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United Statc~ Department of the Interior Speaker of the House of Representatives The Secretary of the Interior is required by section 102 of Public Law 96-205 to subr.it to the Congress by January 1, 19E1, a plan for health care and related programs for people of the Marshall Islands. To afford to the new Ad.m,inlstrationas muck flexibility as possible, we are submitting at this time only a preliminary report, with the expectation that a final plan w~ll be submitted to you sometime after the Inauguration. I should like to set forth below certain of the key provisions of the statute, a statenent of some of the areas in which the statute presents problems of construction, information concerning the Interior Department’s efforts to implement the statute, and brief summaries of the proposals received from our contractors to help us ti,plement section 102. At this time the Depart.mer+t neither endorses nor rejects the conclusions contained in the Section 102 of Public Law 96-205 contains the following provisions relevant to our current undertaking: -- The plan required of the Secretary of the Interior results from the United States’ nuclear weapons testing progra~ conducted in the Marshall Islands during the period 1946 to 1956. -- The beneficiaries of the plan are to be “the people of the atolls of Bikini, Enewetak, Rongelap, and Utirik and.~~the people of such other atolls as may be found to be or to have been exposed to radiation from the nuclear weapons testing program”. -- The plan is to consist of “a program of medical care and treatment and environmental research and monitoring for any Injury, illness, or condition which may be the result directly or indirectly of such nuclear weapons testing program”. The plan is to include (1) “an integrated, comprehensive health care Pro9rar including prinary, secondary, and tertiary care with special sanphasis upon the biological lffects of ionizing radiation”, (2) an environmental monitoring, research~ and dose assessment program, and (3) an education and information program.
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-- The Secretary of the Interior is to submit the plar.by January 1, 19:1, together with recommendations, if afiy, for further legislation, and including his recommendation as to the - feasibility of using the Public Health Service. -- Costs ass~ciate~ with the development and implementation of the plan are to be borne by the Secretary of Energy. In our discussions with interested Federal agencies and with representatives of the affected people of the Marshall Islands, several areas of disagreement as to what the statute requires A principal disp~te among the interested parties relates to the islands and atolls covere~ by the statute. No doubt exists as to the application of the statute to the four atolls explicitly named -- Bikini, Enewetak, Rongelap, and Utirik. At least one non-Federal party contends, however, that the statute and a foreseen program of comprehensive medical care must extend to all of the people of the Marshall Islands, on the ground that all islands and atolls in the Marshall Islands have received at least some radioactive fallout as a result of the nuclear testing program~ and that all the people of those islands and atolls have therefore been “exposed” tc some extent by that program. Immediately following the President’s approval of Public Law 96-205 on March 12, 1980, the Departments of the Interior and Energy undertook to arrange the necessary funding to support the preparation of the plan. As soon as financial arrangements permitted us to do SO, we invited representatives of the Marshallese and of the interested agencies to meet with us to discuss implementation of the statute. With Department of Energy funding, the Department of the Interior invited and paid the travel costs of two representatives from each of the named atolls and from the Government of the Marshall Islands, the lawyer for each if he was not Washingtonbased, and interpreters. Meetings with the above-mentioned persons were held in Washington on August 4 and August 6, 1980. The basis for the meetings was a Discussion Paper prepared by the Interior Department and distributed to the interested parties in advance. All were afforded an opportunity thereafter to submit written comments on Interior’s
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in pre~~rin: for us or a contract basis the medical plar, req~ire: by lg\”. The re;d es: for propasals was sent to, among Others, all pcte:.ti211y ir.tezeste2 parties suggested to us by Marshallese representatives. A contract was awarded in early October to the School of Health of Loma Linda University, located in Lora Linda, California. Giver; the statutory deadline for the submission of the Interior plan to the Congress, the time available to our contractor was limited, but the contractor met the deadline of At the request of the Department of the Interior, the Department of Energy prepare5 proposals for the two other components of the plan that the statute requires: an environmental monitoring, research, and dose assessment program, and an education and The three documents in question became available and were distributed to those interested, including August attendees, in early December, and a further meeting of the interested agencies and the Marshallese representatives was held on December 10 in Washington to discuss them. ~ opportunity to supply written comments through December 17 was afforded. The three proposals Attached are copies of the proposals that formed the basis of our December 10 discussions. In brief, 1. The Health Care Proposal, prepared by the Loma Linda University Schoo3 of Health under contract with the Department of the Interior, presents the two alternative plans required by the Interior contract: a program of comprehensive health care for all of the Marshal16, and a program of comprehensive health care for the people of the four named atolls. Because the peoples of the four named atolls now reside throughout many of the islands and atolls of the Marshalls (it being esttiated that they now live on SO% or more of the 26 atolls and hundreds of islands that constitute the Marshals), and because of the ethical and practical difficulties of providing one kind of medical service to one individual while not providing it to others in the same community, the Loma Linda proposal outlines an upgrading of the overall health program and the provision of comprehensive health care throughout the Marshall Islands. This llternative vould provide for medical assistants on each of the inhabited iulands and atolls, supported by a professional medical ctaff that would provide secondary and some tertiary care at the tvo Marshall Imlands hospitals on Majuro and
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Eheye , ar,i therehj reduce the substaritial volume of trazsp~rtatio~ facilities, notably service by the Airline of the Marshall Islands where available, anclor. fielti trip ships and chartered vessel service elsewhere, rather than the provision of dedicatea surface vessels or aircraft. Improved radio communications betweer, the medical staff at the hospitals and the medical assistants on inhabited islands an2 atcils would be essential, not only for the exchange of necessary medical information and instructions b.~t also for decisions as to emergency medical evacuations. This alternative provides a suggested organization of the health-delivery system of the Marshall Islands, with the United States playinS a major role in the direction and management of the program but preserving local authority and participation. The estimated cost for the first year of this plan would be 10,908,300, of which $3 million would be funded by the Marshall Islands Government. The second alternative contained in the Loma Linda proposal is comprehensive medical care for only the peoples of the four named atolls of Enewetak, Rongelap, Utirik, and Bikini. This alternative would provide improved primary care on the four named atolls and on other islands and atolls where peoples from.these four atolls now reside. This alternative, like the first, provides for the improvement of the secondary and tertiary services at the hospitals on Majuro and Ebeye. The hospital-senice improvements would provide the necessary support for the primary care system and would reduce costs associated with medical referrals out of the Marshall Islands. The estimated cost for the first year of the proposal for provls~on of special care for the peoples of the four named atolls is approximately $10,603,700, of which $3 million would come from Marshall Islands Government funds. This estimated first-year cost is close to the estimated first-year cost under the first alternative because much of it reflects the cost of improving services at the hospitals at Ebeye and Majuro which would be required under either alternative.
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et our Derer.ber 10 meeting believed it would be useful tc t,e’;cz COS: fiqxre for a plan of lesser scope, WE asked Loma Linda tc provide cost figures for a pla~. that would provide primary care only to the currerit re~ide~ts of Enewetak, ROngelap, Litirik, and Kill (there being no current residents of Bikini, with Xlli being the residence for the largest group of fomner displaced Bikinians), with secondary and tertiary care to be provided for them outside the Marshalls. Lorria Linda has adt’ised us that a program of this scope would cost $2,855,400 for the first year. 2. The Environmental Monitoring, Research, and Dose Assessment Program, prepared for Interior by the Department of Energy, under contract, contemplates for each of the four named atolls the carrying out of comprehensive surveys and analyses of the radiological status of the atolls at appropriate intervals, but not less frequently than once every five years; the development of an up~ated radiation dose-assessment; and an estimate of the risk associated with predicted human exposure. The Environmental Monitoring, Research, and Dose Assessment Program Plan would utilize results of past and current DOE research programs in the Marshalls, but would also require new and direct monitoring of samples of locally-produced foods, soil samples, groundwater and cistern water-samples, dietary and consumption habits, and Gamma measurements. Additionally, research would be conducted on a wide variety of other questions, such as radionuclide cycling in atoll ecosystems, radionuclide distribution in copra products, and radiological dose assessment and risk analysis. The estimated cost of this new program for the first full year would be $1,140,000 if it were carried out in conjunction with on-going DOE Marshall Islands programs. The cost would increase to $4,170,000 for the first year if the program were conducted by individuals or organizations that functioned independently of current DOE Marshall Island programs. 3. The Education and Information pro9r~~ PrePared for Interior by the Department of Energy, under contract~ contemplates a program to enable the people of Bikini, Enewetak, Rongelap, and Utirik, and the people of other atolls or islands found to be or to have been exposed to radiation from the nuclear tests, to better understand nuclear radiation and its effects. The basic llement of the program plan is direct? face-to-face
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c z---tinicatior.wit}. the people of Bikini, Enew’etak, be cor.-~nication with officials of the GovernneT.t of first in the Marshall= and later in the United States tc carry out the education progr~.. Pretaped ra3i9 pro~ra~s in both Marshallese and English would provide information about nuclear radiation and its possible effects. There would be systematic evaluation of the effectiveness of the communication process and modifications of the prograrrtas necessary. The pro:ran would be a continuing one, to reinforce, review, anc update the information. The estimated cost of the Education and Inforrrlatior. Progr=l for the first full year would be $950,000. Attached is a chart showing the total estimated costs of ali three programs for each of the first five years. Also attached are copies of three letters received subseqent to our meeting of December 10 with representatives of the Marshallese, among others, and pursuant to our invitation for written comments concerning the three programs then presented: -- A letter of December 15 from Jeffrey Jefferson, representing the people of Rongelap, Utirik, and several other atolls, stating, among other things, that the monitoring and education programs are inadequate in their coverage, and that the health program does not sufficiently address the radiation-related health care needs of the Marshallese; -- A letter of December 15 from Jonathan Weisgall, representing the people of Bikini, recommending among other things, that primary care be provided for Bikinians resident only on Kili and Ejit, and Eneu should some Bikinians later move there, but that secondary and tertiary care be provided for all Bikinians, possibly outside of the Marshalls, as at present; and -- A letter of December 17 from Elaine Falender, representing the Marshall Islands Government, stating, among other things, that the health care proposal is in l rror in stating that there are minimal radiation-related health lffects evident in the Marshall Islands, and stating that the Government of the Marshall Islands continues to believe that Public Law 96-205 requires that health care be provided to all of the people of the Marshalls.
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by the Depa:-+~er.t or ottler affected agencies, nor have the proposals for health care, m~nitoring, and education bee:. inte;xated. They differ as to their geographical coverage anti contain some duplicatic~. Gf costs, as in the case of trazsportatioc and communication. In addition, the cost lstimates have not been reviewed in any detail. The developmer,t of a single, integrated plan based on the three attached proposals cannot effectively be accomplished? until various issues are resolved, and accordin~ly, none of the three proposals here transmitted has the endorsement of this -partment or the Administration. We believe them to be useful and professional products, however, and they will unquestionably be irrlportantin the development of the plan required by the law. From the foregoing, it will have become clear that a number of questions require further consideration. The most fundamental is the matter of the coverage of the prograr, -- whether it should extend to all of the people of the Marshalls, to the people of the four named atolls wherever they reside and to the people of the ‘other atollsn that are found to have been affected, or to the current residents of selected atolls only, and if a distinction should or can be made between radiation and non-radiation related injuries and illnesses. Should an effort be made to provide for health care for peoples of named and affected atolls that is separate and apart fror. the health care program available to the general population of the Marshall Islands? Does the term ‘integrated”, which the statute uses in describing the comprehensive health care program, mean that such program is to be integrated with medical programs of the Marshall Islands Government, or does it instead describe the relationship between the primary, secondary, and tertiary levels of care? To what extent should the beneficiaries of the health program, in whatever way they are defined, receive secondary and tertiary care within the Marshall Islands? Finally, if the peoples of atolls other than the four named in the statute should be provided the comprehensive care envisioned by Public Law 96-205, through what means and by what criteria should those other These are among the issues ,that will require attention in the weeks to come.
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P* 51 - DOE Environmental Monitoring Program Plan. (Covers 4 atoll~ only. Fiqures not adjusted for inflation.) P.,45 - DOE Education and Information Program Plan. (Covers 4 atolls only. Figures not adjusted …
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