Letter to W O Green, Subject: Comments on Behalf of Govt of Marshall Islands Concerning Proposed Health Care Plan for Marshallese

Page 1

CO VI NGTON & BURLING Assistant Secretary Designate Territorial and International Affairs Office of the Secretary Department of Interior After reviewing the study prepared for the Department of the Interior by the Loma Linda University School of Health, entitled Marshall Islands-A Health Care Proposal in Education and Information Program Plan (the “Education Plan”) and t!!eEnvironmental Monitoring Research and Dose plan”), prepared for the Department of Energy by the pacific Northwest Division of the Battelle Memorial Institute, and in light of the meetings held at the Department of Interior~ on December 10, 1980, to discuss these Plans~ I offer the following co~ents on behalf of the Government of the Marshall Islands. Due to strike related airline scheduling difficulties, and in order to return home in time for the Christmas holiday, Chairman Jeton Anjain, Foreign Secretary DeBrum, and the other members of the delegation of the Government of the Marshall Islands who attended the December 10 meetings, departed for Majuro immediately thereafter. The delegation may wish to submit additi.onal,comments on the Plans from Majuro. However, in or~er to meet the December 17, 1980 deadline for comments, announced by Mrs. VanCleve at the December 10 meeting, I forward these preliminary comments to you at this time.

Page 2

Health Care Plan Considering the constraints imposed by the scope of its contract and shortness of time available to prepareplan, the Loma Linda University School of Health has submitted an exceptionally fine health care plan which would address critical health care needs in the Marshall Islands and which accurately reflects the mandate of Public Law 96205. As will be discussed below, however, we must take strong exception to certain critical and erroneous conclusions, based on sparse and scientifically biased data, regarding the presence~ or lack of presence, of radiation related health effects in the Marshall Islands. The following comments on this and other issues are presented below roughly in the order in which they arise from the text of On page three of the Introduction~ the rep=t refers to meetings with various officials of the Marshall President is the chief executive of the Constitutional ~ Government of the Marshall Islands and that the Marshall Islands does not have a “king.” We also point out an historical error on page one of the Cultural and Historical Data section in which the report states that the 14arshall Islands were a part of the imperial holdings of Spain and were seized from Spain by Germany. The Marshall Islands, in contrast to many other island groups in the same general area of the Pacific Ocean, was never part of the Spanish empire. In 1873, Spain attempted to establish its jurisdiction in the Marshall Islands by requiring vessels sailing for the Marshall Islands to pay license fees and custom duties. However, Germany and Britain, the two other major trading nations in the area, refused to comply or to recognize Spanish jurisdiction. On November 28, 1878 at Jaluib the Imperial German Government recognized the independence of the Marshall Islands by signing a commerce and navigation treaty with Iroij Laplap Kabua and Iroij Letabalin. The German Government recognized the Marshallese flag and established a consulate in Jaluit. Accordingly, the 14arshall Islands was an independent state in 1885 when Iroij Laplap Kabua and four other I.roij of the Marshall Islands signed an agreement of protec-

Page 3

torate with Lieutenant Captain Roetger, a gunboat commander acting on behalf of the Government of Germany. The report submitted by Loma Linda should be amended to reflect these The Government of the Marshall Islands shares the view of Loma Linda that inter-atoll air transportation is critical to the delivery of the health care services required by P.L. 96-205 and, particularly, in relation to emergency referrals. The Health Care Plan assumes that such services will exist. The Government of the Marshall Islands has created the Airline of the Marshall Islands to provide inter-atoll air services and has undertaken an active program of airstrip construction on the outer islands. Unfortunately, recent decisions of the Government of the United States regarding the establishment of a Marshall Islands civil aviation authority and the certification and inspection of aircraft severely hinder the continuation and expansion of air services and thereby deny crucial emergency services to the outer atolls. While refusing to permit a Marshall Islands air authority to be established for aircraft inspection and certification the United States also refuses to certify and inspect Marshallese aircraft itself. The Government of the Marshall Islands places top priority on the resolution of these issues and, in this connection~ reiterates its repeated previous requests that the Department of the Interior make every effort to obtain from this Administration an executive order explicitly extending to the Marshall Islands in the preterrnination period, pending the establishment of a Marshallese civil aviation authority, Titles V, VI, and VII of the Federal Aviation Act of 1958, The Government of the Marshall Islands takes the most strenuous exception to the statement in paragraph three of the Executive Summary of the Loqa Lirida report that “[t]here are minimal radiation related health effects evident in the Marshals.” Similar statements also appear elsewhere in the report. As”the representative of Loma Linda admitted in the meeting of December 10, 1980, the mandate of the Interior Department contract with Loma Linda did not ask the contractor to determine the extent of radiation related health effects and, therefore, Loma Linda made no independent medical effort to detect potentially radiation related health effects. The statement in the report apparently was based entirely on a cursory review of

Page 4

incomplete medical records~ brief interviews with a limited number of Marshallese citizens and a quick reading, without independent analysis? of reports prepared by the Brookhaven National Laboratory. We do not fault Loma Linda for not undertaking the extensive medical, epidemiological and other scientific testing necessary to analyze the health effects of radiation exposure on the Marshallese people. However, absent such independent testir.g and analysis~ we cannot accept a conclusion by Loma Linda disclaiming the existence of radiation related health effects. At the present time, the data necessary to determine the extent of radiation related health effects throughout the Marshall Islands simply is not available. The Government of the Marshall Islands has repeatedly requested since May of 1979 that medical analysis, including blood chemistries, be conducted to detect potentially radiation related diseases throughout the Marshall Islands? and particularly in the northern atolls, other than Bikini, Enewetak~ Rongelap and Utirik. Unlike Bikini, Enewetak, Rongelap and Utirik, these other atolls virtually have been ignored by “ previous United States investigations. Although we have engaged in extensive discussions with the Department of Energy and the Department of Interior regarding the initiation of such a program, and were told that the United States was prepared to begin medical and other blood chemistry analysis in these previously ignored northern atolls, no such testing has been conducted. Similarly, the United States repeatedly has promised to provide to the Government of the Marshall Islands access to the data accumulated by the United States in the conduct of its Northern Marshall Islands Radiation Survey. However, each time the Government of the Marshall Islands seeks to enforce that promise, as they did at the interagency meetings at the Interior Department in May of 1979, in August of 1980 and again on December 108 1980, the United States has responded that the data was not yet available, but would be forthcoming within the next few months. The Government of the Mars~all Islands must have access to this data, in raw form, in order to conduct the independent analysis which is critical to the effective and statutorily mandated participation of the Government of the Marshall Islands in the implementation of P.L. 96-205 and in me conclusion of the political status negotiations.

Page 5

Although firm, credible, scientific data is not now available to definitively determine the existence of radiation related health effects in the Marshall Islands~ the limited information which has been gathered is profoundly disturbing. In May of 1979, the Government of the Marshall Islands presented to the United States the data gathered from an informal questionnaire answered by many of the people of Likiep Atoll. The people reported repeated incidence of birth defects, thyroid abnormalities and other health problems of a nature frequently found to be radiation related. The United States promised in June of 1979 to send doctors to provide medical care to these people, but the doctors still have not arrived. Similar reports of such health problems repeatedly are heard throughout the Marshall Islands. Moreover, the health statistics included in the Loma Linda report itself, particularly the death statistics in Table 4 on page 10 of the Health Status Section of the report, evidence a great number of deaths from causes frequently linked to radiation exposure. The Loma Linda report, however, passes over this data without comment. - The Loma Linda report apparently accepts at face value conclusions reached by Brookhaven National Laboratories regarding the “normal incidence” of certain diseases in the Marshall Islands. These conclusions rely on comparisons made between some of the people of Rongelap and a supposed “control population” of other Rongelap people and Marshallese people of other atolls. As the Government of the Marshall ‘ Islands previously has pointed out, the concept of a control population is wholly inappropriate within the Marshall Islands, where all atolls received exposure to radiation from the weapons testing program and where people and food stuffs from the more heavily exposed areas have travelled throughout the Marshall Islands. The Loma Linda report states this problem quite well on page 12 of the Health Status section, but fails to addres~ the” linkage between the lack of a viable control population and the invalidity of conclusions, predicated on the false concept of a control group, reached in much of the existing learning. In view of the radiation exposure received by the entire Marshall Islands, in varying levels, as a result of the nuclear weapons testing program, and the known and suspected, long and short term health effects of both high

Page 6

and low levels of radiation exposure, the Government of the Marshall Islands views as critical to the implementation of P.L. 96-205 the conduct of medical screening, including blood analysis and other testing~ of people of all of the atolls of the Marshall Islands. Such testing, and the even more critical follow up medical care, are long overdue and go to the heart of the health care program mandated by P.L. Despite the unjustifiable conclusions stated in the Loma Linda report regarding the existence of radiation related health problems in the Marshall Islands, many of the -~ other observations made and conclusions reached in the report, particularly in the section entitled Four Atoll Proposal, are extremely sound and echo views previously expressed by the Government of the Marshall Islands. We particularly wish to express our concurrence with the conclusion of Loma Linda that the only cost effective? economically sensible way to implement the health care plan required by P.L. 96-205, given the great number of fixed costs, is to have the health care services which are pro- ““ vialed utilized by the entire population in the area serviced, namely the entire population of the Marshall Islands. In addition to the economic wastefulness of limiting the available services to some, but not all residents~eiwe strongly affirm the conclusion of the Loma Linda School of Health that denial of available medical services to part of the Marshallese population would be ethically impermissible under the guidelines of the medical profession and general ethical principles. It remains the position of the Government of the Marshall Islands that every atoll in the Marshall Islands was exposed to radiation from the nuclear weapons testing program within the meaning of P.L. 96-205 and that health care made available under that law must be provided without discrimination to the people of all of the atolls of the Marshall Islands. . The Loma Linda report sta;es on page 2 of the Four Atoll Proposal section that “[i]t is medically impossible to distinguish in any particular individual whether a disease complex or symptom is radiation related or not.” Similarly, on page 12 of the Health Status section the report states that “[it) is inherently difficult and impractical to dis-

Page 7

tinguish with any precision in any individual case whether a particular illness is radiation related or not.” Throughout the report and in the oral presentations on December 10, 1980, Loma Linda implies that attempts to make such distinctions would not only lead to medically inconclusive results but also would require extremely costly testing procedures. The report also recognizes that attempts to classify the health problems of certain individuals as not being radiation effects will undoubtedly provoke continuing protracted and costly legal disputes. In view of these statements and imputations in the report, it is crucial that the Department of Interior obtain an estimate of the likely costs involved in conducting the necessary tests even to attempt to determine, with any degree of certainty, that particular health effects evidenced in an individual are not radiation related. It is our belief that these costs, considered together with the costs of providing health care to all of the people of Bikini, Enewetak, Rongelap and Utirik, will far exceed the cost of providing health care services to the entire population of the Marshall Islands as we believe is mandated by P. L. 96-205. Pending further input from the Marshall Islands Government delegation to the December 10, 1980 meetings, I offer two general comments with regard to the Education Plan. On page 5 of the Plan, the Pacific Northwest Division lists several government officials with whom they spoke .. prior to drafting the plan. This listing gives the impression that the contractor held formal consultations with the Government of the Marshall Islands. As Foreign Secretary DeBrum pointed out at the December 10 meeting however, no such consultations were held. In fact, the Pacific Northwest Division insisted on coming to the Marshall Islands at a time when they specifically had been notified by the Government . of the Marshall Islands that the appropriate government officials would not be in Majuro but would be in Hawaii for political status discussions with the United States. Although the contractors undoubtedly obtained useful input from those persons with whom they spoke, they timed their visit so as not to afford themselves the opportunity to consult with the Jnost informed and directly involved government officials. The Government of the Marshall Islands looks forward to participating in the implementation of an education plan but insists that full consultations, with appropriate officials

Page 8

designated by the government for that purpose be, carried out on an ongoing basis. The program presented in the Education Plan is characterized as directed only to the people of Bikini, Enewetak, Rongelap and Utirik. As discussed in relation to the Health Care Plan, P.L. 96-205 mandates that the programs provided under the law be provided to people of all atolls exposed to radiation from the nuclear weapons testing program. This requires that the Education Program be directed to …