1. Hawaii State Health Equity Summit Micronesian Health Advisory Coalition September 11, 12, 2009

2. Micronesian: history Geo-cultural term Total area equal to entire United States, but total land mass area equal to size of State of Rhode Island Micronesia = Marshall Islands, Pohnpei, Yap, Palau, Chuuk, Kosrae, Northern Marianas, Guam,Nauru, Kiribati Federated State of Micronesia (FSM), Republic of the Marshalls (RMI), and Republic of Belau commonly referred to as “Micronesia”

3. Colonial and Political Rule Under Colonial Rule for 400 yrs Spain 1500  Germany 1860  Japan end WWI US, end of WWII, under UN Trusteeship Agreement, obtained Administrative Oversight of Northern Marianas, Palau, Truk, Yap, Kusaie, Ponape, and Marshall Islands Became TTPI ( Trust Territory of the Pacific Islands) as “Strategic Trust of US” under UN Security Council US set up Military base in Marshall Islands (Kwajalein Missile Range) and began US Nuclear Weapon Testing Program Trusteeship Agreement objective : eventual self – reliance of TTPI ( Economic, Health, Education)

4. Freely Associated States (FAS) 1977 ending of US TTPI : US offered political self –determination to Northern Mariana, Palau, Marshalls, Chuuk, Yap, Korsare, Pohnpei Net effect: Northern Marianas became Commonwealth (CNMI); Palau, Marshall Islands, FSM became Freely Associated States (FAS)

5. Freely Associated States Relationship with US Governed by COMPACT of Free Association (CFA): Each entity has own COMPACT with US – Financial support, grant support, political relationship, military relationship COMPACT with FSM and RMI – 1986-2001; extended to 2004; amended 2004 to 2024 Republic of Palau – different cycle. Intial COMPACT 1994, renegotiate with US 2009

6. Compact of Free Association(CFA) – FAS nation sovereign except for Military matters( Strategic Denial of access to FAS airspace and waters) – Af fords FAS citizens broad migration rights ( right to reside and work), no visa or labor certification, no limitations of stay – FAS categorized by INS initially as “Qualified Aliens” who are “Permanently Under Color of Law (PRUCOL)”, means they are legal residents in the US under administrative discretion – 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) changed PRUCOL to “Non Qualified Aliens” status rendering FAS migrants ineligible for fed public assistance

7. FAS Nation Population Chuuk- 54 K Kosrae- 8K Pohnpei- 34K RMI- 60K ROB- 18K Yap- 11K

8. Health Indicator- Infectious diseases dengue fever cholera epidemic syphilis epidemic hepatitis B endemic TB endemic Hansen’s endemic

9. Health Outcomes Infant Mortality: (RMI- 4 x US) (ROB- 4 x US) (FSM-6 x US) Longevity : (RMI 64 yrs) (FSM 65 yrs) (ROB 67 yrs) (US 77 yrs) Malnutrition and Vitamin A Def Rampant Suicide rate

10. Health Indicators – lifestyle 50% of people over 50 with DM Diabetes – 75% of hospital days 50% of men and women overweight Ischemic Heart increasing CVA (strokes) increasing CA increasing Smoking/ ETOH high

11. Health Expenditures

12. Legacy of US Nuclear Weapon Testing Testing 1948-1958, Above Ground Associated with 26 Cancers Power of 7200 Hiroshima Bombs 2004 NCI Report- 530 excess CA 250 occur after 2004 (latency)

13. COMPACT IMPACT COMPACT Impact on FAS nations – Poor health and Education Persists – Economic Development Challenged – Large outmigration – Actual Nos. Unclear Outmigration to US – 20,000 HI, Guam, CNMI 8000 Hi 2004; 13,000 HI 2009 – 9000 Marshallese in Arkansas, 4000 Marhsallese Costa Mesa CA

14. FAS migrants in Hawaii 2000 US Census 8,725 Micronesians in Hawaii. This population is now estimated to be between 12,000 – 15,000 in 2007 2000 US Census listed 22,223 Micronesians in the total US population – 40 % resides in Hawaii Emigration key drivers: economic opportunity, employment, medical and subsistence ( Graham, 2008)

15. Public Health Impact of CFA Poor health status of FAS migrants reflecting dismal health indicators in FAS nations According to Hawaii Dept of Health FAS migrants have numerous health problems such communicable and chronic diseases FAS migrants children have low immunization rate further adding to public health risk Other health indicators: poverty or poor living conditions, language and cultural barriers, poor health behaviors making treatment and education difficult

16. Communicable Diseases among FAS migrants in Hawaii Recent report FAS migrant have high rates of hepatitis (FSM - 12 % to 15 %,RMI - 12 %,ROP - 12 % to 15 %) 2008 17.7% of new TB cases were from FAS Hansen’s Disease FAS highest ( 94% of new cases in 2008 from FAS) CDD spent a total of $918,458 in 2007 attributable to services to FAS migrants

17. Non communicable Diseases among FAS migrants in Hawaii Data lacking on chronic diseases among FAS migrants in Hawaii Significant morbidities and mortalities associated with obesity, diabetes, cardiovascular diseases, and lifestyle associated cancers About 110 on renal dialysis and 130 – 160 on chemotherapy according to recent report 2004 NCI study predict more nuclear related cancers

18. Socioeconomic Indicators Average household size – 6 Range from 1-2 people to 17 in the household Age range <1 yr to 78 yrs, average age 23 yrs old Housing issues ( overcrowding, affordability, homeless) Education: 35% less than HS education, 34% with HS education, 15% some college or college degree Most in Service Occupations ( restaurants, security guards, airport/airline cargo services, hotels/cleaning services, retail sales, delivery services Lack of Language Access Services (Ann Pobutsky, 2007)

19. LANGUAGE ACCESS SERVICE Limited English Proficiency ( LEP) pervasive among FAS migrant population in Hawaii LEP barrier to Quality Health Care and services further increasing health disparity among FAS migrants Need State policy advocating provision of Culturally and Linguistically Appropriate Services (CLAS) for FAS migrants with LEP Language Access Service (LAS) ‘cross – cutting theme’ in all aspects of health care delivery CLAS provides the necessary health connect from access of care to quality of care

20. CENSUS Better demographic data collection or census specific to FAS migrants in Hawaii Census to inform health policies affecting FAS migrants Health policies based on accurate census help eliminate health disparities related to FAS migrants Census has funding implications under the Compact Impact Funding under CFA agreement

21. Compact Impact Aid Hawaii -estimated $90 million annually in uncompensated care from FAS Migrants Divided between Guam, CNMI, Hawaii Federal COMPACT IMPACT Aid = 30 million annual – Divided between CNMI, Guam, Hawaii Hawaii’s share is 11.1 million Manifestly inadequate

22. Federal Remedies Increase COMPACT IMPACT Funds Legislation to allow COFA Migrants onto Medicaid Increase COMPACT IMPACT Funding Increase Resources for Hlth and Education in COFA Nations Reverse 1996 Fed PRWORA – make FAS migrants eligible for federal assistance

23. State and Community Remedies Micronesia Health Advisory Coalition (MHAC): propose a Resource Center to promote Culturally and Linguistically Appropriate Services (CLAS),Wellness, and other health and socioeconomic issues Recommendations of 2008 Micronesian Voyages of Hawaii Conference State COFA committees: COFA Task Force and 2004 Hawaii Un-insured Policy Brief -Impact of the COFA on Hawaii

24. MHAC STAFF Wilfred C. Alik, M.D., Chair Email: wilfredalik@hotmail.comwilfredalik@hotmail.com Innocenta Sound, Vice Chair Email : innocenta.soundkikku@gmail.cominnocenta.soundkikku@gmail.com Carmina Alik, Secretary Email: c_alik8690@hotmail.com