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



JUL 2303

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.


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