Testimony
Statement by
Nathan Stinson, Jr., Ph.D., M.D., M.P.H.
Deputy Assistant Secretary for Minority Health
Office of Public Health and Science
U.S. Department of Health and Human Services
on
HHS Health Care Activities in the Pacific Island Territories
before the
The Subcommittee on Human Rights and Wellness, Committee on Government
Reform, United States House of Representatives |
I. INTRODUCTION
Good afternoon. I am Dr. Nathan Stinson, Deputy Assistant Secretary for
Minority Health and Director of the Office of Minority Health (OMH) in
the Department of Health and Human Services (HHS). I want to thank the
Committee for the opportunity to testify today on the Department’s
activities in the United States Pacific Island territories (USPIT), primarily
Guam, Commonwealth of the Northern Mariana Islands (CNMI) and American
Samoa. In addition, I will provide information on health disparities and
the unique challenges associated with delivery of health care and improving
the health of the people in this region. The Department sees this hearing
as an important opportunity to identify collaborative strategies and actions
that can have a positive impact on disease control and prevention in the
Pacific Basin.
One cannot stress strongly enough the region’s remoteness from
the continental United States and the wide time zone differences across
the region. This reality is coupled with the characteristics of the population
including its youthfulness. A map of the USPIT appears in Appendix 1.
Background on the region’s demographics and geography is included
in Appendix 2.
As I brief you on the Department’s activities to address health
disparities in the Pacific Basin, it is important to bear in mind that
they are being carried out in the context of Secretary Thompson’s
national commitment to “close the health gap.”
II. BACKGROUND of DISPARITIES and COMMON CHALLENGES in the PACIFIC BASIN
Over the years, racial and ethnic minorities, including Asians and Native
Hawaiians and Pacific Islanders, often have been characterized as “hard
to reach,” largely due to the socioeconomic, geographic, cultural,
and linguistic barriers that can inhibit the communication, receipt of
information and services, and understanding of critical health messages.
The 2003 issue of Health, United States, the annual report card
on the health status of the American people, documented significant progress
in the overall health picture of the Nation, but reinforced the fact of
the continuing health-related burdens experienced by the racial and ethnic
minority populations compared to the U.S. population as a whole. Unfortunately,
those communities experiencing disparities suffer worse health status
and higher rates of death and disease. This is unacceptable. The real
challenge for HHS and the Pacific Basin jurisdictions is not debating
whether disparities exist, but in developing and implementing programs
to improve the outreach efforts and knowledge, accessibility of appropriate
health services, and quality of care.
Cancer and cardiovascular disease (CVD) are typically among the top three
leading causes of death in the jurisdictions, but this is not uniform
across entities.
- Guam (1995 - 2001): CVD; cancer; accident/trauma
- Northern Marianas (1997 - 2001): CVD; cancer; other
- American Samoa (1998 - 2000): heart disease; neoplasms; diabetes
- United States (2000): heart disease; malignant neoplasms; cerebrovascular
diseases
The estimated infant mortality rates for 2003 (CIA World Fact Book):
- Guam 6.46 deaths per 1000 live births
- Commonwealth of Northern Mariana Islands 5.52 deaths per 1000 live
births
- American Samoa 9.82 deaths per 1000 live births
- United States 6.75 deaths per 1000 live birth
The total reported AIDS cases in 2002 include:
- Guam 76
- Commonwealth of the Northern Mariana Islands 3
- American Samoa (2001) 1
- United States 42,745
According to the national Behavioral Risk Factor Surveillance Survey
(BRFSS), in 2001 the obesity rate in Guam and the United States was 59
percent and 56 percent, respectively. Because the island of Guam is and
continues to be the only entity of all the U.S. affiliated jurisdictions
included in this survey, data from the other jurisdictions are not available
for comparison.
Before describing some of HHS’s programs to improve health services
and health status in the USPIT, which attempt to respond to the specific
challenges in a given jurisdiction, it is important to note common challenges
across all jurisdictions, including inadequate health care delivery, the
poor infrastructure, limited resources, and isolated location. While these
challenges exist in the continental U.S., they are of much greater magnitude
in the Pacific Basin. The following observations and anecdotes are from
health care experts in Hawaii, the USPIT, and HHS’s Health Resources
and Services Administration’s (HRSA) Community Health Centers based
in the Pacific. These startling stories demonstrate the significant challenges
confronting the health care systems and residents:
- Depleted medical supplies and an extended back order is common, which
can be attributed to pharmacies not being paid so no orders are delivered,
one person doing multiple tasks, distance between the islands, migration
of persons from one island to another island to obtain services, and
other factors. For example, a physician in American Samoa could not
provide insulin to a pregnant diabetic woman because there was no insulin
in supply.
- Lack of specialists and tertiary care limits treatment options and
quality of care thereby impacting the quality of life. Factors include
the low salary, the remoteness of the jurisdictions, the living conditions,
and the lack of housing. Health professionals are so profoundly difficult
to come by, that organizations in the Pacific Basin must draw from a
variety of health education systems in Fiji, Southeast Asia, as well
as the United States. As a result, cultural and linguistic differences
between patients and providers are not uncommon. In some cases non-physician
Medical Officers, rather than fully licensed physicians, are used. The
Pacific Islands often recruit National Health Service Corps providers
(another HRSA funded program). Qualified nurses are often quickly recruited
to jobs in Hawaii or other states which pay higher salaries than the
jurisdictions can afford.
Women with breast cancer who are treated on Guam are more likely to
undergo mastectomy as opposed to breast conserving therapy (lumpectomy
and radiation). Therefore the "treatment options" are not "real
options” to the women in this jurisdiction. American Samoa, for
example, provides dialysis but has no resident nephrologist. Other island
jurisdictions have limitations regarding basic services—mammography,
for instance, is frequently not available on the island of Saipan because
often a properly trained technician is not available for months at a time.
The lack of tertiary hospitals generates enormous costs involved with
sending patients off the island for specialty care. For example, because
radiation therapy, chemotherapy, and oncologist services are by and large
unavailable, cancer patients frequently need to travel to another jurisdiction
or Hawaii. The costs associated with such referrals consume a large part
of the health budget and benefit only a few patients. Because of unpaid
bills for services provided in Hawaii and California, physicians cannot
refer many patients off island to these locations for necessary tertiary
care.
In particular, the health care systems of the Federated States of Micronesia
and the Republic of the Marshall Islands are inadequate to meet the needs
of the population, giving rise to inter-jurisdiction travel in order to
receive appropriate health care. An extensive GAO Report (GAO-02-40, October
2001), Migration from Micronesian Nations Has Had Significant Impact
on Guam, Hawaii, and the Commonwealth of the Northern Mariana Islands,
found that in 2000, 43 percent ($4 million) of all identified Commonwealth
of the Northern Mariana Islands impact costs were related to health care.
A Commonwealth of the Northern Mariana Islands’ Department of Public
Health Services official noted that neonatal intensive care was a key
issue for the Freely Associated States (FAS) migrants—which are
the Federated States of Micronesia (FSM), Republic of the Marshall Islands
(RMI), and Palau—and that expectant mothers often have no insurance
and no prenatal care until they arrive at CNMI Community Health Care.
As a result of the Compact of Free Association between the United States
and FAS, these residents are allowed to freely enter the United States,
including its insular areas. The House Joint Resolution 63, the Compact
of Free Association Amendments Act of 2003, was signed into law December,
2003. The legislation includes “compact impact” funding earmarked
for Guam, Hawaii, American Samoa, and the Northern Marianas, all of which
have been burdened by costs associated with migration. Poor education
and health care facilities in the Marshall Islands and the four FSM states
made migration to locations such as Hawaii and Guam more attractive. Furthermore,
not only could FSM and RMI citizens work and study on U.S. soil, they
could also use healthcare facilities, as well as apply for public assistance
and put their children into CNMI, Guam, and Hawaii schools.
In its 2000 assessment, Guam identified unpaid services by Guam Memorial
Hospital to FAS patients, totaling over $5.4 million, as its largest single
area of health impact. Officials reported patients’ reliance on
the hospital’s emergency room for primary health care and not urgent
conditions. Although FAS represented approximately 5.0 percent of Guam’s
population, they accounted for approximately 12.0 percent of the emergency
room patients per month. Similar to CNMI, expectant FAS mothers arrive
at the hospital close to delivery with no prior prenatal care. The Governor,
at the time of the GAO report, stated that the U.S. naval hospital on
Guam was underutilized and could provide care for FAS migrants.
- Long distances must be covered to provide care to individuals in
remote areas.
- Lack of potable water, fluoridation of the water supply, and sanitation
services.
- Lack of non-profit entities. All health center grants in the Pacific
are awarded to the jurisdiction's government which administers the grant
and employs the health center staff. Most jurisdictions are heavily
reliant on Japanese tourism as its major source of revenue. The weakened
Asian economy and reduced tourism in the Pacific jurisdictions have
resulted in the plummeting of the government's general fund revenues.
As a result, some governments, such as Guam, have implemented hiring
freezes, reduced hours, or reduced salary, which affects health center
staff. Because most jurisdictions are not set up to accommodate non-profit
entities, the government is the only provider of care or services.
- Data may undercount mortality and morbidity. For example, American
Samoa reported 9.82 deaths per 1000 live births in 2003. However, many
pregnant women from Western Samoa go to American Samoa for the delivery
and then return home. The births would be counted in American Samoa
data but subsequent deaths would not appear in the infant mortality
statistics.
- In Guam, physicians must participate in a “house call”
rotation as condition of having hospital privileges. This burden is
becoming increasingly problematic with repeated threats from the physician
community to refuse to take “house calls.” For example,
in the Department of Obstetrics and Gynecology, approximately 40 percent
of the deliveries are for “house patients.” The physicians,
who are primarily in private practice and dependent on the generated
revenue, are concerned about the level of uncompensated care they provide.
- The physical terrain of the Pacific Basin itself poses a threat to
residents in receiving care. A physician recently reported in American
Samoa that there was one road, parallel with the shore that leads to
the hospital. Storms and typhoons cause mud slides that would block
transport of health care providers and patients to the facility.
III. HHS-FUNDED PROGRAMS in the U.S. TERRITORIES OF THE PACIFIC BASIN
HHS’s funded programs do contribute to breaking down some access
barriers and connecting people to the services they need; informing and
educating people to take charge of their health status; and uncovering
new knowledge to help prevent, detect, diagnose, and treat disease by
improving the quality of health care delivery.
Examples of HHS-funded programs include the following:
A. ACCESS
1. CMS Funding and Grant Programs - The Social
Security Act specifies the relationship of the Centers for Medicare
& Medicaid Services (CMS) with the territories. CMS works closely
with the territorial governments to help them in their efforts to
provide high quality health care. Medicaid and the State Children's
Health Insurance Program (SCHIP) provide significant health care funding
for pregnant women, families with children, people with disabilities,
and individuals over age 65 in the U.S. territories of American Samoa,
Guam, and CNMI. Unlike the funding received by U.S. states, the Medicaid
and SCHIP funding for these territories is capped. Federal funding
for services to individuals covered by Medicaid and SCHIP in Federal
fiscal year 2003 totaled:
|
Medicaid |
SCHIP |
Samoa |
$ 3,727,000 |
$ 396,900 |
CNMI |
$ 2,255,000 |
$ 363,825 |
Guam |
$ 6,321,000 |
$1,157,625 |
Total |
$12,303,000 |
$1,918,350 |
The total amount of Federal Medicaid and SCHIP funding for each
of the U.S. Territories is set by law. The Medicaid and SCHIP programs
require that Federal funds be matched with State and Territorial funds,
and the law sets a specific Federal Medicaid matching rate for the
territories. Each of the three Pacific territories provides significant
additional territorial funds, beyond Federal matching requirements,
to fund additional services.
In addition, CMS awarded competitive grant funds in the Pacific
territories to help build the infrastructure needed to assist aged
and disabled individuals who live in the community. Guam received
both a Community Integrated Personal Assistance grant for $300,000
and a Real Choice Systems Change grant of $673,106 in 2001 to improve
community long-term care support. CNMI received a Real Choice Systems
Change grant for $1.385 million in 2002 to build a support system
for people with developmental disabilities.
American Samoa, CNMI, and Guam operate their Medicaid programs with
broad flexibility to accommodate their smaller, public health dependent
systems. Medicaid State Plans of all three Pacific Territories specify
that they cover the following services: inpatient hospital services,
outpatient hospital services, laboratory and x-ray services, nursing
facility services, physician services, home health care, medical and
other types of remedial care, optometrist services, other practitioner's
services, clinic services, dental services, physical therapy, prescribed
drugs, dentures, prosthetics, eyeglasses, and health-related transportation.
Additional Medicaid services are provided by some of these territories,
such as private duty nursing, occupational therapy, and speech, language,
and hearing services.
Medicare also provides significant resources for health services,
to elderly and disabled beneficiaries, although data for FY 2003 are
not yet available.
Each year for the past several years, CMS has held a territorial
summit with the Directors of the Medicaid programs in the territories.
CMS staff in the San Francisco Regional Office, including a Pacific
representative at our Hawaii Field Office, have developed expertise
and provide ongoing technical assistance to address the unique needs
of the Pacific territories, most frequently on Medicaid and SCHIP
eligibility, services, and billing issues. More recently, CMS established
one National Account Representative in the Regional Office and one
in Central Office for each territory and state, to devote additional
attention to the needs of their jurisdictions. These initiatives focused
CMS efforts on issues of interest and concern to the territories.
Discussions have centered on the impact of Federal requirements on
the territories and the ways health care services can be prioritized
when resources are limited, including the provision of Early Periodic,
Screening, Diagnosis and Treatment (EPSDT), off island referrals,
and Federally Qualified Health Center (FQHC) services. CMS staff assist
the territories in obtaining additional Federal funds within the statutory
limits of the programs. For example, technical assistance and additional
funding were provided to the territories for Y2K preparedness.
The Medicare Modernization Act (MMA) contains special provisions
for the U.S. territories. The three Pacific territories plus the Caribbean
territories of Puerto Rico and the U.S. Virgin Islands are eligible
to share a special pool of funding in proportion to each territory’s
share of the total number of Medicare beneficiaries living in all
five territories. These funds will be used by each territory for Transitional
Assistance to help low-income Medicare beneficiaries pay for prescription
drugs purchased through the temporary drug discount card program.
Each territory has broad flexibility to design a Transitional Assistance
program that best suits its unique circumstances. To receive a portion
of the funds, the territory must submit a plan to CMS by March 12,
2004. CMS held conference calls with the territories to provide information
on these provisions and developed a template for the territories to
assist them in the design and submission of their proposals. Two of
the territories (Guam and CNMI) have already submitted their draft
plans for CMS review. The MMA contains similar special pools with
flexible funding for the territories to share to provide assistance
to low-income Medicare beneficiaries under the permanent Part D Medicare
drug benefit that begins in 2006. The law gives the Secretary authority
to waive Part D requirements to the extent that may be necessary to
assure access to Part D drug coverage for Medicare beneficiaries living
in the territories.
2. Community Health Centers-- HRSA’s Bureau
of Primary Health Care (BPHC) funds the Community Health Centers (CHC)
in the Pacific. CHCs provide family-oriented primary and preventive
health care services for people living in rural and urban medically
underserved communities. CHCs exist in areas where economic, geographic,
or cultural barriers limit access to primary health care for a substantial
portion of the population, and they tailor services to the needs of
the community. Guam and American Samoa received $403,470 and $416,663,
respectively, in fiscal 2003.
The Pacific Basin health centers have clinical issues that are very
different from those in the continental U.S. Prevalent health conditions
of Pacific Islanders include those typical for developing countries
(e.g., tuberculosis, dengue fever, cholera) as well as health conditions
that plague developed countries (e.g., diabetes, heart disease, cancer).
Despite these challenges, the health center program is a key part
of access to health care in the Pacific. In many jurisdictions, the
CHCs are the only providers of care for uninsured patients or the
CHC is the sole provider of health care.
4. Children’s Services Program: Funded by the Center
for Mental Health Services (Substance Abuse and Mental Health Services
Administration - SAMHSA), Guam received $1 million in fiscal 2002
for a six year project. Guam plans to develop and implement a child-centered,
family-focused system of care that delivers effective, comprehensive,
community-based, culturally competent mental health and related services
for children and adolescents with serious emotional disturbance and
their families and to ensure longitudinal studies of service systems
outcomes. The system will honor the community’s commitment to
live true to the island heritage of “taking care of our own”
and filling gaps by providing supports on the Island, rather than
sending children thousands of miles away to off-island placements
or not serving them at all.
5. Maternal and Child Health Services Block Grant (Title
V): Administered by HRSA’s Maternal and Child Health
Bureau, the largest portion of Title V goes to the States and territories
through a formula-based block grant process. The Federal/State partnership
develops service systems to meet challenges in reducing infant mortality,
providing and ensuring access to comprehensive care for women, and
promoting the health of children through primary care services. All
three of the U.S. Pacific jurisdictions received fiscal 2004 allocations,
ranging between $506,369 to $886,000.
B. HEALTH STATUS
1. Special Populations Network for Cancer Awareness Research
and Training: Administered by the National Cancer Institute’s
(NCI) Center to Reduce Cancer Health Disparities, National Institutes
of Health (NIH), the purpose of the Special Populations Networks (SPN)
is to build relationships between large research institutions and
community-based programs and to find ways of addressing important
questions about the burden of cancer in minority communities.
The major goal of the SPN is to establish a robust and sustainable
infrastructure to promote cancer awareness within minority and medically
underserved communities, and to launch from these communities more
research and cancer control activities aimed at specific population
subgroups. The SPN projects cover three phases. In the first year,
cancer awareness projects were implemented in the community and project
plans were developed. In the second and third years, partnerships
between the project and NCI sponsored groups should enhance minority
training and minority participation in cancer trials. In the last
two years, investigator-initiated research grant applications will
be developed.
Examples of projects the SPN is funding in the Pacific territories
include:
- Pacific Islander Cancer Control Network: Two
centers of the University of California, Irvine (the Chao Family
Comprehensive Cancer Center and the Center for Health Policy and
Research) in collaboration with the National Office of Samoan Affairs
(NOSA) and eight community-based organizations propose to establish
the Pacific Islander Cancer Control Network (PICCN) that will improve
cancer awareness, enhance recruitment to clinical trials, and increase
the number of cancer control investigators among American Samoans,
Tongans, and Chamorro/Guamanians in the United States. The community-based
organizations (CBOs) are located in California, Washington, Utah,
American Samoa, and Guam, where the large majority of Pacific Islanders
reside. The CBOs, with the University’s centers, NOSA, NCI,
and other voluntary groups, comprise a Steering Committee that coordinates
the network activities. Some project activities include assessing
existing cancer education materials aimed at Pacific Islanders and
developing new culturally-sensitive materials when appropriate,
enhancing recruitment of Pacific Islanders to clinical trials by
establishing relationships with cancer centers, and promoting participation
of Pacific Islander scientists in research by identifying candidates
and developing a new training opportunity at the University.
- `Imi Hale, the Native Hawaiian Cancer Research and Training
Network: This project aims to reduce cancer incidence and
mortality among Native Hawaiians through the establishment of a
sustainable infrastructure to:
1) promote cancer awareness within Native Hawaiian communities;
and
2) initiate cancer research, training, and control activities. In
Hawaii, the target population are Native Hawaiians who reside in
the State of Hawaii.
Through an administrative supplement to the `Imi Hale SPN grant
from the Center to Reduce Cancer Health Disparities and the NIH National
Center on Minority Health and Health Disparities, a project entitled
“Pacific Islands Cancer Initiative” was
funded in 2002 to begin addressing the cancer health needs in all
the U.S. associated Pacific Island jurisdictions. The strategy to
achieve the goal depends on creating a team that can articulate the
cancer health needs of indigenous Pacific Islanders, strengthening
and sustaining community capacity, and including Pacific Islanders
in NCI and NIH programs and services that address those needs. Accomplishments
to date include completed cancer assessments in all the jurisdictions
that document current capacity in cancer prevention and control, convening
of three meetings with clinical and public health representatives
from the jurisdictions to discuss and set priorities in cancer prevention
and control, establishment of the Cancer Council of the Pacific Islands
with elected officers, and adoption of implementation plans based
on regional priorities (i.e., increase laboratory capacity, develop
resources, improve cancer care services, and establish cancer registries)
and jurisdiction/state-specific actions.
2. State-Based Diabetes Prevention & Control Program
(DPC): Administered by HHS’s Centers for Disease Control
and Prevention’s (CDC) Division of Diabetes Translation (DDT),
this program operates in all jurisdictions. Several of the recent
activities supported by the territorial DPC program include:
- Guam is preparing a program to identify and conduct meetings
with pertinent partners, as they are required to complete an assessment
and prepare a program improvement plan for DDT. Pacific Diabetes
Today training continues for community based diabetes prevention
and control program activities.
- Northern Mariana Islands developed a diabetes prevalence registry
of persons receiving diabetes care by age, sex, ethnic group, insurance
coverage, and complications, thus providing information on the burden
of diabetes among the Chamorro and Carolinians, the CNMI’s
indigenous population. A conference for Primary Care Provider and
Community Members was held October 17-18, 2003. Standards for Diabetes
Care and how to perform a complete foot exam were the focus of the
conference for the providers, and food demonstrations and physical
activity was the focus for community members. The Northern Marianas
also participated in an immunization program to assure that at least
100 influenza vaccinations will be given on Saipan and 50 doses
for each of the outer islands. Another accomplishment was development
of a diabetes awareness education program for the media and lay
person leadership.
- American Samoa improved a patient registry through collaborative
efforts between the DPC Program coordinator, the hospital diabetes
coordinator, hospital dietitian, the medical clinic staff, and the
hospital quality management. They address sharing responsibilities
for the entry, maintenance, and sharing of data collected through
the Diabetes Care Monitoring System. The DPC Program has completed
the Diabetes Guidelines for use in hospital-based physicians’
offices, private clinics, and dispensaries, which improved the adherence
to care standards. Continuing media outreach efforts aim to increase
public awareness and diabetes information in the community. The
DPC Program, in collaboration with the National Diabetes Education
Program (NDEP) representative facilitates a weekly 30-minute TV
Program of care improvement topics, which are drawn from quarterly
reports of the Diabetes Care Monitoring System.
3. HIV Prevention Projects for the Pacific Islands:
The CDC is providing funding to support HIV Prevention Projects for
the U.S. associated Pacific Island jurisdictions. Six awards are expected
to be made this April. Project activities focus on delivering evidence-based
HIV prevention interventions, including preventing perinatal HIV transmissions;
increasing the proportion of HIV-infected persons who know they are
infected by increasing the number of providers who routinely provide
HIV screening in health care settings, increasing the proportion of
HIV-infected people who are linked to appropriate prevention, care,
and treatment services; and strengthening the capacity of health departments
and community-based efforts to implement effective HIV prevention
programs and evaluate them.
C. QUALITY
1. Disparities Collaborative: The CDC is working with HRSA’s
BPHC and the Institute for Healthcare Improvement to improve diabetes
care within federally funded health centers. To increase access and
decrease health disparities among medically underserved populations,
Centers participating in this collaborative agree to adopt shared
national measures, as well as local measures based on proven guidelines.
Guam has been of the Pacific West cluster since 2000, and has completed
the 12 months of intensive learning sessions on the elements of providing
good chronic care and on a method for testing and implementing changes.
Some of the preliminary results show challenges. For example, approximately
40 percent of patients’ seen at the participating health centers
in Guam have a hemoglobin A1c average of 10.0, which is above the
goal of 7.0 average. Less than 20 percent of the patients received
the annual dilated eye exam.
As part of the collaboratives, the teams noted some strengths and
challenges. Strengths include using locations and communities where
people congregate and collaborating within their own communities.
Several of the challenges are similar to those previously mentioned,
as well as:
- Diabetes is much more prevalent in these populations compared
to those in continental U.S. Diets have moved away from the “traditional”
Pacific diet towards a more “westernized” diet consisting
largely of tinned/packaged convenience and fast foods. Difficulty
with technology, including cost and reliability of phone and Internet
connections, affects the collaborative teams’ ability to communicate
as well as maintain their registries.
- Problems in getting some medications and test reagents also persist.
2. Data Infrastructure Grants: The Commonwealth
of the Northern Mariana Islands, Guam, and American Samoa each received
$50,000 in FY 2002, which was awarded by the Center for Mental Health
Services in the Substance Abuse and Mental Health Services Administration
(SAMHSA). The Commonwealth of the Northern Mariana Islands will develop
its capacity to produce information to assess and improve the quality
of care for mentally ill adults and children with emotional disturbances.
Guam is committed to the development and implementation of an automated
information system that will provide statistical data to be used to
improve community mental health services for its residents.
3. Office of Minority Health Resource Center (OMHRC) HIV
Team: The OMHRC HIV Team has extended its programmatic efforts
to the Pacific Island Jurisdictions with its sessions on Guam during
FY 2004. Two regional capacity building trainings will be held, as
well as direct technical assistance (TA) to agencies working in the
field of HIV/AIDS prevention and treatment. The trainings will include:
- Obtaining salient information to perform TA services through
a needs assessment process;
- Working with local providers and other government agencies and
federal partners who already have a presence on the islands;
- Identifying what type of technical assistance can be provided;
- Creating a strategic plan to implement services with local partners;
and
- Finding appropriate resource persons to provide these services.
The TA will cover: 1) organizational infrastructure; 2) cultural
competence; 3) community outreach; 3) programmatic design; 4) training
initiatives; 5) communications assistance.
4. Ryan White CARE Act: The Ryan White Comprehensive
AIDS Resource Emergency (CARE) Act, enacted in 1990 and reauthorized
in 2000, is administered by the HIV/AIDS Bureau, HRSA, and provides
funding to states, territories, and other public and private nonprofit
entities to develop, organize, coordinate and operate more effective
and cost-efficient systems to people living with HIV/AIDS and their
families.
- Title II helps health departments improve the quality, availability,
and organization of HIV/AIDS health care and support services. This
title also contains the AIDS Drug Assistance Program (ADAP), which
provides low income individuals with life-prolonging medications.
In FY 2003, Guam received $142,612, which includes a proposed $91,319
for ADAP. As of February 2003, Guam’s ADAP faced capped enrollment
and four people are on the waiting list. In FY 2002, for the first
time, the other two Flag Territories, American Samoa and the Commonwealth
of the Northern Mariana Islands, received Title II awards. In FY
2003, each of the two jurisdictions continued to receive approximately
$50,000 in funding.
- Title IV focuses on the operation and development of primary
care systems and social services for women and youth, two groups
that represent a growing share of the epidemic. In FY 2002, the
Northern Mariana Islands were awarded $50,000 under Title IV.
5. Inclusion of the Pacific Islands in Vital Statistics
Data and National Surveys: In 2003, the National Committee
on Vital and Health Statistics’ (NCVHS) Subcommittee on Populations
held two hearings on health data needs for the Asian and Native Hawaiian
and Other Pacific Islander (ANHOPI) populations. The hearings were
attended by academic researchers and community representatives. Each
group stressed the need for developing statistical methodologies that
would increase the numbers of ANHOPI in national surveys so that data
could be reported yet avoid survey participant disclosure. The NCVHS’
recommendations for HHS action are relevant for Pacific Basin populations.
They include:
a. Develop a long- term data collection, analysis, and dissemination
plan to ensure that the Nation's system for monitoring the health
status and health care of its subgroups, especially those concentrated
in geographically distinct areas.
b. Devise sampling frames for national health surveys that would
increase sample sizes for racial and ethnic minority groups that
would support appropriate analysis and information dissemination.
c. Conduct targeted surveys to collect detailed, timely, and accurate
data on specific subgroups of specific racial and ethnic minorities,
especially those concentrated in geographically distinct areas.
The Subcommittee also urged collaboration with States, territories,
Tribal governments, private foundations, and other stakeholders to
develop methods, procedures and resources to accurately collect health
data that ensures that the diversity of the U.S. population is fully
reflected.
Also, the ANHOPI community has expressed frustration over what they
perceive to be the Federal agencies’ noncompliance in collecting
racial and ethnic data in accordance with the revised Office of Management
and Budget categories. The HHS Data Council’s Working Group
on Racial and Ethnic Data is developing a data primer that will be
written in plain language to assist all, including the general public,
to better understand the data collection and reporting process. The
data primer will provide clarifying information regarding how data
are collected, factors that impact the release of data, and the meaning
of some key terminology, (e.g., data not statistically reliable, data
not stable, data not collected, etc.). The data primer is planned
to be disseminated widely and could be useful for the USPIT.
As previously mentioned, Guam is the only jurisdiction included
in national surveys, such as BRFSS. Including the other territories
for track and comparison would also be useful for the USPIT.
6. In 2001, President Bush signed Executive Order 13216,
entitled "Increasing Opportunity and Improving the Quality of
Life of Asian Americans and Pacific Islanders," which extended
the White House Initiative on Asian Americans and Pacific Islanders
(AAPIs) and the President's Advisory Commission for another two-year
term. The EO calls for a government-wide effort to address the unmet
needs of Asian Americans and Pacific Islanders and increase AAPI participation
in federal programs where they may be underserved. The Interagency
Working Group (IWG) advises the President through the office for the
White House Initiative on AAPIs, currently housed in HHS. In 2002,
the IWG developed an inventory of programs affecting Asian Americans
and Pacific Islanders and a FY 2002 performance report. Additionally,
each agency is responsible for developing an annual plan for achieving
the mandates of the EO.
Finally, HHS is a focal point in the areas of coordination and collaboration
with public/private sector groups, including the Federal Emergency Management
Agency, whenever a federal disaster proclamation is issued, and the Pacific
Island Health Officers Association. Additionally, HHS chairs both the
Federal Regional Council in Region IX and its Outer Pacific Committee.
These collaborations enhance discussions of regional issues and concerns,
promote interagency resolutions, and improve communication.
IV. CONCLUSION
There are clearly significant health and health care challenges facing
the U.S. Pacific Island territories, such as the poor infrastructure of
the health care system; limited health care providers, specialists, and
resources; limited technology; dearth of community-based organizations;
isolated location; and limited funding. These contribute to documented
health disparities.
HHS’s efforts are concentrating on improving the accessibility
and quality of health care and health status of these populations. It
seems that our challenge, in a collective sense, is to use strategies
that can accommodate the unique aspects of the region—using broader
and more flexible approaches, working with the leaders and residents of
the Pacific Basin, respecting the governing body and policies, cultures
and traditions of the people, to improve the capacity and infrastructure
of the health care system and, in turn, the health status of the people.
Again, thank you for the opportunity to testify before you today. I would
be happy to answer any questions.
Appendix 1
Geographic Location of the U.S. Pacific Island Territories (Guam,
Commonwealth of the Northern Mariana Islands, and American Samoa)
Source: http://www.nsrc.org/OCEANIA/oceania.html
Appendix 2
GEOGRAPHY and DEMOGRAPHICS
The United States Associated Pacific Basin territories (USAPBT) consist
of six island jurisdictions, including the main focus of today’s
hearing—Guam, Commonwealth of the Northern Mariana Islands, and
American Samoa—which are considered U.S. flag territories. The other
three jurisdictions—Federated States of Micronesia (FSM), Republic
of the Marshall Islands (RMI) and Republic of Palau (Palau)—are
independent countries but are freely associated with the United States,
meaning they are politically independent but each has signed a Compact
of Free Association with the United States establishing specific rights
and responsibilities. These latter three territories are collectively
known as the Freely Associated States or FAS.
Guam is Micronesia’s largest and most populous island and is the
southernmost island. Guam has a total land area of 210 square miles and
is 30 miles long and 9 miles wide. According to the 2000 Census, Guam’s
population is approximately 155,000. The indigenous Chamorro population
comprise approximately 50 percent of the population, followed by Filipino
(25.0 percent), White (8.9 percent), and African American (1.1 percent).
Approximately 31 percent of the residents are under age 20.
The Commonwealth of the Northern Mariana Islands (CNMI) consists of about
14 islands with a total land area of approximately 477 square kilometers,
which is approximately 2.5 times the size of Washington, D.C. Approximately
21 percent of the population is Chamorro and 4.0 percent Carolinian, 56.0
percent Asian, and 2.0 percent White. About 90 percent of the population
speak a language other than English at home.
American Samoa is in the South Pacific Ocean, approximately half-way
between Hawaii and New Zealand. It is approximately a five hour plane
ride from Hawaii to American Samoa. The total land area is approximately
77 square miles (199 square kilometers), which is slightly larger than
Washington, D.C. Tutuila is the large island, covering approximately 55
square miles. Of this population (2000 Census), approximately 88.2 percent
are Samoan and the remaining population includes Tongan, White, Filipino,
and other Asian. Approximately 58.3 percent of all families in America
Samoa are below the poverty level.
The Federated States of Micronesia is unique in that it has 607 islands,
of which there are four constituent island groups, Yap, Chuuk, Pohnpei,
and Kosrae. The four islands fall into three different time zones, as
displayed below. These islands cover approximately 270 square miles (702
sq kilometers) and the population is comprised of nine ethnic Micronesian
and Polynesian groups.
The Republic of the Marshall Islands land area covers approximately 70
square miles (181 square kilometers), scattered over 500,000 square miles
of the Western Pacific. Approximately 90 percent of the population is
Marshallese. Two-thirds of the population live in Majuro and Ebeye. Direct
U.S. aid accounted for 55 percent of the Marshalls’ $98.5 million
budget for FY 2003.
The Republic of Palau is approximately 190 square miles (458 square kilometers)
in eight main islands plus more than 250 islets. Population is less than
20,000 and the racial/ethnic composition is primarily Micronesian. It
is the furthermost jurisdiction—less than 500 miles from the Philippines—and
is a 16-hour plane trip to Hawaii. Only eight islands are inhabited and
approximately 70 percent of the Palauan population lives in the capital
city of Koror on Koror Island. About 40 percent of the residents are under
the age of 20 years, and 73 percent of the total population is below the
poverty level.
In addition to the distance from the Pacific Basin relative to the United
States continent, as well as among themselves, they are located in separate
time zone that is up to six hours behind and up to 17 hours ahead of the
eastern standard time (EST). For example, if it is 12:00 pm/noon (EST)
Monday in Washington, D.C., it is:
- 9:00 am Monday in California
- 7:00 am Monday in Hawaii
- 6:00 am Monday in American Samoa
The other four Pacific Islands are significantly ahead of the EST:
- 2:00 am Tuesday in Palau
- 3:00 am Tuesday in Guam, Commonwealth of the Northern Mariana Islands,
Chuuk (FSM) and Yap (FSM)
- 4:00 am Tuesday in Pohnpei (FSM)
- 5:00 am Tuesday in the Republic of the Marshall Islands and Kosrae
(FSM)
Last Revised: April 16, 2004 |