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10. Health facilities maintenance and development should be addresses beginning

with a comprehensive survey of Pacific hospital facilities.

11. Systematic parity in Pacific public health should be achieved through

incentives, mandates, and technical assistance. The U.S. federal government should extend its "Objectives for the Hation" initiatives to Pacific juris

dictions with appropriate geographic and cultural adaptation.
9. Systematic capacities in mental health and substance abuse programs and

services should be establ1shed, commensurate with existing needs in the
Pacific. Priority attention over the next ten years should be given by
the U.S. federal government, Pacific governments, and International
agencies to address the numerous interrelated sociocultural and health

policy Isues surrounding the complex problem of alcohol abuse.
10. Capacities in dental health expertise, program, and services should be

strengthened through manpower development, reorientation of care delivery to a preventive rather than curative mode, and the improvement of dental health related information.

CONCLUSION

It is highly likely that without actions such as I have outlined, the health future of the U.S.-related Pacific jurisdictions will be negatively 1mpacted by several combined and separate crises. These include significant manpower shortages; the absence of dellberate, aggressive health planning and policy formulation; rapidly increasing populations; diminishing resources; demographic turbulence; and the general neglect of public health practices in the region. Without our collective resolve to act and without sustained commitment, the chasm between health needs and resources is likely to widen. with minimal levels of assistance, some slight progress has been made over the past five years. Our challenge then is to provide even more concerted, focussed, and deliberate effort to improve Pacific health conditions and health status in the 1990's and beyond.

Senator INOUYE. I would like to congratulate the University of Hawaii for assuming the role that should be undertaken by the U.S. Government, because, as I have said on many occasions, we do have a moral obligation and a legal obligation to concern ourselves with the health problems of the people in the Pacific.

Do you have data available that we could use to draw a health profile of the people in the Pacific area 50 years ago?

Dr. MICHAEL. A profile 50 years ago?
Senator INOUYE. Yes.

Dr. MICHAEL. Yes; we do, Senator. I think with some accuracy, if not precision, we can draw a profile from data that are available from the available material.

Senator INOUYE. Would you provide that to the committee, because we would like to compare and see what it was 50 years ago and what it is today.

Dr. MICHAEL. I would be delighted to do that, Senator.

Senator INOUYE. I would think the picture today would be horrendous compared to what it was 50 years ago. Would that be the situation?

Dr. MICHAEL. I think we have shown some progress in the health profile, not the kind of progress we would like to have seen. If we compare the profile of 50 years ago in Micronesia with the profile of the American Indian 50 years ago, there is a great deal of comparability, and if we use that-and you know this area very well, Senator.

If you use that and look at the change, then we would see that the progress for the American Indian has been significantly better. And I think that is a shame.

Senator INOUYE. I am glad you are focusing on prevention because, with all the urging that this committee has done, our latest numbers indicate that 2 years ago we spent approximately 50 cents per American for prevention, 50 cents. At the same time we spent over $1,500 per American for curative medicine.

It has been suggested that if we increase preventative medicine by 50 cents, make it $1 per American, we could cut down the curative medicine in half. But somehow it does not have the sex appeal, so we still struggle along with 50 cents per American for prevention.

I hope we will wise up in the Pacific on that.
Dr. MICHAEL. So do I.

Senator INOUYE. Before I call upon my colleagues from Hawaii, may I hear from the Dean of the School of Social Sciences.

STATEMENT OF RICHARD DUBANOSKI Dr. DUBANOSKI. Thank you, Senator, Congresswoman Mink, Representative Abercrombie:

I am here to testify about the importance of social sciences in understanding health problems and health promotion. As you all know, there are serious health problems that exist in Hawaii, Guam, Samoa, Micronesia, even though much concern has been shown, resources have been given, and programs have been implemented.

One reason why certain problems still exist is the inadequacies of the model that has been used to understand certain of these problems. Typically, we forget that health and illness are due not just to medical factors; they are also due to social and cultural factors. We must appreciate the roles that these factors play in health and illness if we are to develop successful programs of intervention and prevention.

Many of the serious problems that Hawaii faces and the Pacific faces—hypertension, cardiovascular disorders, drug, alcohol abuse, sexually transmitted diseases, mental illness, et cetera-all have social origins. It is difficult to understand these problems without understanding the individual psychological components, the social conditions, and the cultural contexts of these problems.

The field of social sciences will be of help in discovering the roles of social factors in health problems and health promotion. Through evaluation of personal, cultural, and social dimensions, the social scientists will reveal those aspects that are typically overlooked in health assessment.

Beyond the medical and public health factors, we need to have a better understanding of the role of family patterns, social support systems, individual psychological makeups, changing social roles, economic resources, self-esteem, et cetera, in playing an important role in the occurrence of these illnesses.

We must develop a matrix of the social factors and see how they interact with the medical factors if we are to firmly grasp all the causes of illness. We must understand the social dimensions along with the medical and public health dimensions if we are develop successful models and programs of intervention and prevention.

The social science approach will also be useful in assessing ongoing programs of service provision. The deputy director of Health in Hawaii and I are exploring ways that social scientists can help improve the mental health services in State of Hawaii. The dean of the school of medicine and I are discussing ways that social sciences can be of help in one of the school's more innovative health programs, Hawaii Health, Inc.

The dean of public health and I are working together to look at the relationship between health and the environment.

PREPARED STATEMENT In sum, many of the problems that we see in Hawaii and the Pacific have social causes. Through the social sciences, we will be able to discover the role these social factors have and in turn be able to develop successful programs of health, intervention, and prevention.

Furthermore, significant gains can be made by supporting cooperative efforts among the disciplines of medicine, public health, and the social sciences along with the agencies that provide health services.

Thank you.
[The statement follows:)

STATEMENT OF DEAN RICHARD DUBANOSKI During this testimony I wish to suggest the range of health problems existing among the islands of Hawaii and the former U.S. insular jurisdictions and suggest some roles which social science research might play in addressing these problems.

The United States has been an active agent in social interventions in these areas for much of the past three decades. A number of these interventions, unfortunately, have not succeeded in reducing and preventing serious health problems in the Federated States of Micronesia, the Marshalls, Palau and the Commonwealth of the Northern Mariana Islands (CNMI). It may be said that the failure was due, in part, to the fact that some of these interventions were based on inappropriate models of these societies. Our notions of what was “good for them” has not proven to be correct. Faced with what are now daunting health problems many of which stem from social conditions, I think that it is imperative that we recognize the importance of addressing these problems from a different perspective. Because some of these health problems and conditions have a direct social etiology, we should begin to develop a social intervention model. It is important to understand the social factors that assect the pattern of incidence which has come to characterize these societies if we want to reduce or prevent the occurrence of these illnesses.

I wish now to discuss three issues: incidence; the state of treatment and facilities; and innovations and evaluations which could be used to address to these problems.

INCIDENCE

The health status in the region varies and reflects to a large extent the classic "epidemiological transition” from communicable to chronic diseases, but with important exceptions. In Guam, American Samoa and, to a lesser extent, CNMI-morbidity and mortality parallel U.S. patterns-exacerbated by high rates of diabetes, hypertension and it would appear, some cancers. The patterns of cardiovascular, respiratory diseases and cancers are familiar to us as so-called diseases of modernization. Obesity and accompanying hypertension, diabetes and heart disease can be traced directly to shifts away from traditional diet and activity patterns. Guam in 1990 had an HIV/AIDS rate per 1,000 population second only to Australia. The Marshalls, Federated States of Micronesia and to a lesser degree Palau have increasing rates of non-communicable diseases and elevated rates of infection and infant mortality. Cholera is a recurrent problem. Alcoholism, suicide, Hepatitis B, sexually transmitted diseases and HIV inlections are of increasing concern.

Throughout the region as a result of rapid population growth, crowding, underemployment, one can observe increased alcohol consumption, drug abuse, homicide, hypertension, smoking, suicide and injuries due to motor vehicle accidents. High levels of urbanization also have increased the incidence of epidemics from infections, crowded

conditions, poor food preservation, contaminated water supplies and poor hygiene. The relationship between changes in the social environment and disease patterns is fairly clear.

The situation in Hawaii is different in part because of the level of economic development and the size of the population. However, as the Congress has recognized in passing the Native Hawaiian Health Care Act, Hawaiians suffer comparative in. creased rates of mortality and morbidity for a wide range of pathologies. Mental health problems exist at elevated levels for native Hawaiians. Tentative research suggests that family violence issues may also be abnormally high among this population. Again, these conditions have environmental or social correlates.

TREATMENT/FACILITIES Within the Pacific Island states the focus in the past has been on the creation of visible infrastructure, focused on the medical model. Typically, these facilities have been poorly maintained and run, with serious problems existing with respect to the recruitment and retention of human resources for the health sector, including training, management and evaluation. Again, although differences exist within the region, one can identify a neglect of immunizations, nutrition, dental, sanitation, waste management, clinics and dispensaries. Routine health care tends to be nonexistent. Often equipment purchased for Pacific jurisdictions is found to be inappropriate for the environment: new equipment deteriorates in this climate ad there is no access to maintenance. Within the health care sector budget, much of external assistance has gone into the budget of hospital services with little left over for fundamental preventive and primary care. Lack of supplies and appropriate drugs is chronic.

Lip service has been paid to the support of community-based health workers trained to address the social bases of many of these disease states, but in practice they have been poorly supported. Mental health services in Micronesia in particular have high staff turnover, frequently run out of medication and are underfunded by local governments. As more and more people migrate to Guam, Hawaii and the U.S. mainland for employment, the family structure will change and the islands will become a residual population of the very young and the very old. The outer islands are already without a working age population. Mental health services if they are to be effective will have to plan for the economic transformation of the islands. Such population shifts are bound to have an impact on both the physical and mental health of individuals leaving the community and those staying within the community.

Although Hawaii is thought to offer an effective health care model because of its Universal Health Insurance, high life expectancy, low infant mortality and lower death rates from some major diseases (except for cancer), it is characterized by many of the same issues and problems that characterize health and health care in the rest of the United States. These include, for example, high copayments and outof-pocket expenditures, no long-term care coverage (for a relatively higher increase in older population), no specific focus on chronic diseases by State Health Department and an exploding of the private home health care industry and home health services by families with little quality control.

Mental health services in Hawaii deserve special mention. The State of Hawaii Division of Mental Health, Department of Health, historically has and continues to operate in a structural context which reproduces the poor state of mental health services. This is not a question of personalities or intentions, but of the structural conditions which define the services. When one examines other states with superior state operated mental health services, one frequently finds that the senior staff are hired through full-time, tenure track academic appointments in schools of medicine, social work, nursing and university departments of psychology. These staff are judged by academic standards of creativity and publications. We do not have that extensive participation by the University of Hawaii in state-operated mental health services.

With respect to health services provided directly to native Hawaiians, one can note that the organizational context of health services has produced limited access to these individuals, a lack of continuity of service and an absence of preventive

care.

INNOVATIONS/EVALUATIONS The social sciences could contribute to addressing these health issues from a vari. ety of perspectives. One major thrust would be to conduct evaluations among the various populations designed to demonstrate the role of social effects in the production of disease. This should not be seen as an esort to replace medical interventions, but rather to indicate where they must be supplemented by appropriate social interventions in order to be effective. We must begin to assess the social origins of illness in order to devel programs that will successfully prevent their occurrence.

Another major thrust is in the evaluation of service provision. Orien services have been provided in an inadequate or inappropriate manner and have had the unfortunate effect of contributing to the very problems they have been designed to solve. Social science research could lead administrators to develop more adequate and appropriate health and human services. Onæ again, this begins with evaluation and assessment.

A third thrust is to evaluate recent innovations in health care provision, especially those which embrace notions of social causality. In this regard I would suggest an evaluation of the implementation of the Native Hawaiian Health Care Act, an evaluation of Hawaii Health Inc., an esort by the John A. Burns School of Medicine and existing community health clinics in Hawaii to train medical students within the problem solving paradigm while sited in community settings (the involvement of social scientists is heartily endorsed by Christian Gulbrandsen, Dean of the School of Medicine), an evaluation of Hawaii's particular esorts to engage in both universal health care and control costs, an evaluation of Hawaii's pattern of legislative provision for mandated benefits, and a proposal for the evaluation of mental health serv. ices in Hawaii, including assessment of underlying philosophy and organization. I also would recommend that studies might be funded on the long-term organization of mental health services for Micronesia and Guam. The list, of course, could go on and on.

In sum, I propose that the social sciences have much to offer in understanding and alleviating a number of health problems that occur in Hawaii and the Pacific. I believe that significant gains can be made with the support of cooperative ventures among the disciplines of medicine, public health and the social sciences.

Thank you for your attention and concern.

Senator INOUYE. At what stage are you now in your effort to collaborate your work with the other departments?

Dr. DUBANOSKI. I am new at the job and so I just began my effort to try to spread the word of the social sciences and the importance of the dimensions to these other areas. Fortunately, I have a very good ear with Jerry and with Chris Gilbronson on these matters. So I figure that in a year or two we will be able to have some very significant collaborative efforts among these three disciplines. Senator INOUYE. Is that type of effort found on other campuses?

Dr. DUBANOSKI. I am always amazed to understand, to realize that a lot of people within the social sciences understand the significance of the social sciences in health, but do not collaborate with the other disciplines, such as medicine and public health. So it is not a nationwide activity at all.

Senator INOUYE. I am not a professional in any sense of the word, but what you say makes good sense.

Dr. DUBANOSKI. I believe so. Fortunately, my colleagues believe the same.

Senator INOUYE. Thank you very much.
Mrs. Mink.

Ms. MINK. Thank you, Senator Inouye. Just following on the Senator's comments, I note in your testimony a paragraph noting the particular difficulty that our State has had in the area of mental health services to our community and the constant low ratings that we have received from a couple of national organizations that have assessed our services.

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