ORIGINAL ARTICLE

An international rotation for family medicine residents in the Republic of the Marshall Islands

Jill OMORI, Rebecca H. GLADU, Sheldon RIKLON, Neal A. PALAFOX and Gregory MASKARINEC



University of Hawaii John A. Burns School of Medicine, Hawaii, USA

The University of Hawaii Family Medicine Residency Program has developed a unique international experience in the Republic of the Marshall Islands (RMI) for residents in family medicine. The rotation provides a context for residents to explore: (i) the health care system of a non-industrialized nation; (ii) the politico-economic health consequences an unsustainable, of US designed health system; (iii) radiation related illness; and (iv) relying upon one's clinical acumen to diagnose diseases in a developing country. Residents spend one month in their second residency year and one month in their third year immersed in a developing country's experience where medicine is practiced with few resources.
Benefits to the residents' education are numerous: improved clinical acumen, involvement in health projects with the RMI Ministry of Health and Environment, learning about the health consequences of the US nuclear and missile defense testing programs, exposure to how bilateral political and economic policies shape health care delivery, an immersion experience to improve cultural sensitivity on an individual and international level, experiential learning about personal, clinical, moral, ethical, and political responses to the situation in the RMI, and a first-hand introduction to US foreign policy.

Key words: international family medicine, Republic of the Marshall Islands, residency education, rural rotation.

Introduction

The Family Medicine Residency Program of the John A. Burns School of Medicine, Hawaii, has established a unique international rotation, beginning in 1999. The rotation is based in the Republic of the Marshall Islands (RMI), a sovereign island nation of 50 800 people (1999 census). It provides a context for residents to explore: (i) the health care system of a non-industrialized nation; (ii) the politico-economic health consequences of an unsustainable US designed health system; (iii) radiation related illness; and (iv) relying upon one's clinical acumen to diagnose diseases in a developing country. This rotation adds significant personal, academic, and clinical depth to the residents. Of greater importance, the family medicine residents serve the health care workers in the RMI by providing education, development, and continuing medical education.

Background

The RMI is one of six US Associated Pacific Basin island nations. Political and economic ties with the US began after World War II when the US took possession of the Marshall Islands under United Nations Trusteeship, a choice determined by the strategic military location of Micronesia (Fig. 1). With the acquisition of the Marshall Islands came the responsibility for its health, education and welfare as part of the trusteeship agreement.¹

The US tested 67 thermonuclear weapons in the Marshall Islands between 1946 and 1958. The weapons tests were largely detonated above ground and in the atmosphere, with a composite megaton equivalent of 7200 Hiroshima bombs. The testing resulted in Marshall Islanders (who were downwind of the hydrogen bomb test site) being exposed to radioactive fallout; contamination of land and food sources; displacement of Marshallese from homes; and a history of distrust and resentment toward the US.^2,3

Another facet of the RMI and US relations is the US Army Base at Kwajelein Atoll (USAKA), which is a major center for the US Strategic Defense Initiative. The RMI attempting to negotiate a new, settlement, called the Changed Circumstance Petition, with the Congress of the US, for the damages caused by the US nuclear weapons testing program.⁴

It is in this setting of a rapidly changing socio-political environment that the Residency Program interfaces with the RMI.

Health Status of the RMI

There has been and continues to be a tremendous disparity in health care status between the people of the US and the Marshall Islands. Much of the health status of the Marshallese Population Icould be greatly improved by de-emphasizing a US built hospital / curative based system and by emphasizing public health and prevention. The infant mortality rate is 37 of every 1000 births, six times that of the US; the population growth rate is 3.8%;^5,6 tuberculosis, vitamin A deficiency, hepatitis B, typhoid, and Hansen's disease are endemic.^7-10 In the summer of 2003, an epidemic of measles infected a large percentage of the islands' population and one year before, a cholera epidemic ravaged the people of Ebeye.11,12 In addition, there is an estimated 50% prevalence rate of diabetes mellitus type 2 in people over 50 years of age.13 Heart disease and stroke are rising, and cancers are prevalent. About 55% of women over 50 years of age are obese.^11,14 Furthermore, there are health consequences from the nuclear testing program that require care.4

The RMI health system which cares for this burden of illness is lacking in resources and infrastructure. It is not uncommon for the hospitals to be out of most medications, laboratory and X-ray supplies. See Table 1 for more information about the Marshall Islands in general.

The Relationship of the Program to the RMI

As one of the activities of the US is to compensate and monitor damages suffered as a result of the nuclear weapons testing program, the US Congress mandated that the Marshallese people who received direct exposure from the Bravo hydrogen bomb detonation in 1954 would be treated and monitored for radiogenic illness. Therefore, US$1.1 million per year were provided for medical care and another US$800 000 per year were provided for logistical support of this medical mission. The contract to provide the medical care to the affected population was awarded to the Pacific Health Research Institute (the grant administrator) and its partners - Straub Hospital and Clinics (to provide tertiary care for radiogenic illness in Hawaii) and the University of Hawaii's Family Practice Residency Program (to provide screening for radiogenic illnesses, primary and secondary care in the RMI). The principal investigator for the project is the department chair. The logistics grant was awarded to Bechtel Corporation, Nevada. The entire project is overseen by the US Department of Energy.

The residency program has strong historical and programmatic ties with the RMI. The department chair lived in the RMI from 1983 to 1992, before entering academic medicine. He served in the RMI as a clinician, the medical director for the initial program for radiation affected peoples, and was the medical director for Preventive Health Services. Additionally the residency program has graduated one resident who is the second US-trained Marshallese physician, and who now has returned to the Marshall Islands as the medical director for the program, serving as site director and preceptor for the residents. These collaborations with the RMI provided the credibility to win the competitive contract.

The residency program

Rotation structure

Since its beginning in November 1999, the UHFP residency program has sent one resident to the Marshall Islands every month. The rotation, once elective, is now mandatory, with residents rotating one month in their second year and one month in their third year. Through December 2004, 53 residents have participated, 16 of them doing two rotations. All costs of the rotation are covered through the contract with the US Department of Energy. Residents are provided housing in an apartment and the use of a car while on the rotation.

There are four geographic sites in the RMI for clinical activities. One clinic is located in the capital of the RMI, an atoll with about 20 000 people. A second clinic is located on the military base, and serves the affected population which lives on Ebeye, which is a 30-minute barge ride from the military base. This island is one of the most densely populated places on earth: 10 000 people living on 66 acres.

The hospital on Ebeye was in disrepair and there was no running water in most of the hospital. The new Ebeye hospital, built in 1992, was only recently opened in 2003 to replace the dilapidated Ebeye Hospital. However, the island of Ebeye still lacks consistent running water and electricity. Two additional clinic sites are located on outer islands that can only be accessed by a 4-5 hour boat ride over open ocean, or by a local 16-seat turbo-propeller plane which lands on a coral runway.

The residents perform several functions while in the RMI. The primary function of residents is to work with the onsite Marshallese medical officer who has the day-to-day responsibility for the affected population. When morning clinic and screening duties are completed, the residents have their afternoons open to work with the RMI Government hospitals and health facilities in a voluntary capacity. They work in the outpatient clinics, and develop individual projects with the Ministry of Health's Preventive Services and Public Health Bureaus. These projects range from diabetes research projects to high school health career mentorship activities, to assisting public health nurses with community outreach. Residents are required to provide one continuing medical eduction (CME) seminar to the local physicians and health staff in the RMI during their rotation. Additionally, residents take call in the emergency room one night per week.

Costs

The expense of the rotation is borne by a contract with the Department of Energy. The annual expense breakdown is listed in Table 2.

Intrinsic value

The RMI rotation has had a positive effect on residents. The experience has facilitated:
1 the development of the clinical skills in resource-limited settings;
2 the involvement of residents in applicable health projects with the RMI Ministry of Health and Environment;
3 onsite learning about the health consequences of the US nuclear testing program;
4 onsite learning about bilateral political and economic policies as they shape health care delivery;
5 cultural efficacy - improved sensitivity to the social and cultural dimensions of health and increased awareness of how culture influences experiences, expressions, and treatments of illness; and
6 personal, moral, ethical, and clinical, adaptation to living and working in developing countries.

The RMI rotation has had a positive effect on the people of Marshall Islands. The monthly presence of the residents
1 provides much needed cost-effective physician manpower;
2 helps with needed community and public health projects;
3 provides staffing for call and clinics;
4 creates an academic learning environment for the health care providers in the Marshall Islands;
5 provides ongoing and frequent home care for the radiation-affected people of the Marshall Islands;
6 provides CME to the health care providers;
7 offers true primary care for the radiation-affected people;
8 provides a group of young physicians who will advocate for the health and welfare of the Marshallese people; and
9 increases the capacity for health care delivery in the Marshall Islands.

Cultural efficacy

The per capita expenditure of US monies tied to grants, compensation for US thermonuclear weapons testing, bilateral negotiated monies for development and government operations, lease payments for the military base, and monies tied to the trusteeship are perhaps one of the highest in the world. The expected economic development, health status and the general education levels of the Marshallese people are far less than what would be expected of these expenditures.

Insensitive and uninformed reports have portrayed the plight of the Marshallese as the result of their being lazy or a consequence of the leadership being corrupt and uncaring about its people. At another level of analysis the Marshallese are subject to impulsive foreign policy and colonization, and are given minimal control over their own affairs.^4,13

These attitudes contribute to cultural incompetence. The dominant power, the US, has made incorrect assumptions about curative health strategies which would work and be sustainable in the Marshall Islands. Conversely, many Marshall Islanders have unrealistic expectations of the Western based curative health systems ability to improve health care. There appears to be little public understanding of the real cost of an unsustainable curative system to economic development and self sufficiency. The assumptions and expectations of the two countries appears to be incongruent and there-by fosters the continuance of an ill-prepared health system and poor health outcomes in the RMI.¹⁵

In the past, the lack of cultural sensitivity by foreigners working in the health system has been apparent. Residents immediately begin to appreciate language barriers and cultural differences in health care delivery in the RMI. To work effectively in this environment, residents must constantly examine their own cultural biases and challenge harmful stereotypes that they may have previously accepted. A culturally sensitive resident is not expected to know everything about Marshallese culture, but must be open to learning more from each patient in each clinical encounter, developing new listening skills that serve well not only when treating Marshallese patients but in the care of all patients.

Scholarly activity and community participation

The high rates of infectious disease, chronic illnesses, nutritional deficiencies, and health infrastructure dilemmas leading to medication and medical supply shortages, stimulate curiosity and problem-solving mechanisms in residents and faculty. The residents assist the RMI in providing CME, health manpower support in the clinics, assistance with maintaining databases and with the development of a diabetes prevention and treatment clinic on Ebeye Island.

Personal discovery

The Marshall Islands rotation does not suit all residents. Some feel powerless and not in control of the clinical situation because of a lack of technology and laboratory support. Some feel helpless because of the politico-economic forces that are present. Others feel anger at the military, the US, and at the Marshallese for making the situation what it is. Some residents feel growth as they learn to cope and be creative with dire circumstances. For others, the experience is one of despair and surrender. For all it is a learning situation - sometimes a very difficult one.

Telling comments from residents about the rotation

There is the language barrier so you really need a local person who is willing to be your counterpart, but they are all so complacent, with an 'it's never going to change' attitude, but you really need local counterparts who are willing to work with you, to set things up, make contacts… and none of us, except perhaps Dr Palafox [Chair of the UHFP Department], have enough local credit to do something on their own.

The patients are very interesting, it's good to work with the limitations we have, you need to be very creative.

Even the bad experiences you learn a lot from.

I think a lot of the world works like it works there, so it's not a bad exposure.

The unemployment is visible, the whole history is so tangible, people are not very cheerful, people have really been made dependent. They just come into that trailer and sit there like, okay, prove you're worth it and then how are you going to help me.

Definitely a cultural experience, the most important aspect was the chance to see new disease processes; for example TB, that we normally treat early on, there you see end stage disease pathology.

Others that you don't see here at all, such as Hansen's disease and marasmus; this allows you to come to understand disease in a new way. That was pretty powerful.

I really enjoyed the people I stayed with. Probably my best memory was taking this boat out to this little island, they just take fresh fish and cut it up into sushi, everyone just hanging out in the water, watching the sunset.

I didn't see many gray-haired people there.

I felt so lucky when I came back.

I got there and I felt, damn, I have absolutely no idea what's going on. First thing that comes to mind, seeing things we don't see here, lots of infectious disease, syphilis, TB, Hansen's disease, there's lots of other infectious disease, lots of bacterial infections, fish poisoning, lots of it the result of their infrastructure, you see kids getting scrubbed down by their moms in the front yard with a bucket of water.

…made me a better person, I want less, many things don't seem so important, and other, simple things, like drinking tap water, seem really great. I think I knew those things from where I grew up, but it helps remind me how good things are for us.

The whole experience was good, it may not have increased my knowledge base a lot, but it was invaluable for training, because you get to test out what you can do and can"t do, there's a lot of times when you're making the decisions, and the medicine you practice when you're making the decisions is different than what you practice when you're not making the decisions - more conservative

Conclusion

The international rotation in the RMI has been beneficial to both the RMI and to the residency program. The rotation has been an awakening for the residents regarding medicine, politics, cultural efficacy and self-awareness. It is an invaluable rotation which is a 'win-win' situation for the residency program and for the RMI.

References

1	Feasley JC, Lawrence RS. Pacific Partnerships for Health, Charting a Course for the 21st Century. Washington, DC: National Academy Press, 1998; 141-54.
2	Simon SL. A Brief history of people and events related to atomic weapons testing in the Marshall Islands. Health Physics 1997; 73: 5-20.
3	Niedenthal J. A history of the people of Bikini following nuclear weapons testing in the Marshall Islands with recollections and views of Elders of Bikini Atoll. Health Physics 1997; 73: 28-36.
4	Petition presented to the Congress of the United States of America regarding changed circumstances arising from US nuclear testing in the Marshall Islands, submitted by the Government of the Republic of the Marshall Islands, pursuant to Article IX of the Nuclear Claims Settlement approved by Congress in Public Law 99-239, September 11, 2000: Attachment VI. Medical Analysis, pp. 1-39. In press.
5	15-Year Strategic Plan 2001-15. Ministry of Health and Environment, Republic of the Marshall Islands April 2000, pp. 58.
6	http://www.rmiembassyus.org/statistics/pdf/Health/ EstLifeExpectEtc8899.pdf Accessed 30 December, 2003.
7	Palafox NA, Gamble MV, Dancheck B, Ricks MO, Briand K, Smeba R. Vitamin A deficiency, iron deficiency and anemia among preschoological children in the Republic of the Marshall Islands. Nutrition 2003; 19: 405-8.
8	Gamble MV, Ramakrishnan R, Palafox NA, Briand K, Berglund L, Blaner WS. Retinol binding protein as a surrogate measure for serum retinol: studies in vitamin A deficiency from children in the Republic of the Marshall Islands. American Journal of Clinical Nutrition 2001; 73: 594-601.
9	Palafox NA, Yamada S. The health predicament of the US-associated Pacific Islands. What role for primary health care. Asian American and Pacific Journal of Health 1997; 5: 49-56.
10	Diaz A. The health crisis in the U.S. associated Pacific Islands: moving forward. Pacific Health Dialog 1997; 4: 116-29.
11	Langridrik J, Edwards R, Briand K et al. Public health dispatch: measles epidemic - Majuro Atoll, Republic of the Marshall Islands, July 13 - September 13, 2003. MMWR Weekly, 19 September, 2003; 37: 888-9.
12	Beatty ME, Jack T, Sivapalasingam S, et al. An outbreak of vibrio cholerae O1 infections on Ebeye Island, Republic of the Marshall Islands, associated with use of an adequately chlorinated water source. Clin Infect Dis 2004; 38: 1-9.
13	Republic of the Marshall Islands, Office of Planning and Statistics. Statistical abstract 1988/1989.
14	Cortes L, Gittelsohn J, Palafox N. A formative research to inform intervention development for diabetes prevention in the Republic of the Marshall Islands 2001. Health Education and Behavior 2001; 28: 696-715.
15	Palafox N, Buenconsejo-Lum L, Riklon S, Waitzfelder B. Improving health outcomes in diverse populations. Competency in cross-cultural research with indigenous Pacific Islander populations. Ethnicity and Health, Year? ; 7: 279-85.

 

Fig. 1. Map of The Republic of the Marshall Islands. Distance to Hawaii, San Francisco, and Washington, D.C.