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To the Speaker of the House and the President of the Senate The Secretary of the Interior is required by section 102 of Public Law 96-205 to submit to the Congress by January 1, 1981, a,plan for health care and related programs for people of the Marshall Islands. ~ to - Administration as much ~ as possible, we are submitting at this time only a preliminary report, with the expectation that a final plan will be submitted to you someetf.meafter the Inauguration. I should like to set forth below certain of the key provisions of the statuter a statement of some of the areas In which the statute presents problems of construction information concerning the Interior Department’s efforts to implement the statut~ and brief summaries of the proposals we have elicited to form the basis for the plan to be submitted later to the Congress Section 102 of Public Law 96-205 contains the following provisions~ relevant to our current undertaking: -- The plan required of the Secretary of thelInterior results from the ,.. United States)nuclear weapons testing program conducted in the Marshall Islands during the period 1946 to 1958. -- 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
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nuclear weapons testing program”. ~ to consist of “a program of medical— The plan is care and treatment and environmental research and monitoring for lny injury, illness, or condition which may be the result directly or indirectly of such .- w (1) “an integrated, comprehensive health care program including primary~ secondary and ter($)arycare with special emphasis upon the biological lffects of ionizing radiation”, (2) an environmental monitoring, research~ and dose assessment program, and (3) an education and information program. -- The plan is to be developed by the Secretary of the Interior in consultation with the Secretaries of Defense, Energy, and Health and Huiuan Services, and “with the direct involvement of representatives people of each of the affected atolls and from the government of the Marshall -- The Secretary of the Interior is to submit the plan by January 1, 1981, together with recommendations, tf any, for further legislation, and his recommendation as to the feasibility of using -- Costs associated with the development and are to be borne by the Secretary of Energy. t the Public Health In our discussions with interested Federal agencies and with representatives of the affected people of the Marshall Islands, several areaa of likely agreement and disagreement aa to what the statute requires have emerged. While unanimity may be lacking, we believe that there is a consensus on the following points:
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— The medical care to be provided is primary, lecondary, and tertiary care, and accordingly not - limited to injuries, from the nuclear weapons testing program. illnesses, or condit~ons resultfng — With respect to the four atolls named in the statqte, the medical care and other program benefits to be provided are not to be limited to the current residents of those atolls, but are instead to be provided to the “people” of those atolls, wherever they may now There is dispute among the interested parties, reside in the Marshall 3“ however, as to the : %slands and atolls covered application of the statute by the statute. No doubt exists as to the m- l to the people of the four atolls explicitly named — ~“~ Bikini, Enewetak, Rongelap, and Utirik. At least one party contends, however, Sz that the statute and the foreseen program of comprehensive medical care must 22 extend to all of the people of the Marshall Islands, -on the ground that all islands and atolls in the Marshall Islands have receive as a result of the nuclear testing progrm, and thatJ~- the people of those islands and atolls ~ to some extent by Department of the Interior belleves that the Congress intended to provide a ~rojzramto benefit more than the people of the four named atolls, but that.- intend that the progr . That is, that the soundest reading of the statute ~ that the (,wherever they may now reside, to apply to the people of the four named atoll plus the people of such other atolls as were ~ affected by the wea ons testing progr~in some manner significantly great~r than were people in other parts oi!the world. The question then arises as to how “such other atolls” are to be identified. A procedure that could be utilized would be a rule-making under
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the Administrative Procedure Act,’by which the Secretary of the Interior would lstablish the criteria to be used in determining which “other ltolls” have been affected by the testing progr=. We would expect would be developed in the first instance by an inter-agency Federal agencies are concerned with the matter of radiationJ procedure, therefore, for the designation of”’’otheratolls” that those criteria group, because many . that would benefit from the program required by Public Law 96-205 would necessarily be a protracted one. There would unquestionably be disputes among those interested as to what the criteria should be, and whether stills are or are not comprehended by 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 the us to discuss Interior’s proposed 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 G&ernment of the Marshall Islands, the lawyer for each - Meetings with the~~ 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
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Folloving the meeting, Interior issued a request organizations and individuals who were believed to be for us on a contract basis the medical plan required by the law. The request for proposals was sent to, among others, all ~ suggested .- to us by Marshallese representatives. A contract was awarded in early October to the School of Health of Loma Linda University, located in Loma Linda, California. Given the statutory deadline for the submission of the Interior plan to the Congress, the time available to our contractor was limited, $he contra:; deadline of early At the request of the Department of the Interior, the Department of Energy prepared 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 information program. The three documents in question became available and were distributed to those interesteddin early December, and a further meeting of the interested agencies and the Marshallese representatives was held on December 10 in Washington to discuss them. An opportunity to supply written comments through December 17 was affordedt “ . 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 School of Healt~ under contract with the Department of the Interior, presents the two alternative plans required by the Interior contract:
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a program of comprehensive a program of comprehensive health care for all of the MarshalIs, snd health care for the people of the four Because the peoples of the four named atolls now re6ide throughout many of the islands and atolls of the Marshalls (it being estimated that they now live on 50% or more of the 26 atolls and 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 & an upgrading of the overall health programA and omprehensive health carer throughout the Marshall Islands. This ~ would provide for medical assistants on each of the inhabited islands and atoll~ supported by a professional medical staff that would provide secondary and some tertiary care at the two Marshall Islands hospitals on Majuro ~arxithereby reduce the substantial volume oft and Ebey>/ ~ secondary and tertiary care 4s currently provided in hospitals in Honolulu. The plan calls for a training program for medical as 4 maintenance. The plan relies primarily on local transportation ~service by the Airline of the Marshall Islands trip ships and chartered vessel service elsewhere, rather than the provision of dedicated surface vessels or aircraft. ~ -Improved radio communications between the medical staff at the
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hospitals and the medical assistants on inhabited i61ands and atolls would be essential, not only for the exchange of necessary medical information and instruction% but also for decisions as to emergmcy medical evacuations. This alternative provides a suggested organization of the health-delivery system of the Marshall Islands, with the United States playing a major role in the direction and management of the program~ preserving local authority and participation. The estimated cost for the first year of this plan would be $10,908,3OO, of which $3 million would be~mrshall The second alternative contained in the Loma Linda proposal G-’-P+-’: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. # the improvement of the secondary and tertiary services at the hospitals on ?lajuroand Ebeye. The hospital-service improvements . would provide the necessary support for the primary care system and would reduce costs associated with medical referrals out of the Marshall Islands.
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The estimated cost for the fi=st year of the proposal for provision of special care for the peoples of the four named ltolls IS approximately $10,603,700, of which $3 ~llion wo~d C- from Marshall Islands Government fundsk This estimated first-year cost is close to the lstimated first-year cost under the first alternative because much of it ~ the costs of improving S“~~~iCES A: the hospitals at Ebeye and *juro$ which would be required ~der Because several representatives of the Marshallese at our December 10 meeting believed it would be useful to have a cost figure for a plan of lesser scope, we asked Loma Linda to provide cost figures for a plan that would provide primary care only to the current residents of Enevetak, Rongelap, Utfrik, and Kili (there being no current residents of”Bikini, with ~ residence d the largest +&m& of secondary and tertiary care to be provided is currently the case. Loma Linda has advised us that 2. The Environmental Monitoring, Research, and Dose Assessment Program, prepared for Interior by the Department of Energy, under
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contract, contemplates for each of the four named ltolls tbe carrying out of comprehensive suneys and lnalytsesof the radiological status of the atolls at appropriate internals, but not less frequently than once every five years; the development of an updated radiation doseassessment; and an estimate OS 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 habits, and Gamma measurements. Additionally, research would uted M be conducted ~ a wide variety of~~ such as radionucllde 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 3. The Education and Information Program, prepared for Interior by the Department of Energy, under contract, contemplates a program to enable the people of Bikini, Enewetak, Rongelap, and Utirik, and
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the people of other atolls or islands found to be or to have been exposed to radiation from the nuclear test% to better understand nuclear radiation and its effects. The basic llament# of the program plan a& direct, face-to-face communication with the people of Bikini, Enewetak, Rongelap, and Utirik and others affected. There would be coxmnunicationwith officials of the Government of the Marshalls as well. ~ mrshallese ~would be ~ first in the Marshalls and later in the United h Pretaped radio programs~ in both Marshallese and English4 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 program as necessary. The program would be a continuing one, to reinforce, review, and update the information. The estimated cost of the Education and Information Program for the first full year would be $950,000. ~-r*’3 As an examination of the three enclosed document6 will quickly disclose, the~ have not yet been integrated. They differ aisto bheir geographical .. . coverage+ and some duplication of costs, as in the case of transportation of a single plan$ base on the three attached proposals~ cannot effectively be accomplished until various issues are resolved, and accordingly, none of the three proposals here transmitted has the endorsement of this
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Department. We believe them to be useful and professional products, lnd they will unquestionably be important in the development of the plan we will withhold endorsement until an integrated plan From the foregoing, it will have become clear that l number of questions require further consideration. The most fundamental is the =tter of the geographic coverage of the program — whether it should extend to4the people~ of the MarshalIs, to tbe people of the four named atolls wherever they reside~ to the people of the “other atolls” that are found to have been affected,e~o the current residents of selected atolls only. Should an effort be made to provide for health care for peoples of named and affected atolls that is separate and apart from 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 car%? To bhat extent should the beneficiaries of the health program, in whatever way they are defined, r;ceive secondary and some tertiary care withtn the Marshall Islands? If the peoples of atollsq other than the four ~~medh~ should be provided the comprehensive care envisioned by Public Law 96-205, through
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what means and ~ what criteria should those other ltolls be identified? M …
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