which is charged by the Department of Energy pursuant to Public Law 95-134 to provide diagnosis and treatment of radiation-related diseases occurring in inhabitants exposed to radioactive fallout, has broad- ened its health service over the intervening 29 years to include a comparison unexposed population of Marshallese, as well as the children of both exposed and unexposed groups. Thereis, in addition, an informal agreement under which the medical team undertakes to assist the Marshall Islands government in its efforts to provide health care to all residents of Rongelap and Utirikatolls. Health Care Delivery An annualsix-week pediatric survey provides complete medical examinations and care to children 15 years of age and younger. A similar survey for adults is also undertaken, at which timea sickcall is provided for the children. The medical teams, comprised of Marshallese and Americans, include physicians, a pediatric dentist, nurses, laboratory technicians, and an x-ray technician. Both Rongelap (population approximately 220) and Utirik (population approximately 450) atolls have a permanenthealthclinic staffed by a health aide whose training is roughly equivalent to a physician’s assistant. These clinics do not have the capability orfacilities to perform laboratory and dental functions. For this reason, the medical! team utilizes a ship under the United States governmentcharter that is appropriately fitted to provide essential laboratory and dental support. Laboratory services on board include electronic blood cell counting andsizing, differential leukocyte and platelet counts, serum electrolytes, blood chemistries (includingliver function tests, glucose, creatinine, amylase and hemoglobin Aj¢ levels), culture andsensitivity testing for both aerobic and anaerobic bacteria, routine microscopic evaluation of urine and stool, and serum preparation for tests that must be sent to outside laboratories. Standard x-ray services, with the exception of barium studies, are available, as are electrocardiograms. Theshipis anchoredin the lagoon and adult patients and/orlaboratory specimensare ferried back and forth to the ship by small boats. For reasonsofsafety, children are examinedashore. On thelargerislands, the ship is used to supplement on-shore medicalfacilities. Between the twice yearly visits of the medical team, a Brookhaven physician based on Kwajalein atoll makes periodic visits to Rongelap and Utirik, providing follow-up to problemsidentified by the medical team and addressing their current health needs. The problem CLINICAL PEDIATRICS ~. * JUL 2303 7 January 1984 of continuity of care, especially for chronic diseases, is one of the mostdifficult aspects of health care in an island setting, and on-going instruction and reinforce- ment of health aides is critical to any success in this area. The health aides residing on Rongelap and Utirik atolls have access to radios that, when operational, provide a meansof contact with medical facilities on Majuro. Nowthatairstrips have been built on the outer islands, periodic visits and any indicated medical referrals can be facilitated. Heaith Status During the 1982 pediatric mission, a total of 513 children, varying in age from 2 days to 15 years, were examined. A broad spectrum of problems were en- countered. Well child care (preventive maintenance, health education, safety, counseling, and immuniza- tions) formedthe bulk ofthe cases, but conditions such as incontinentia pigmenti, toxoplasmosis, and lepromatousleprosy in a young adult addedto the uniqueness of the experience. Of 487 problemsidentified, the most commonfindings were skin and scalp infections (28.1%), dental disease (14.6%), and ear/hearing abnormalities (11.4%). Althoughtheislands of Utirik and Rongelap had previously had a high prevalence ofintestinal helminths,® studies performed on this trip indicated a relatively low prevalence, the result of an intensive mebendazole (Vermox) intervention pro- gram.Satisfactory sanitation habits have beendifficult to establish, primarily because of a limited supply of fresh water. Multiple ear problemsincluded acute and chronic purulent and serousotitis media, and pebbles and other foreign bodies in the ear canals. Some of the ear problems appeared to be related to the sig- nificant amount of time children spent playing and swimming in the warm tropical lagoons. Theselection of pediatric oral agents for treatment of identified problems frequently presented a therapeutic challenge. Theliberal use ofantibiotics by health aides has been associated with the emergence ofsig- nificant bacterial antibiotic resistance, even in this re- mote island setting. Cloxacillin suspension preparations, which generally might be indicated for treatment of impetigo in infants and youngchildren, are stable for less than 48 hours at temperatures greater than 70°F unless refrigerated. The year-round mean temperature in the Marshall Islands is greater than 80°F andvirtually none of the homeson the outer islands and only a few in the population centers have electricity. Thus, stability became oneofthecritical factors in selecting oral agents for the pediatric population. 31 a Se egeR 8er keRE agE OOaESI anSAO EE HETeiit He a PEDIATRICS IN THE MARSHALL ISLANDS