1. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: James Rarick “No relationships to disclose”

2. Public Health Issues for Hawaii and the U.S.- affiliated Pacific Islands Presenter: James Rarick, MPH

3. The American Public Health Association works to: Ensure access to health care Protect funding for core public health services Eliminate health disparities

4. American Samoa Guam Commonwealth of the Northern Mariana Islands Federated States of Micronesia (Pohnpei, Chuuk, Yap, Kosrae) Republic of the Marshall Islands Republic of Belau (Palau) Flag Territories: Freely Associated States (FAS): U.S.-affiliated Pacific Islands

6. Guam and American Samoa A Village on Guam Prior To World War II Pago Pago Harbor, American Samoa

7. TTPI Established in 1947 Republic of the Marshall Islands (RMI) and Federated States of Micronesia (FSM) established in 1979, and signed CFA with U.S. in 1986 Northern Mariana Islands established as commonwealth in political union with U.S. in 1978 Republic of Belau established in 1981, signs CFA with U.S. in 1994 THE CREATION OF THE U.S. TRUST TERRITORIES OF THE PACIFIC ISLANDS

8. BRAVO SHOT: March 1,1954 Total Yield Largest hydrogen bomb ever tested in the U.S. Approx 7,200 Hiroshima bombs Equal 1.6 Hiroshima bombs per day 12 year test span 6.3 billion of curies of I-131 released into the atmosphere – 42 x > Nevada, 150 x Chernobyl incident Ignited an international controversy Led to US-USSR Limited Nuclear Test Ban Treaty

9. SHORT TERM - Direct fallout on people of two atolls and more - causing acute radiation poisoning and radiogenic related illnesses LONG TERM - Long term contamination of lands and food chain - Destruction of culture/ communities, social structure - Loss of ability to self sustain Source: Presentation of Dr Wilfred Alik, Marshallese Physician, at the 2005 Pacific Global Health Conference OUTCOMES

10. US Position - Lots of money - You had your chance - Legal Document - Other Priorities - Nuclear Issue Settled RMI Position - Nuclear issues not resolved - All aspects must be settled - Never had enough in the first place - Inadequate settlements - Standard of care -- not equitable A LEGACY OF MISTRUST

11. Disparities between USAPIs Source: Pacific Islands Health Officers Association

12. Females 80.282.279.372.6873.074.481.1 Males 72.975.973.968.868.967.875.3 Total 76.478.976.570.670.971.078.1 Life Expectancy at Birth American Samoa Guam CNMI FSM RMI Palau U.S. Infant Mortality Rate American Samoa Guam CNMI FSM RMI Palau U.S. 8.7 6.5 6.7 27.0 26.4 3.7 6.3 Source: CIA World Factbook, 2008 est.

13. Defines the relationship that the FSM, RMI, and ROP, as sovereign states, have entered into as associated states with the U.S. Initial agreements provided guaranteed financial assistance over a 15-year period administered through the Office of Insular Affairs in exchange for certain defense rights. In 2003, the Compacts between the RMI and FSM were renewed for 20 years. These new Compacts provide $3.5 billion in funding for both nations. U.S. $30 million was also provided to Guam, Hawaii, and the Northern Mariana Islands as "Compact Impact" funding. U.S. treats these nations uniquely by giving them access to many U.S. domestic programs, including disaster response and recovery and hazard mitigation programs under FEMA. The new Compacts also changed certain immigration rules. RMI and FSM citizens traveling to the U.S. are now required to have passports, but they do not have to apply for visas for U.S. entry. Current CFA for Palau expires in 2009. Forging a new type of relationship with the U.S. – the Compact of Free Association

14. DeathsRate American Samoa712.14 Mariana Islands55.91 U.S. Virgin Islands65.53 Palau14.8 Guam63.46 Vermont193.06 Micronesia32.78 Alaska172.49 Highest Fatality Rates in Iraq Conflict through March 26, 2008 Pacific Islanders in U.S. Armed Forces Source: Time Magazine, April 7, 2008

15. Change in Ethnic Composition of Guam’s Population, 1980 - 2000 Impact of FAS emigration

16. CFA Population (1997) Adults who are H.S. Grads – 43.6% Adults in Workforce - 44.6% Per Capita Income - $3,759 Speak English at Home - 15.8% HI Pop. (1999-2000) Adults who are H.S. Grads – 84.6% Adults in Workforce - 64.5% Per Capita income - $21,525 Speak English at Home - 73.4% Challenges for CFA Population in Hawaii

17. In 2002, Hawaii Dept. of Human Services saw a 20% increase as compared to 2001 in the number of FAS migrants served, at a cost of over $11 million in financial assistance ($4,521,240) and medical assistance ($6,746,008) Federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) made FAS migrants ineligible for federal public assistance State now covers the entire costs of the FAS migrant when they enroll in QUEST (a managed care Medicaid program) and other medical and financial assistance programs. Under PRWORA, only treatment of emergency medical conditions may be submitted for federal reimbursement. Source: Impacts of the CFA on Hawaii’s Healthcare System, A Policy Brief prepared by the Hawaii Uninsured Project, 2004 Burden of healthcare costs for Hawaii

18. Micronesian Homeless in Hawaii

19. Biennial Pacific Global Health Conference

20. Recommendations: Establish centralized place for information sharing/dissemination Need more accurate data on Micronesians in Hawaii Increase clarity from State of Hawaii regarding the programs/services Micronesians qualify for Establish pool of qualified interpreters in all major languages Support more cultural competence training for providers Have more meetings/conferences to promote dialogue among stakeholders Increase the number of mentoring/bridging programs for Micronesian youth Increase collaboration between Hawaii State government and CFA governments. Micronesian Voices Conference, April 2008

21. Mahalo Nui Loa Si Yu`us Ma`ase (Chamorro) Fa`afetai Tele (Samoan) Kommol tata (Marshallese) Kulo maluhlap (Kosraen) Kam Magar (Yapese) Kelangan (Pohnpeian) Kili So Chapur (Chuukese) Sulang (Palauan) Thank You Very Much! www.hawaiipublichealth.org