DUNGY ET AL. Because oftheir stability in tropical climates, erythromycin ethylsuccinate and trimethoprim/sulfamethoxazole were particularly useful therapeutic agents. Examination ofchildren wasfacilitated by the great amountoftrust the children exhibited to their adult caretaker. The Marshallese have an extended family network. Therefore, the primary adult caretaker may not be a biological parent. Children exhibited little fear or anxiety when held by their adult caretaker. The logistical problems of providing health care to an island community may be best exemplified by the following case reports. complete, was possible because of the recent completion of a small coral airstrip at Utirik. Prior to completion of the airstrip, transfer would have required emergency diversion ofa ship followed by a 30- to 40-hourboatride to the hospital facilities on Majuro or Kwajalein atoll.It is unlikely that the child would have survived if the pediatrician and medical team had not been present. Summary A method of providing health services to children on island communities has been presented. It incorporates day-to-day coverage by paramedical personnel, supplementedbyinterval visits of physicians supported byfacilities for laboratory diagnosis. The program de- scribed cannotbe called a “‘model” because the current Case 1 Ontheisland of Ebeye (Kwajalein atoll), an 18-month-old male was brought to the clinic with the complaint that the child had been noted to have “trouble breathing since he was born.” The child had been seen on multiple occasions by several local physicians and previously was diagnosed as having “bronchitis’’ and had received several courses of antibiotics. The physical examination revealed a small, irritable, tachypnic infant (20th percentile for length and well below the 5th percentile for weight) with a heart rate of 140/min and a liver palpable 5 cm below the costal margin in the midclavicularline. His blood pressure was noted to be 130/ 30 mm Hgin the right arm, and the peripheral pulses were bounding. A grade IV/VI machinery murmur was heard over the precordium maximumatthe left base. The electrocardiogram revealed left ventricular hypertrophy. The chest roentgenogram showed marked cardiomegaly, predominately left sided, and markedly increased pulmonary vascularity. The infant was diagnosed as having a patent ductusarteriosus with congestive heart failure and was treated with furosemide (Lasix). Referral to a center in Honolulu was initiated. Corrective surgery was successful. The successful outcomeis most likely due to presence of the medical team and the correct diagnosis by the team’s pediatric cardiologist. Case 2 Uponarrival of the ship on Utirik island, a 7-month-old female with a 3-week history of fever, rapid breathing, and decreased appetite was broughtto theclinic. She had been treated with oral ampicillin for 2 weeks without improvement. Despite her progressive deterioration, no effort had been madebythe healthaide to obtain radio consultation orinitiate evacuation prior to the arrival of the medical team. Examination revealed a febrile, tachypneic, undernourished female in marked respiratory distress with decreased lung sounds on the right, and rales and rhonchibilaterally. Chest x-ray revealed consolidation of the right lung field. Arrangements were madewith the Governmentof the Marshall Islands and the Kwajalein Missile Range for transfer of the patient to the U.S. Army hospital on Kwajalein. An Armyaircraft with a nurse and respiratory support personnel was dispatched from Kwajalein to air evacuate the patient for appropriate hospital care. The process, which took less than 12 hours to 32 approachis an evolved rather than a plannedstrategy, and there is no objective measure of its overall effectiveness. Its inadequacies are all too obvious to those who mustdeliver medicalcare in such a difficult setting. Thelogistics ofproviding health servicesto island populations make it imperative that health professionals workcooperatively to develop effective models for delivery of care so thatall individuals, no matter where they live, may have an opportunity to enjoya healthful life. Acknowledgment The authors wouldlike to thank Marion Sheppard and Nanette Gustavsen for their assistance in the preparation of the manuscript. References 1. Conard RA, et al. Review of medicalfindings in a Marshallese population twenty-six years after accidental exposure to radioactive fallout. Brookhaven National Laboratory, 1980. 2. Cronkite EP, et al. Someeffects of ionizing radiation on human beings: a report on the Marshallese and Americans accidentally exposed to radiation fallout and a discussion of radiation injury in the human being, Anatomic Energy Commission—TID 5385, 1956. $. Larsen PR, Conard RA, Knudsen KD,et al. Thyroid hypofunction after exposure to fallout from a hydrogen bomb explosion. JAMA 1982;247:1571-5, 4. Conard RA, Dobyns BM, Sutow WW. Thyroid neoplasia as a late effect of acute exposure to radioactive iodines in fallout. JAMA 1970;214:316-24. 5. Sutow WW, Conard RA, Griffith KM. Growth status of children exposed to fallout radiation on Marshall Islands. Pediatrics 1965;36:721-31. 6. Conard RA. A case of acute myelogeous leukemia following fallout radiation exposure. JAMA 1975;232:1356-7. 7. Neel JV, Ferrell RE, Conard RA. The frequency of “rare” protein variants in Marshall Islanders and other Micronesians. Am J Hum Genet 1976;28:262-9. 8. Krotoski Wa, Cogswell FB, Knudsen KD,et al. Parasitologic surveys and suppressive anti-heliminth treatment on Rongelap and Utirik atolls, Marshall Island, 1977-1979. In: Conard RA, ed. Review of medical findings in a Marshallese population twenty-six years after accidental exposure to radioactive fallout. Brookhaven National Laboratory, 1980. Vol. 23 DU) 2504 No. 1 CLINICAL PEDIATRICS