Year of Graduation Year Number of Graduates 1992 15 1993 8 1994 14 Early 1996 8 Late 1996 23 1997 2 TOTAL 70 SOURCE: Dever (1997). TABLE 2.7 PBMOTP Budget, FY 1986 to FY 1996 Year Budget 1986 $894,358 1987 716,288 1988 884,954 1989 1,165,000 1990 1,660,000 1991 1,577,000 1992 1,800,000 1993 1,700,000 1994 1,500,000 1995 1,482,000 1996 1,456,000 TOTAL $14,836,426 SOURCE: Dever (1997).

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 53 TABLE 2.8 Number of PBMOTP Graduates Currently Working in U.S.-Associated Pacific Basin Jurisdictions Jurisdiction Total American Samoa 9 FSM 42 Chuuk 16 Kosrae 7 Pohnpei 13 Yap 6 RMI 6 Palau 13 TOTAL 70 NOTE: Some graduates were sponsored by one jurisdiction but are currently working in another jurisdiction. So, for example, American Samoa only sponsored seven students at the PBMOTP, but two students from other jurisdictions moved to American Samoa to practice, resulting in nine total PBMOTP graduates working there. SOURCE: Dever (1997). Many of the female PBMOTP graduates will likely assume leadership positions in the jurisdictions' health care delivery system. This is widely viewed as a positive step. As stated earlier, women are underrepresented in the professional physician workforce. Their absence was particularly problematic given the many cultural restraints and taboos associated with indigenous male health professionals caring for female patients, especially regarding reproductive health issues. Continuing Education and Training for PBMOTP Medical Officers Now that the medical officers have received their basic training and have begun to practice formally, they will be the mainstay of the physician workforce, particularly in Palau and throughout the FSM states. Nonetheless, they will still need continued education and training. Such activities help medical officers improve their skills, which will help build the public's confidence in their competence and capabilities. The lack of ongoing education and training was given as one of the problems faced by the region's older cohort of medical personnel. PBMOTP graduates will need to share the knowledge they have learned in school and in practice with other health care workers. Their positions as role models will help them achieve this goal, but such community outreach efforts will also require continuing education and training.

REGIONAL HEALTH AND HEALTH CARE SERVICES OVERVIEW 54 Replication of PBMOTP Although the committee believes that PBMOTP was a remarkable success, it does not see any current application for replication of such a program within the mainland United States. It does believe, however, that the model would serve other developing nations well as they seek to train indigenous people to be health care practitioners. The U.S. Department of Health and Human Services and the U.S. Agency for International Development are encouraged to share information about the program's design and curriculum with officials in those developing countries. The following aspects of PBMOTP are especially worthy of duplication: • having community leaders nominate students, • using a problem-based teaching approach, • emphasizing the development of clinical skills from the start of the program, and • using an approach that allows student to climb a career ladder as they increase their skill levels. However, if such a program were to be replicated, the committee recommends working more closely with existing local educational institutions rather than setting up completely new—but temporary—institutions.

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The U.S.-Associated Pacific Basin consists of six island jurisdictions: American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, the Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau. This book examines one aspect of the ties and U.S. involvement with this part of the world—its role in the region's health care delivery system. Although the health status of the islanders and the challenges faced by the health care systems naturally vary within and among the jurisdictions, in general, almost all health indicators for the islanders are worse than those of mainland Americans. The health systems in the area must deal with conditions normally seen in developing countries (e.g., malnutrition, tuberculosis, dengue fever, and cholera) and in developed countries alike (e.g., diabetes, heart disease, and cancer). In examining the strengths and weaknesses of the area's systems, the volume provides a regional health overview and assessments of health care in individual jurisdictions, evaluates the Pacific Basin Medical Officers Training Program, and lays out a strategic plan for future health services in the U.S.-Associated Pacific Basin.

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