Hearings and Business Meetings
July 19, 2005
SD-366 Energy Committee Hearing Room 02:30 PM
Dr. Neal Palafox
STATEMENT OF NEAL A. PALAFOX, MD MPH
PROFESSOR AND CHAIR
DEPARTMENT OF FAMILY MEDICINE AND COMMUNITY HEALTH
JOHN A. BURNS SCHOOL OF MEDICINE
UNIVERSITY OF HAWAII
TO THE SENATE ENERGY AND NATURAL RESOURCES COMMITTEE
July 19, 2005
The purpose of this testimony is to speak to the health consequences of the US Nuclear Weapons Testing Program (USNWTP) in the Republic of the Marshall Islands and the health system that is needed to address those consequences. The current status of the health care services of the RMI and the medical programs designed for those who were adversely affected by the USNWTP (177 Health Program/ DOE Medical Program) will be discussed. Finally, the cost and rationale for three health system solutions to address the varied health consequences of the nuclear weapons testing program will be presented. .
Health Effects of the US Nuclear Weapons Testing Program
Health, as defined by the World Health Organization (WHO), is “a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity.” The health consequences of USNWTP are acute medical conditions, chronic medical conditions, cultural impacts, mental health impacts, and social impacts.
A holistic approach to health must be part of any discussion on health consequences of nuclear testing because “health” in nuclear testing is often distilled to ionizing radiation and cancers. Health consequences of nuclear testing are a product of the bomb blast and the effect the process of testing had on the humans living in that environment. Utilizing a holistic approach is crucial in health care systems affecting indigenous Pacific populations.
Cancers, hypothyroidism and thyroid nodules are clearly linked to ionizing radiation exposure. The 2004 NCI report estimates 530 excess cancers from the USNWTP in the RMI. Half of the 530 excess cancers have yet to manifest themselves in the Marshall Islands population because of the length of time (latency) it takes for a cancer to manifest itself following the deleterious effects of ionizing radiation.
The latest scientific information on the biological effects of low dose ionizing radiation 2005 BEIR VII report from the National Academy of Sciences adds that exposure to even extremely low doses of ionizing radiation may place individuals at a risk for cancer. BEIR VII also notes that intergenerational (hereditary) genetic effects may be possible in humans since intergenerational effects caused by ionizing radiation have been noted in mice and insects.
Cultural and social disruptions from the USNWTP are associated with adverse health outcomes and illness. Alienation from the land and critical natural resources through radioactive contamination or forced evacuation destroyed the physical and cultural means of sustaining and reproducing a self-sufficient way of life. It also destroyed community integrity, traditional health practices and sociopolitical relationships. Furthermore, community history and knowledge is destroyed when there is no lineage land from which to pass on knowledge about the local environment.
Food supplementation became necessary for those who were displaced from their land and for those whose lands and food sources were contaminated with radiation. For many years, the U.S. Government has provided USDA foods, mostly white rice and other processed foods, to the people of the four atolls. Although some atoll communities are now using U.S. funding to purchase and ship their own foods rather than USDA foods, several adverse health impacts of USDA food supplements are evident in the recipient communities, as noted below:
1. The natural diet has been altered.
2. The available Western diet is high in fat, high in carbohydrates, low in fiber, and lacks Vitamin A and iron.
3. There has been a loss of the cultural activities and norms surrounding food gathering and preparation.
4. The loss of the physical activities surrounding food preparation has resulted in a more sedentary lifestyle.
5. Diseases such as diabetes, atherosclerotic diseases, and hypertension have been exacerbated by the Westernized diet and more sedentary lifestyle.
6. The industriousness and work ethic needed to prepare local foods from coral atolls with few natural resources has been stifled.
7. Dependency on food supplementation has become a norm destroying the fabric of a once self-reliant community.
Bodily harm is a tragedy that affects an individual for a finite period of time, whereas cultural destruction adversely affects the health of entire communities for generations. Cultural, mental and social impacts are difficult to quantify and measure and so it becomes easy to pretend they do not exist. The cancer burden that was generated from the nuclear testing program was quantified by the NCI 50 years after the insult. Other health consequences will likely be quantified soon.
Health Care Environment and Services in the RMI
RMI Ministry of Health and Environment
The present health care environment of the Republic of the Marshall Islands is brittle. Many unnecessary illnesses and deaths occur because the health care system cannot systematically respond to the health needs of the people. The health situation will get worse as the population expands, as the proportion of elderly increases, as the burden of costly chronic illnesses grows, and as the limited health dollars and finances wane. The infant mortality rate is 3-4 times that of the US, and the longevity of Marshallese is 12 years less than people in the US. Hansen’s disease (leprosy) and TB are commonplace.
The 15-year RMI Strategic Health Plan (2001-2015) describes a health system that is not financially sustainable with its present resources. According to the RMI Health Plan, the Ministry of Health is projected to lose an equivalent of $21 million dollars in services over the next 15 years under present funding and levels of health care. The RMI pays nearly $2 million dollars a year, a significant portion of all its annual health expenditures, for medical cases sent out of the country for treatment because of lack of health infrastructure. The monies spent in referral health centers abroad are not directed towards the RMI health infrastructure.
Compact funds are the primary source of healthcare dollars and resources. Funding from the Compact represents nearly half of the Gross National Product of the RMI and 40% of all health care funding (direct Compact funds, Section 177 funds, US Federal Grants) in the RMI. Another 23% of the health care dollars have been derived from the RMI General Fund. Less than 1 % of health dollars has been derived from local user fees.
The total amount of all the sources of health revenue for fiscal year 2005 is about $14 million dollars. As a comparison, the Commonwealth of the Northern Marianas is struggling with an annual health budget of $45 million annually. The populations of these two Pacific countries are similar, 55 thousand people.
The 2004-2005 Budget Portfolio of the RMI Health Services describes some changes in health allocations with the amended Compact. There is now a Ebeye Special Needs fund in the amount of $3.1 million of which $1.5 million is allocated to the Ebeye hospital. While this special fund is being added to the health care budget, the amount for the 177 Health Program has decreased by 1 million annually. On balance there has been a modest gain in finance.
In Majuro Hospital there are sometimes no oxygen supplies for the operating room and critical patients, there are no reagents for many simple laboratory tests, and there are no biopsy needles for examination of common cancers. Renal failure is commonplace because of high rates of diabetes, yet there is no dialysis unit in the RMI.
Federally Funded Medical Programs for Marshallese affected by the USNWTP
There are two Medical care programs for people affected by the USNWTP, the DOE Medical Program and the 177 Health Program.
Section 103(h) of the Compact “provide(s) special medical care and logistical support” to the populations present on Rongelap and Utrik during the Bravo test on March 1, 1954. The Department of Energy program also provides medical care to a comparison population. Members of the comparison group were not exposed to the Bravo fallout in 1954. However, they were resettled on Rongelap with the Bravo victims at a time when radiation contamination of the atoll was still an issue.
Between the mid 1950’s until 1997, Brookhaven National Laboratory (BNL) was contracted by the DOE (for $1.1 million annually) to provide medical care to those exposed to the Bravo detonation and to the comparison group. BNL healthcare consisted of monitoring and treating the designated population for radiogenic illnesses on a biannual basis.
From 1998 to 2004, the RMI and the DOE jointly developed a more comprehensive health care program for the USNWTP affected population. Clinics on Kwajalein and Majuro were established to deliver year round healthcare and adjunct programs were instituted to develop the health capacity and infrastructure of the RMI.
In 2005, the DOE redirected the medical program towards focusing largely on cancer care. Capacity building with the RMI Ministry of Health and more comprehensive health care elements for the affected population are now being eliminated.
The funding for the program participants is adequate; however utilization of health services is limited by the design of the program. Funding for this program could be used more effectively in the RMI for maintaining the primary care services, capacity building, as well as the cancer care aspects of the program.
177 Health Care Program
The 177 Health Care Program provided in the 177 Agreement is designed to provide primary, secondary and tertiary medical services to the people of Enewetak, Bikini, Rongelap and Utrik islands who were affected by the USNWTP. This includes most of the people enrolled in the DOE medical program. The 177 Health Care Program’s design was developed through the US Public Health Service (USPHS) in 1985. The design of the program by the USPHS is laudable, having essential elements of primary, secondary and tertiary medical care. However, delivery of what was proposed by the USPHS has been impossible because of limitations in funding and the RMI health care infrastructure.
The chart below illustrates the cost per person per month (PPPM) to achieve basic levels of primary, secondary and tertiary health care in the United States as compared to the 177 Health Care Program. These figures, calculated by Mercy International, are based on 1997 Health Care Dollars and do not reflect increased health care costs during the past seven years.
Commercial Population $135
Medicare (Nebraska) $221
Medicare (New York) $767
Medicaid (Michigan) $120
Section 177 $13.60*
*The PPPM for the RMI is calculated as follows: $2 million dollars annually, divided by 12,259 patients, divided by 12 months equals $13.60 PPPM.
The funding for the 177 program in 2005 has dropped from 2 million annually to 1 million annually. In 2003, the program operated only on $500,000. Each fiscal year the tertiary care budget for 177 patients is consumed within the first three months.
RMI Ability to Address the Health Care Consequences of the USNWTP
The ability for health services in the RMI to systematically address the daily medical encounters is limited. The RMI health system, although improving, struggles to provide adequate routine health care for its citizens. The 177 program is severely under funded and contributes modestly to the overall health care needs of the 177 participants. The DOE program is adequately funded for its patient base and present mandates, however, the program design lacks comprehensive care and lacks a proactive stance towards building the capacity of health services.
There were 530 excess cases of cancer generated by the USNWTP. Is the present RMI Health Services able to care for the burden of cancer? From October 1, 2004 through June 6, 2005 there were 26 Marshallese patients with cancer who were presented to the medical referral committee which determines if they would benefit from off-island referral to a tertiary care center. Eleven of the 26 cases were denied referral because the cancers were too far advanced.
Far advanced cases suggest that the health system is unable to provide timely screening, early medical interventions and that the patients are not aware of their risks and conditions There is no mammography unit to detect breast cancer or colonoscope to detect colon cancer in Ebeye, no operational CT scanner in the RMI, and no operational dermatome in the lab to process cancer specimens. When there is no medical oxygen in the hospital due to medical equipment problems, major surgery, which many cancer patients require, is not an option. And if the oxygen does arrive, there is no way to process the specimen without a dermatome.
The fact that 26 cancer patients were referred suggests that necessary medical care could not be provided in the RMI. Chemotherapy is not given in the RMI because of deficiencies in qualified laboratory, nursing and pharmacy staff.
Comprehensive cancer care requires local health systems to address prevention, screening, biopsies. pathology services, surgical expertise, intensive unit care, chemotherapy expertise, scanners, lab support, palliative care and issues of survivorship and quality of life. None of these systems are fully operational, and some are non-existent. In 2003, only 9% of women who were in the age category to receive cervical PAP smears (to screen for cervical cancer) actually received a PAP smear. There is neither an oncologist nor a cancer registry in the RMI.
Tthe inability to handle difficult medical problems, such as cancer, places a burden on surrounding areas that have cancer services. Many of the folks who are not supported by the RMI health system as a referral find their way to Hawaii or Guam, and enter the medical systems there. These patients have no resources for the very expensive cancer care in Hawaii and or Guam. Although all RMI medical debts have now been paid, in the past there has been difficulty keeping up with payments because of a lack of RMI funds. Such interactions place a strain on the good will and medical / business relationships of the RMI, Hawaii and Guam.
Building a health care system for cancer: (system 1)
The costs of a health system to care for cancer patients are dependent on the answer to several questions which will determine the system design.
1. What is standard of health care that we are trying to provide? Are we building a US level of health care system and facility or designing a different type of system?
2. What standard of health care will be provided to cancer patients with other illnesses (diabetes, heart disease, high blood pressure, asthma, complications from treatment)?
3. Can all services/ components be sustained in the RMI or will some services/components to be provided at another center or site?
4. How many cancer patients will be treated?
5. Should the patients deserve to have most of the cancer care in their home environments?
6. Over what period of time will the system need to be intact?
7. Is the objective to build the capacity of the RMI to care for cancer patients?
The components of a comprehensive cancer care system are well known.
Data tracking including a cancer registry, medical records
Screening (mammography, colonosocopy , colposcopy, ultrasound)
Diagnostic testing (CT scanning, x-ray, laboratory tests)
Treatment (surgical intervention, chemotherapy, pharmaceuticals, radio-therapy)
Medical support (intensive care, nursing, transfusion, antibiotic support, pain management)
Social services and health education services
Comprehensive cancer care requires access to high functioning primary, secondary and tertiary health systems.
Using the following assumptions:
1. That a US Standard of care be provided for the cancer patients because the USNWTP caused the excess cancer rates.
2. That the system is capable of providing a US Standard of health care for other health problems in cancer patients, especially at the time of cancer treatment.
3. That the system will provide comprehensive cancer services, with some specialized needs being met in Hawaii or other tertiary health care sites.
4. That there will be a minimum of 265 (.5 times 530) cancers resulting from nuclear testing and some 2800 (.5 times background 5600 cancers) over the next 30 years as extrapolated from the 2004 NCI report. The 265 excess cancers will be indistinguishable from cancers which have occurred as part of the background cancer rate.
5. That an appropriate system of cancer care would deliver as much care as possible in Majuro and Ebeye.
6. That capacity building is the best approach as it is one of the objectives of the amended Compact and makes the most economic and developmental sense.
The comprehensive cancer care system requires an intact primary care system, screening system, cancer registry, mammography, colonoscopy, medical laboratory, pharmacy, surgical capabilities, intensive medical care capabilities, supplies, prosthesis, pharmaceutical, CT scanner, x-ray unit, ultrasound, and the medical expertise to staff and run the system. A sophisticated hospital is needed with these capabilities. In the RMI adequate screening should be available to the people of the outer islands. They should be brought to the urban hospitals to get recommended cancer screening.
The facilities, infrastructure, and manpower required to provide comprehensive cancer care, and provide the medical care of cancer patients who are suffering from other illnesses during times of cancer care will be significant. The recurrent operations costs for such a 10 acute bed facility at the base cost of about $1300 / acute bed / day would be about 5 million dollars annually. Kwajalein Military Hospital (USAKA) has 11 acute beds and the annual budget is about $5.5 million.
The outer island screening and primary care as well as the specialty referral services to Hawaii would be another 2.5 million dollars in cost annually.
The total operations health care costs for a comprehensive cancer system would be in the order of 8 million dollars annually. Capital costs would be in the order of 6 million dollars. Notably, a separate cancer facility and cancer system would have to be built to make this system functional. Adding 8 million dollars to the existing RMI system would dilute the effort and not allow the comprehensive cancer system to reach a US standard of health care.
177 Health Care System (system 2):
The 177 Health Care program serves about 14,000 Marshallese. The 177 Program was designed to provide primary (prevention), secondary (hospital), and tertiary (referral) care for the program participants. It is unfortunate that the level of funding did not support the program design to any reasonable standard of care. Assuming a US Standard of Health Care System to provide primary, secondary, and tertiary care would cost about 50 million dollars ($300 per person per month X 12 months x 14,000 participants) annually.
The four atoll membership bears the largest proportion of cancers that was generated from the USNWTP. Except for the DOE subset of patients (200 people), the remaining 14,000 program participants have no better access to adequate cancer screening, treatment, and services than the rest of the RMI patients. The 177 members should have US Standard cancer health services.
The 177 Program in particular suffers from the difficulty of quantifying social, cultural and mental health impacts. Caring for the participants with a 50 million dollar primary, secondary, and tertiary health care system would address cancer and the other health consequences for this population.
Economy of Scale (system 3):
Building a comprehensive cancer health system, providing a high standard of health care for the 177 health care recipients, and managing the DOE Medical Program can be done for an operations cost of 45 -50 million annually. The system and facilities that would be constructed would have the absorptive capacity to provide a high level of health care for the RMI, in general. The Common Wealth of the Northern Marianas, which supports a similar population to the RMI (55,000 people), has an annual operations budget of 45 million dollars annually. Capital costs would be in the order of 50 million dollars.
Building such a system could provide comprehensive cancer care to all Marshallese while meeting their comprehensive health care needs. The NCI report suggests that the ionizing radiation which caused cancers reached beyond the four atolls and even beyond the northern atolls of the Marshall Islands. The lack of a defined boundary of who was affected and who was not affected by nuclear fallout makes a nation-wide system ideal.
A program which provides high standard comprehensive health care for all Marshallese would address the health consequences of the USNWTP in a cost effective, capacity building manner. This system would also address the health care needs of over 300 Marshallese and other indigenous Pacific islanders who participated in the clean-up of Bikini and Enewetak atolls who live in the RMI. This subgroup has little access to extra health care services.
Developing a health care system to address the health consequences of the USNWTP in the RMI is related to the illness(es) that must be addressed, the burden of that illness, and the standard of care to be applied for that illness.
The cancer burden has been clearly defined by the NCI. Other health consequences are more difficult to quantify or have yet to show themselves (genetic effects). All three systems of health above are structured to address the cancer burden in the RMI. The 177 Program and the economy of scale program, as defined above, are designed to address the cancer burden and the other health effects of nuclear testing.