Discussion Paper Health Plan for the Marshall Islands Meeting of August 4, 1980

Page 1

Office of the Ass$stant Secretary Territorial & International Affairs Health Plan for the Marshall Islands Meeting of August 4, 1980 “-The purpose of the meeting is to discuss the content of the health @an, ‘requiredby law to be developed by the Secretary of the Interior and ~. submitted to the Congress no later than January 1, 1981. .. 1. The statute. The pertinent statute is Public hw 96-205, approved March 12, 1980, which provides in section 102: “(a) In addition to any other payments or benefits provided by law to compensate inhabitants of the atolls of Bikini, Enewetak, Rongelap, and Utirik, in the Marshall Islands for radiation exposure or other losses sustained by them as a result of the United States nuclear weapons testing program at or near the atolls during the period 1946 to 1958, the Secretary of the Interior (herein after in this section referred to as the ‘Secretary’) shall provide for the people of the atolls of Bikini, Enewetak, Rcmgelap, and Utirik and for 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, 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 program shall be . impkmanted according to aplandevelopedby the Secretary in consultation with the Secretaries of Defense, Energy, and Health, Education, and Welfare and with the direct involvement of representatives from the people of each of the affected atolls and from the government of the 14arshallIslands. The plan shall set forth, as appropriate to the situation, condition, and needs of the individual atoll peoples: “(1) an integrated, comprehensive health care program including primary, secondary, and tertiary care with special emphasis upon the. biological effects of ionizing radiation; “(2) a schedule for the periodic comprehensi~e r- survey and analysis of the radiological status ~ of the atolls to and at appropriate internals, but not less frequently than once every five years, the development of an updated radiation dose assessment, together with an estimate of the risks associated with the predicted human excnxure, for each such atoll; and

Page 2

enable the people and information program to of such atolls to mxe fully— — understand nuclear radiation and its effects; “ (b)(1) The Secretary shall submit the plan to the Congress no later than January 1, 1981, together with his recommendations, if any, for further legislation. The plan shall set forth the specific agencies responsible for implementing the various elements of the plan. With respect to general health care the Secretary shall consider, and shall include in his recommendations, the feasibility of using the Public Health Sen7ice. After consultation with the Chairman of the National Academy of Sciences, the Secretary of -ergyt the Secretaxy of Defense, and the Secretary of Health, Education, and Welfare, the Secretary shall establish a scientific advisory committee to review and evaluate t??e implementation of the plan and to make such recommendations for its improvement as such committee deems advisable. “(2) At the request of the Secretary, any Federal agency shall provide such information, personnel, facilities~ logistical support, or other assistance as the Secretary deems necessary to carry out the functions of this program; the costs of all such assistance shall be reimbursed to the provider thereof out of the sums appropriated pursuant to this section. “(3) All costs associated with the development and $mplemantation of the plan shall be assumed by the Secretary of Energy and effective October 1, 1980, there are authorized to be appropriated to the Secretary of Energy such sums as -y be necessary to achieve the purpose of this section. “(c) The Secretary shall report to the appropriate - ‘ committees of the Congress, and to the people of the ,1 affected atolls annually, or more frequently if necessary /’” - 1 on the *lamentation of the plan. Each such report shall include a description of the health status of the individuals examined and treated under the plan, an evaluation by the scientific advisory cdttee, and any recommendations for improvement of the plan. The first such report shall be submitted not later than 2. What the statute requires. Section 102, quoted above, is not free of ambiguity. It has been argued by some that the plan required of the SecretAry of the Interior, and the program resulting from it, should be restricted solely to the four named atolls, and then only to injuries, illnesses,~or conditions resulting from the nuclear testing program. It has been a$gued by others that the plan, and the resulting program, should apply to all atolls and islands of the 14arshallIslands, and should provide ccnnprehensivemedical care to all people of the Marshall

Page 3

respect to the scope of not reached any definitive position with .... plan required, or of the program to arise . . from it. “It would welcome the early expressions of views from any -. source as to the requir=ents of the s-tute. Preliminarily, the Interior ~- “ - Department suggests that the most reasonable reading of the statute appears to be that the Secretary’s plan should provide for comprehensive health care for the inhabitants of the four listed atolls — Bikini, Enewetak~ ?xqelapl and Utirik; and that the inhabitants of additional atolls -should also be afforded comprehensive health care if they have been affected by radiation from the nuclear weapons testing program. In deciding ‘whetherthe inhabitants of additional atolls have been so affected, ““’the Secretary would consider information obtained from on-site health evaluations of the people of those atolls, and other relevant evidence

Page 4

Brookhaven now has 26 years of medical research findings and experience -. in the field with the people of Rongelap and Utirik. It is regarded, therefore, as essential that any health care organization that develops a plan for future health care of the people of the ‘affected atolls” ._work closely with the Medical Depar~ent of the Brookhaven National Labortory on past and current medical activities, as well as reconmtendations “For the future. It is estimated that costs to the Medical Department of 4. Brookhaven National Laboratory to participate in this phase of the .-planningwork will be in the range of $40,000 to $50,000. The basic contract must include reimbursement funds for the Brookhaven National Laboratory for participation in the overall health plan contract. The Brookhaven medical program for the people of I&xgelap and Utirik basically has been a medical research program, but this mandate has, of necessity, over the years been expanded to include care of non-radiation related diseases. This has been occasioned by the lack in the past of adequate primary medical care in the llarshallIslands. In 1954, 04 Rongelapese were exposed to fallout. Of these 04 originally exposed individuals, 50 are still living. There are also some 500 to 600 unexposed Rongelapese, made up of descendants of the exposed group plus the Marshallese who have Rongelapese blood or marriage a filiation. itAbout 500 of the unexposed Rcmgelapese have been on occasio~~ a “comparison” group to the exposed population. The original Utirik exposed group consisted of 158 individuals, of which 120 still are alive. Another 500 unexposed Utirikese, of the exposed group and Narshallese with Utiri.kblood affiliation, also fall into the Utirik category. Some larger group have been studied as a “comparison” group Bikini Atoll was the site of 23 U.S. a-spheric tests made up of descendants to the exposed ,/ resident there in 1946 were removed from ~e atoll in March 1946 prior to the start of the testing program. After several years of very unsatisfactory resettlement efforts in other parts of the Northern Marshalls, the Bikinians were resettled in March 1948 on the isolated island of tili in the southern Marshalls. Thus, from March 1948 onward the main body of the people Qf Bikini have lived well outside the zone of the nUCkSE

Page 5

NO radiological monitoring or medical examinations were conducted on any Bikinians ‘untilthe early 1970’s, after a small group returned to Bikini Island. Xhe group, at first consisting of workers, then expanded to ‘ family groups, periodically was radiologicallymonitored. In April 1978, some 99 of the 145 residents on Bikini island had whole body count -. examinations as well as medical examinations. These 145 residents were evacuated from Bikini Island in late August 1978. Some of this group have been given follow-up monitoring examinations since the August 1978 “-Today there are wer 900 Bikinians. Some 500 or so reside on Kili .. Island, another 140 live on Ejit Island near Majuro, some 100 or so live ,. in Majuro, and another 100 or so live on Ebeye. Small numbers are scattered in other parts of the Marshalls. In 1969, after certain parts of Bikini Atoll were considered safe for resettlement, small numbers of Bininians began to return to Bikini Islsnd. The first returnees, as noted above, were workers in the cleanup and rehabilitation program started in 1970. Gradually, family members joined the workers and by the mid-1970’s some 60 or so Bikinians were in residence on Bikini Island. By 1978, the group had grown to 145 individuals. It was this group that was evacuated from Bikini Island in late August 1978 when the Interior Department concluded that “body burden levels” exceeded acceptable standards. Cesium 137 ingestion from locally grown foods primarily appeared to be the cause for the rising body burden levels. As a result, it now has been determined that Bikini Island must be off limits for another”60 years. Additionally, some 50-60 Marshallese of non-Bikinian descent lived and worked on Bikini Island for varying periods between 1970-76. These individuals also require special screening. There has also been close association, including inter-marriage,between ,/ ‘ +-hepeople of Rongelap and people of Bikini. At least one exposed Rongelapese and his family were resident on Bikini Island in 1978 when /’ the last evacuation occuxred. The latest resettlement proposal of the people of Bikini involves living on the island of Eneu in the Bikini Atoll, probably on a rotation basis~ and the maintenance of a community on tili Island. Should this pro~=l be feasible, health care must be planned for (1) the Kili Island cOmmunitY, (2) a posstile conmunity on Bikini community in Majuro, residing at Ebeye and other Eneu island, Bikini Atoll, (3) a small and (4) several hundred other Bikinians parts of the Msxshalls. In 1947, ti~ 142 residents of Enewetak Atoll also were evacuated from their home atoll. They were settled on Ujelang Atoll, which lies 124 i miles southeast of Enewetak, in the Northern kiarshalls. From 1948 to 1958, there were 43 test detonations performed at Bnewetak Atoll,

Page 6

Ujelang Atbll is within the region of low level fallout. At least once ~- - during the nuclear testing period, it is reported that the U.S. Navy temporarily evacuated the people of Ujelang by taking the entire coxmmity - to sea during a test operation. -. Today approximately 500 ~c)ple make up the Ujelang-Enewetak community, with another 40 or so Ujelangese living on Ebeye or Majuro. With the start of the cleanup and rehabilitationprogram of Enewetak Atoll in 1976, a small revolving conmnuaity of some 60 Ujelangese was .:”permitted to live on Japtan Island in the southern part of Enewetak Atoll. Most of the members of the Ujelang community have thus lived for at least a’six month period on Japtan Island during the timespan of 1976-1980. In April 1980, the Japtan conmunity was expanded to 140 individuals. As of July 1, 1980, 265 Enewetakese had returned to the three new communities. Most of the remaining ~pulation on Ujelang is expected to return to Enewetak and Medren within the coming year. Ujelang Atoll, however, will continue to be used as a source of fresh food supply and will be in continual use for the next 8-10 years by the Enewetak people, either by having an outpost commun ity there or a revolving Healfi care for the~ople of Enewetak, accordingly, mustbe provided at Ujelang if a co~-ity remains there as well as Enewetak. The Department of Enezgy in the spring of 1980 carried out a “whole body” count on the entire Ujelang group prior to the planned return to the southern parts of Enewetak Atoll. No basic medical suney of the Enewetak group has as yet been carried out. (d) Other Atolls of the Northern Marshalls The Government of the Marshall Islands has expressed considerable concern that other atolls in the Northern Marshalls known to be in the areas of /{: low level radiation fallout, should in reality be listed in the category In early 1979, the Government of the Marshall Islands conducted a Su=ey on the people of Likiep Atoll, and it contends that its survey demonstrates that there is more than a normal incidence of thyroid disorders, throat problems, and other medical abnormalities among the people of that The Government of the Marshalls has requested that the health of the people of~kiep and associated atolls be studied. The Depar=ent Of . Energy has agreed to provide a biochemical screening profile-of the people of ~ep Atoll, and of the people of one other atoll in the Marshalls ~ be selected as a comparison population. Medical Staff would be ificludedin the sunrey team. Negotiations between the Department of the Interior, the Department of Energy, and the Government of the Marshall Islands currently (s~er 1980) are underway to accmnplish the carrying out of the screening profile of the poeple of LiJciepAtoll.

Page 7

AXUNSZ1costs for the medical monitoring, follow up care, and environmenttal - monitoring program of the Deparbnent of Bnergy for the people of Rongelap ~ and Utirik currently are in the range of $3-4 dllion. In contiast, in FY 80, the entire health budget of the Marshall Islands Government was $2.7 million. This amount had to provide curative and preventive medical care and programs for a population of over 30,000 people, many scattered ‘_on outer islands. This amount supperted the major hospital at Majuro, which serves as the only major in-patient facility in the Marshalls. .. The current hospital facility in Majuro has 90 beds and is in very poor r.condition, but funds for a new hospital have been appropriated. In addition to the Majuro hospital and an Ebeye sub-hospital, the Marshalls Health Department suppQrts some 56 out-island dispensaries. Some of Administrative and professional staffing of the health services of the Marshalls has not met minimum acceptable health standards in the past. In an attempt to improve health care, the Marshall Islands Government recently concluded an agreement with a “medical care adjunct” of the Seventh-Day Adventist Mission in Guam to take wer the control and management of health services from the Ministry of Health S-ices. This new health care service agency should be brought into any planning exercise by the contractor at an early stage. (f) Special Problems Related to Diversity of Residence ~nitoring and special health care for the people of Rongelap, Utirik, Bikini, and Enewetak must be provided not only in their home atolls but in other parts …