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Senator INOUYE. Dr. Izutsu, I would like to commend you and congratulate you and the University of Hawaii School of Medicine, because what you are doing is part of our legal and moral commitment, I believe, and it is about time we involved ourselves. For too long they have had to train, where, in Fiji?

Dr. Izutsu. That is right.

Senator INOUYE. It is about time the United States assumed the responsibility that we assumed at the end of World War II. So I am glad that Hawaii is involved in this.

In total, how many doctors have we trained, medical officers?

Dr. IzUTSU. Well, the first class will graduate in 1992. There will be 16 of them graduating. There are 68 in the pipeline. So by 1995 we will have 85, hopefully, graduating.

Senator INOUYE. And how many do we need for that population? Dr. IZUTSU. We need 85 to 100 by the year 2000.

Senator INOUYE. Would that be sufficient to take into consideration the growing population?

Dr. IZUTSU. That will not be. But I think that as we look at the U.S. Public Health Service, which is helping us with the supply of some of the physicians that go there for 2- to 3-year stints-the program that we are embarked on right now is a 10-year program and hopefully by having 85 and then gradually—and hopefully the Fiji school will be up again and we can have them help us at that time, or continue our medical officers training program.

The University of Hawaii also has a program whereby we accept students from Micronesia and the Pacific Basin. A number of the students who graduate from the medical school, John A. Burns Medical School, of course, some have gone back. Some have not.

But by training right in Ponapei in the Pacific Basin, we are hopeful that the students will stay there.

Senator INOUYE. I am well aware of the collaboration that you have had with Trippler Army Hospital.

Dr. IZUTSU. Yes.

Senator INOUYE. How do you find the hospitalization program? Is it working?

Dr. IZUTSU. It is working, and I think that I am very hopeful that as we expand into the VÅ complex in the future that we will be able to help more, because I think that we see about 110,000 veterans in total in the Pacific. And I think with the VA coming up and the cooperation with the medical school as well as Trippler, that we will be able to service that better.

Senator INOUYE. Well, once again I thank you very much, Dr. Izutsu.


May I now call on the dean of the School of Public Health, Dr. Michael

Dr. MICHAEL. Senator Inouye, Congressman Mink, Congressman Abercrombie: I will be in a position this morning to amplify on the other comments by my good friend and colleague, Dr. Izutsu, on health in the Pacific.

When I testified almost exactly 1 year ago on the 20th of this month in 1990, I gave some preliminary data on the two definitive studies of health conditions and services in the Pacific conducted by the School of Public Health at the University of Hawaii, one in 1984 and one more recently, 1989 and 1990.

The U.S. Public Health Service, who commissioned this study for us, is preparing an executive draft to present, as requested, to the Congress. And it is not my intention to second guess that report, but rather to provide some specific and factual data from that study and some of my own personal feelings about what needs to be done to enhance health in the Pacific.

Significant change, of course, is taking place in that region that comprises the U.S.-related jurisdictions, and that kind of rapid change has almost become an immutable way of life. No need to tell our congressional delegation what those territories are or what those jurisdiction, but for the sake of those in the audience, it includes American Samoa, Guam, Federated States of Micronesia, Belau, Commonwealth of Northern Marianas, and the Marshall Islands.

Within those jurisdictions, population shifts are taking place from the remote atolls and islands to capital centers, and that creates additional problems as populations become concentrated in areas where they have not been concentrated in the past.

This changing demography has been hastened by something else Dr. Izutsu mentioned, and that is climbing birth rates, and an additional problem: unprecedented immigration of nonindigenous people in response to an escalating demand for resident technical advice, assistance, and labor needs.

Now, as to the findings, the difference that we have found between the original study and the current study shows some progress, but that progress has not been the kind of progress that we would have hoped for, and it is quite clear that services and conditions continue at low levels of adequacy; clear, substantial room and need for improvement.

My own personal analysis points up two major trends in the current contemporary health status profile of the islands. First, the general health of the island populations as measured by average life expectancy is positively associated with numerous measures of development, such as expenditure per capita, doctors per capita, education. So in contrast to what might be a common notion, modernization and development have been generally beneficial for health in that area.

This has, it seems to me, some significant impact on your judgments as to whether or not additional investment is appropriate.

Second and related to that first trend is that island populations are experiencing a health transition. Dr. Izutsu talked about infectious diseases. Indeed, infectious diseases still are important. But there is a transition to chronic disease problems.

Now, the problems differ from area to area and, as you all know, this is a huge area. If we superimpose that former trust territory on the mainland of the United States, it stretches from California to Maine. It is a huge area and it is not homogeneous.

But in one of the areas, lesser developed areas of that grouping of jurisdictions, health tends to be defined as wellness, and that is Guam and American Samoa. But in the rest, generally the rest, health tends to be viewed as the absence of illness. So there are differences.

But the solutions or the directions for the solutions that I would like to discuss at the end of my presentation I think are sufficiently general in nature to be dealt with by congressional action.

In American Samoa, Guam, the Northern Marianas, and Belau, the ranking cause of death is cardiovascular disease, followed by accidents, cancer, and respiratory diseases. This pattern reflects the extent of sociocultural and economic change taking place in these developing islands.

Further, the resulting shift from traditional diet and activity patterns give rise to risk factors commonly identified with these socalled diseases of modernization: obesity, hypertension, diabetes, and heart disease.

In contrast, the health status picture of the Marshall Islands, the Federated States of Micronesia, show that, while disease patterns are certainly changing as a result of modernization, communicable disease and malnutrition remain important health problems. The ranking cause of death is still infection, with perinatal infectious disease being especially prominent in the Marshall area.

Other common disorders such as otitis media, rheumatic heart disease, are exacerbated or increased by poor environmental sanitation, substandard water quality, and poor nutritional practices. Amazingly, epidemic outbreaks of cholera, not in Peru but in the trust territory area, have occurred recently, and that has been in Truk, influenced by inadequate public sanitation and unusual drought.

Epidemics of dengue fever and leptospirosis have also occurred recently in both the Marshall Islands and the Federated States of Micronesia.

A troublesome additional problem. The developing island centers. A number of health-related problems have appeared in association with social disruption caused by rapid cultural changes. A heavy intake of alcohol, especially among young men in the urbanized areas, has contributed to increasing vehicular accident rates and a growing incidence of social violence and social problems, such as spouse abuse and child abuse.

In some parts of Micronesia, suicide—and this pertains to your earlier comment, Senator, about the consideration by huge numbers of people of suicide some time in their young life-suicide has risen to extraordinary rates among young men below 30 and ranks as the chief cause of death

among that


cohort. Increasing use of drugs, including heroin and cocaine, have also been reported recently in some areas, including Belau. And as you well know and as many have reported and as I have stated in testimony which I have been pleased to present here over the years, many of the underlying conditions and I would say nearly all of those conditions which affect health status are partially or completely preventable, partly through the kinds training programs that Dr. Izutsu has discussed and through others which I should like to highlight.

The recommendations are 13 in number. I should like to just mention the first three:

Enabling legislation should be adopted by the U.S. Congress to express the long-term-long-term commitment to raising the health systems of the Pacific to a level at least of equity with rural America.

Second, the reduction of administrative barriers—and there are many-need to be pursued to permit maximum participation of Pacific jurisdictions in U.S. programs of assistance. That really is needed, and that technical assistance can be provided and it needs to be provided on a knowing basis.

Third, the kind of approach in my judgment that should be taken by the Assistant Secretary of Health because of the unique circumstances in these Pacific jurisdictions should utilize the special knowing strengths of the regional office of the Public Health Service. And I say that as a former Public Health Service officer and Assistant Surgeon General of the United States.

We need to have the kinds of information and support that goes to the people in the Pacific reflect those people who understand the Pacific, who have been there and do not have to be told about where it is. That is critical.

I would summarize the remaining 10 to my good friends and colleagues in the congressional delegation as follows: We need to focus on prevention rather than cure. You cannot turn someone away when they come in with a broken arm, but we need somehow to break the continued pattern of just treating the disease and the sequela of accident and the like. We need to intervene and to give self-empowerment to the people and commit them to help prevent the things that are happening.

That does not always mean, with all due respect to my friend Dr. Izutsu, more doctors. It means more of some other kinds of things as well in the Pacific.

Needed coordination on manpower development, the kinds of things that we are doing at the University of Hawaii, but we need to be joined by the World Health Organization, the South Pacific Commission, and all of the agencies of the Federal Government, the Public Health Service, the Department of the Interior, the EPA.

Sometimes they seem to follow independent lines. That needs to be coordinated to the benefit of the people in the Pacific.

Third, we need to return to a strengthened health planning activity, not for its bureaucratic aspects, but so that we have a sense of where the investment is necessary and, once having invested, we can make the assessments that are valid about which things have worked and which have not.

Now, that seems reasonable, but health planning in the Pacific jurisdictions has deteriorated to a point where it really does not exist, with the exception of Guam and American Samoa.

We need finally to address mental health, environmental health, and dental health, mental health, environmental health, and dental health, which have not had the kind of investment that we need for the future.

In concluding, I would say that it is highly likely that without actions such as I suggest the health future of these U.S.-related Pacific jurisdictions will be negatively impacted by a continuing and combined onslaught of crises. And without a collective resolve to act and without sustained commitment, the chasm between health needs and resources is likely to widen.


We have shown what we can do with minimal investment, and that needs to be continued. We need to continue that commitment. As the senior Dean at the University of Hawaii, I would like to say that, having consulted on this with our president, that the University stands ready to join in that commitment in any way that we are called upon to do.

Thank you very much.
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