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STATEMENT OF JERROLD M. MICHAEL

Mr. Chairman, I am Dr. Jerrold Michael, Professor of Public Health at the School of Public Health of the University of Hawaii, where I have served for 20 years, the past 19 as Dean of the School of Public Health. Prior to that I served for 20 years as a commissioned officer in the United States Public Health Service, retiring at the end of 1970 as Assistant Surgeon General,

I am pleased to provide testimony today on the subject of health in the U.S.-related jurisdictions of the Pacific. Definitive data on Pacific Health status was collected by the University of Hawaii's School of Public Health in & survey conducted in 1984 and again in 1989. I reported to this committee on our preliminary findings almost exactly one year ago on March 20, 1990.

: i The U.S. Public Health Service is currently preparing an executive summary report to the Congress on the results of the 1989 survey. The materials that I present today contains data and opinion from our original scientific study and is not intended to "second guess the Public Health Service presentation. I w111 present factual data from our study that will emphasize the critical need to strengthen and integrate activities that building local health care capacity.

HEALTH IN THE PACIFIC

Throughout the islands of the Pacific, and particularly those jurisdictions that comprise the U.S.-related region, change and rapid change at that has become almost an immutable way of life. Shifts in external governance and countries of influence have been one of the major contributors In this regard. For example, adaptation to successive turnovers in political administrations in American Samoa, Guam, the Federated States of Micronesia, Palau, the Commonwealth of the Northern Marianas, and the Marshall Islands within this century alone has brought about both social development and social disintegration, multiple and often conflicting role demands, a transition from subsistence to marginal cash economies, and modern technological advances. The aftereffects of these modifications from traditional to transitional lifestyles in these small islands where resources are painfully few and finite, are still widely felt. And all combine to impact health status and health seeking behavior.

The introduction of more rapid modes of transportation and fairly efficient mass communication in the last thirty years have prompted an even greater admix of political, economic, cultural and social change. Within jurisdictions, population shifts from remote islands and atolls to the urbanized capito1 centers of government are increasingly commonplace everywhere, for it is in those areas that even limited employment and relatively greater opportunities are concentrated. This rapidly changing demography has been hastened by consistently high and in some jurisdictions climbing birth rates, as well as an unprecedented in-migration of non-indigenous people in response to an escalating demand for resident technical advice, assistance, and labor.

As can be seen in the example of the Commonwealth of the Northern Mariana Islands where the population has exploded from 17,000 to well over 40,000 in just five years' time and where 80% of its people are now concentrated in Saipan, the urban center --rapid growth and development have placed an unprecedented and increasing demand on health services and resources. Not unexpectedly, this development has also sparked inevitable changes in health status, the adjustment to which the jurisdiction is currently 111-prepared to respond with equal rapidity and this despite the recent construction, staffing, and equipping of a technologically advanced, by Pacific standards, acute care hospital.

While the Northern Marianas provides us with the most dramatic example of the effects of change on health and health services, the other Pacific nations and territories have by no means been exempt to these same forces. Even though expressed differently island to island, everywhere is found the same general pattern of change economic, social, cultural, and health. And everywhere

can be found health systems struggling to adapt and develop in as responsive a fashion as possible.

As I noted above, the School of Public Health was twice commissioned by the U.S. Public Health Service to manage the only comprehensive surveys of health services and conditions in the Pacific ever to be undertaken. Our 1984 study noted that health status in the islands had improved steadily over time, particularly under U.S. administrationIt also newly identified significant differences in the availability and access16111ty of health resources in the Pacific. For the first time, health services in the region were described in detall as a three-tiered system, with the Guam health subsystem emerging as the most sophisticated and responsive, and those of Palau, the Marshall Islands, and the Federated States of Micronesia the most basic and severely burdened. Yet, even with these differences, all jurisdictions shared in common the still very developmental nature of their respective health systems. It is important to also note that the findings of the survey served as a benchmark for the initiation of newly focussed U.S. federal and other activities to improve health care in the region.

In redoing our survey in 1989, in these same jurisdictions, it was our intention to determine what, if any, changes had occurred over time in health services and systems. We dicussed that although the three-tiered system still existed to some extent, the changes which manifested gave rise to a new categorization of conditions facing these still developing health systems. Fairly comparable services were found to exist in the flag territories of Guam, American Samoa, and the Commonwealth of the Northern Marianas -- jurisdictions that have closer political ties to the U.S. and whose health services are closely patterned against the U.S. model. Markedly different were those almost Infection, with perinatal infectious disease being especially prominent in the Marshalls. Other common disorders such as otitis media, filariasis, and rheumatic heart disease are exacerbated by poor environmental sanitation, substandard water quality, and poor nutritional practices. Epidemic outbreaks of cholera have occurred recently in Truk, Influenced by Inadequate public sanitation and unusual drought conditions. Epidemics of pertussis, dengue fever, and leptospirosis have also occurred recently in both the Marshall Islands and the Federated States of Micronesia.

in the developing Island centers, a number of health-related problems have appeared in association with the social disruption caused by rapid cultural changes. The heavy Intake of alcohol, especially among young men in the urbanizing areas, has contributed to increasing vehicular accident rates, and a growing incidence of social violence and spouse abuse. In some parts of Micronesia, suicide has risen to extraordinary rates among young men below 30 and ranks as the chief cause of death among that young cohort. Increasingly heavy use of drugs, including heroine and cocaine, have also been recently reported in some areas, including Palau.

It bears repeating that urbanization in these pacific jurisdictions has increased the probability of epidemic infections because of crowded conditions, Inadequate food preparation, contaminated water supplies and poor hygiene. Children and old people are especially at risk for pneumonia, tuberculosis, and influenza diseases which were less transmissible when the island populations were more scattered and isolated. Coexisting with this pattern is the trend toward non-communicable disease as major causes of morbidity and mortality. And as it has been said so many times in testimony to congressional committees nearly all conditions which affect health status are partially or completely preventable.

With the changing pattern of health in the islands has come increased technology utilization and a new demand for specialists where generalists once functioned. Yet these still fragile, developing Pacific health systems are inadequately equipped and staffed to cope efficiently with either disease epidemics or with an increasing incidence of chronic preventable disorders.

We find that even in the face of change, none of the Pacific jurisdictions are pursuing the deliberate development of their health systems through planning, and little activity is taking place to routinely project future health services

needs, goals, and directions. Major shortages in human resources for health continues to exist in every category and at every level, as does the opportunity for short-term and long-term training and education.

Although the dynamics of development feature prominently in the region, chronic and communicable disease control and prevention activities are not adequately organized or implemented. Neither are many other program areas of community health prevention and promotion. Historically, greater resources have always been devoted to clinical health services and tertiary care and, as a consequence, public health continues to be a lesser priority. And this continued presence of preventable health problems only adds to the increasing economic burden of unmet health needs in the region And I emphasize again in the Pacific, this heavy burden is largely from acute and preventable diseases. exclusively government-operated health care systems of the freely associated nations of Palau, the Marshall Islands, and the Federated States of Micronesia.

The original 1984 survey sparked considerable attention to the unmet developmental needs of the region and it is likely that the exhaustive 1989 reevaluation will also have wide impact. While its findings indicate that the six Pacific health systems have made measurable progress over five years, these have been slight. Services and conditions generally continue at low levels of adequacy, and there is clear and substantial room for improvement. Further, its several recommendations which are enumerated in this testimony list a range of additional action that can be appropriately considered by the U.S. Congress and federal agencies to remedy the situation. Given equal weight are those recommendations that are specifically addressed to international agencies and organizations, as well as the island governments themselves.

We have seen that over the past several years, the Pacific Islands have experienced explosive population growth and recovery from a devastating period of population reduction that had begun in the mid-nineteenth century caused primarily by infectious disease especially measles, tuberculosis, dysentery, smallpox, and influenza. Our analysis points to two major trends in the contemporary health status profile of the islands. First; the general health of the island populations, as measured by average 11fe expectancy, is positively associated with numerous measures of development, such as government expenditure per capita, aid per capita, imports and exports per capita, doctors per capita, education, and urbanization. In other words, modernization and development have been generally beneficial for health.

Secondly, and related to the first trend, is that the island populations are experiencing a health transition from infectious diseases to noncommunicable oiseases as the primary cause of mortality. Even sharing this same trend, however, obvious differences emerge between the island jurisdictions. Where the relatively most affluent V.S. territories are concerned about chronic disease, cancer and accidental deaths, the poorer freely associated nations still name malnutrition, diarrhea, and certain communicable diseases as their major health concerns. Access to health care also varies considerably, depending on the number of inhabited island groups, the distances from these areas to the urban center, and the number of practicing physicians and other health professionals per population. Not surprisingly then, health tends to de defined in the first grouping of islands as wellness whereas in the second, health tends to be viewed as the absence of 111ness,

In American Samoa, Guam, the Northern Marianas, and Palau, the ranking cause of death is cardiovascular disease, followed by accidents, cancer, and respiratory disease. This pattern reflects the extent of socio-cultural and economic changes taking place in these developing islands. Further, the resulting shift from traditional diet and activity patterns give rise to risk factors that are commonly identified with these so-called diseases of modernization obesity, hypertension, diabetes, and heart disease.

In contrast, the health status picture of the Marshall Islands and the Federated States of Micronesia shows that while disease patterns are certainly changing as a result of modernization, communicable diseases and malnutrition remain important health problems. The ranking cause of death is still

infection, with perinatal Infectious disease being especially prominent in the Marshalls. Other common disorders such as otitis media, filariasis, and rheumatic heart disease are exacerbated by poor environmental sanitation, suostandard water quality, and poor nutritional practices. Epidemic outbreaks of cholera have occurred recently in Iruk, influenced by Inadequate public sanitation and unusual drought conditions. Epidemics of pertussis, dengue fever, and leptospirosis have also occurred recently in both the Marshall Islands and the Federated States of Micronesia.

In the developing island centers, a number of health-related problems have appeared in association with the social disruption caused by rapid cultural changes. The heavy intake of alcohol, especially among young men in the urbanizing areas, has contributed to increasing vehicular accident rates, and a growing incidence of social violence and spouse abuse. In some parts of Micronesia, suicide has risen to extraordinary rates among young men below 30 and ranks as the chief cause of death among that young cohort. Increasingly heavy use of drugs, including heroine and cocaine, have also been recently reported in some areas, including Palau.

It bears repeating that urbanization in these Pacific Jurisdictions has increased the probability of epidemic infections because of crowded conditions, inadequate food preparation, contaminated water supplies and poor hygiene. Children and old people are especially at risk for pneumonia, tuberculosis, and influenza diseases which were less transmissible when the island populations were more scattered and isolated. Coexisting with this pattern is the trend toward non-communicable disease as major causes of morbidity and mortality. And as it has been said so many times in testimony to congressional committees nearly all conditions which affect health status are

partially or completely preventable.

with the changing pattern of health in the islands has come increased technology ut 111zation and a new demand for specialists where generalists once functioned. Yet these still fragile, developing Pacific health systems are inadequately equipped and staffed to cope efficiently with either disease epidemics or with an increasing incidence of chronic preventable disorders.

We find that even in the face of change, none of the Pacific jurisdictions are pursuing the deliberate development of their health systems through planning, and little activity is taking place to routinely project future health services needs, goals, and directions. Major shortages in human resources for health continues to exist in every category and at every level, as does the opportunity for short-term and long-term training and education.

Although the dynamics of development feature prominently in the region, chronic and communicable disease control and prevention activities are not adequately organized or implemented. Neither are many other program areas of community health prevention and promotion. Historically, greater resources have always been devoted to clinical health services and tertiary care and, as a consequence, public health continues to be a lesser priority. And this continued presence of preventable health problems only adds to the increasing economic burden of unmet health needs in the region And I emphasize again in the Pacific, this heavy burden is largely from acute and preventable diseases.

The changes and trends I have outlined hold many implications for our profession none the least of which is the need to embrace the challenge to develop a realistic and culturally sensitive strategy that extends primary health care to the underserved. This will require that we use different training strategies and will likely also require that we facilitate the Introduction of different kinds of skills underscoring health promotion.

Although the metabolic, chronic degenerative, and malignant disorders that are prominent causes of morbidity and mortality Yn urbanized populations are increasingly seen in the Pacific, this should not be the principal or uniform focus of health improvement efforts throughout the Pacific.

We instead need to learn to prevent disease and promote health, as well as Identify and manage 111ness. And we need to function with a keen sense of

awareness of the place of health among other factors in the total scheme of national government; the relationship of health services to health status; the place of curative care within health services; and the likely consequences of imported programs.

RECOMMENDATIONS

In keeping with these findings, we at the University of Hawait crafted the following recommendations:

Overall Reociimendations to the U.S. Federal Government

1. Enabling legislation should be adopted by the U.S. Congress which

expresses a long-term commitment to raising the health systems of the Pacific to a level of equity with rural America. The legislation should provide minimally for major enhancements in funding over the next ten years in support of manpower development, services development, facilities, development, comprehensive health planning, and the establishment of

equity for public health programs. 2. The reduction of administrative barriers should be pursued to permit

maximum participation of Pacific jurisdictions in V.S. programs of assistance. Technical assistance should be increased to Pacific jurisdictions to aid in their seeking of programmatic resources from the U.S.

federal government. 3. Management of expertise and experience should be the posture taken by the

Assistant Secretary for Health recognizing the unique circumstances surrounding Pacific Island health needs and issues and ut111zing the strengths of the PHS' regional office in San Francisco. All management responsibilities for present and future Public Health Service programs should be assigned to the regional administrator and staff who represent the greatest concentration of knowledge and expertise regarding Pacific health at the federal level.

Specific Recommendations to the U.S., Pacific Governments, and International Agencies and Organizations

4. A long-term, shared Pacific strategy and financial commitment should be

established to raise Pacific health systems to a level of minimal adequacy

and acceptability. 5. Existing financial and programmatic mechanisms should continue to be used

with adjustments until stronger, more long-range alternatives can be created.

6. Coordination among relevant U.S. agencies and with all relevant inter

national assistance agencies should be improved. 7. A strategy of short-term external assistance and long-term capacity

building in manpower development should be pursued, including expansion of the National Health Service Corps in the Pacific; detailing senior public health specialists to provide sustained technical assistance over periods of one to two years; implementing a long-term manpower development strategy: and establishing staffing for community mental health centers as part of a shared manpower development plan for the region.

8. Incentives and positive pressures on Pacific health systems should be

applied to strengthen their overall management in ways whihc promote greater efficiency, effectiveness and quality including the development of quality assurance programs for clinical services and public health programs whihc address the special conditions and circumstances of the Pacific.

9. Health planning mechanisms and activities should be reestablished in each

jurisdiction and for the region as a whole and apply incentives for the use of up-to-date information for decision making derived from improved health information systems. Planning should address facilities, manpower, and services development.

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