General Session II 03 Warkentin 04-19 · (4/19/2017, 1:28 am) 57 In Honor of Dr. Richard Brostrom. General Session II ‐Jon Warkentin April 19, 2017 2017 National TB Conference,

General Session II ‐ Jon Warkentin April 19, 2017

2017 National TB Conference, Atlanta, Georgia National TB Controllers Association www.tbcontrollers.org 1

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“TB‐Free Ebeye” andSocial Determinants of Health in the RMI

Jon Warkentin, MD, MPHMedical Director, TB Elimination Program

Tennessee Department of Health

April 19, 2017

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Introduction

• A personal perspective from one volunteer

• An active TB case-finding project on Ebeye Island, Republic of the Marshall Islands▫ Where is RMI and Ebeye Island?▫ Why TB case-finding on Ebeye?▫ What is the “TB-Free Ebeye” project?

• A broader perspective:▫ Why is there so much TB and diabetes on Ebeye?▫ Social determinants of health on Ebeye Island

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Republic of the Marshall Islands (RMI)

• Located in the western Pacific Ocean west of the “International Date Line,” midway between Hawaii and Australia

• Comprised of 1,156 individual islands and islets, spread among 29 coral atolls

• For your information: Total land area: 70 square miles (rank: 213th) 2016 estimated population: 53,376 (rank: 203rd) Population density: 758.9/sq. mile (rank: 28th) Currency: U.S. dollar Drive on the: Right

Source ‐ https://en.wikipedia.org/wiki/Marshall_Islands



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Republic of the Marshall Islands

Source ‐ https://enewetak.files.wordpress.com/2007/10/rmi_map.gif

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Republic of the Marshall Islands

• Micronesian colonists settled in 2nd millennium BC, first explored by Spanish explorers (1526), later by British explorer John Marshall (1788)

• Occupied early in WWII by the Japanese army, defeated by US army in February 1944

• A US territory until 1979, full sovereignty in 1986 with “Compact of Free Association”▫ Financial , health and security obligations of the U.S.▫ Current program expires in 2023▫ Uncertain future

Source ‐ https://en.wikipedia.org/wiki/Marshall_Islands

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Kwajalein Atoll and Ebeye Island

Ebeye Island• 0.14 sq. mile• Pop. ~10,000

Kwajalein Island• 1.2 sq. miles• Pop. ~1,000• Entirely leased to

U.S. Army

Sources ‐ https://en.wikipedia.org/wiki/Ebeye_Island‐ https://en.wikipedia.org/wiki/Kwajalein_Atoll



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Burden of TB in the Pacific Region:Avg. Case Rates, 2009‐2015

0 100 200 300 400 500 600 700

US

AmSam

US FB

Kosrae

US Homeless

Guam

US 1950

Yap

CNMI

Palau

Pohnpei

USAPI

Ebeye

Majuro

Weno

CASE RATESource: Average TB Rate 2009 – 2015, EpiAnywhere

Courtesy of R. Brostrom, CDC

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Ebeye Island

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Local Hospitaland Community Health Center



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Desalination Plant on Ebeye Island

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“TB‐Free Ebeye Project” ‐ Objectives

• Primary: Active case finding to detect TB early Improve treatment outcomes Reduce TB transmission

• Secondary: Build TB program capacity for sustained intervention Reorganize the TB Program Provide mentoring

Courtesy of R. Brostrom

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Project Leadership

• Dr. Richard “Dick” Brostrom

• Dr. Joaquin Nasa

• Camy Retzl sleeping

• Dick Brostrom not sleeping

or working



13Courtesy of R. Brostrom

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Screening Process











Ebeye Epidemiology Support

• Calculate TB case rates

• Model predicted TB caseload

• Create new forms for

– TB Cases

– TB Contacts

• Improve communication between doctor’s clinic and TB program



Data Update: March 26• TB Cases:

– 26 new TB cases diagnosed. 7 new infectious cases

– 1 teenager, 2 pregnant, 1 hospital worker

– 71 awaiting TB labs and follow‐up CXR prior to diagnosis

• Diabetes:

– 858 tested positive. 315 newly diagnosed.

• High Blood Pressure:

– 923 tested positive. 258 newly diagnosed.

• Leprosy:

– 5 new cases diagnosed



Ebeye Experience

• This activity is not a survey. We are not doing another “counting” activity of people with diseases in the community.

• Instead, we are diagnosing and treating and placing people from the community into the healthcare system.

• To be successful short‐term and long term, this has to be focused on capacity building and improving local programs.

• Success depends on the commitment of our local staff, but also the political will of the Health Ministry.

• Success also depends on the assistance of regional partners, including RMI Ministry of Health, DOI, WHO, ARC, PITCA, NTCA and CDC.

Measuring Success: Beyond TB Case Finding

• Completely reorganized the RMI TB Program, decentralizing DOT to newly trained community outreach workers.

• Added new staff (two new DOT staff, and two new TB nurses from Kiribati).

• With the new DOT workers, we have more than doubled the treatment capacity of the program for at least one year.

• Marked improvements in TB prevention for household contacts. Instituted prevention with Rif, INH/RIF.

• Greatly improved electronic recordkeeping of program activities.

• Initiated induced sputum collection.



TB ACF: Longterm Benefits are “Possible But No Guarantee….”

0

50

100

150

200

250

300

350

400

450

500

2016 2017 2018 2019 2020 2021 2022 2023 2024

TB

Ra

te p

er

10

0,0

00

/yr

Year

TB Program Unchanged

TB Program Improved

TB in CNMI: 1998 – 2012

0

20

40

60

80

100

120

140

160

180

'98 98 '99 '00 '01 '02 '03 '04 '05 06 07 08 09 10 11 12

TB

Rat

e p

er 1

00,0

00/y

r

Year

32,000 Chinese and Filipino workers for garment factories

Average stay 2 years, 1000 new contract workers per month

Institute annual CXR for TB

Factories Close



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Preparation for DOT

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North Camp (“Dump Town”)

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North Camp



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DOT in North Camp

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DOT in North Camp

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Health Status on Ebeye Island

• Population estimates – 2011: 15,000 / 2017: 10,000▫ Overcrowding, lack of jobs leading to migration to Hawaii,

California, Utah, Arkansas • Primary non-communicable disease burden is diabetes

with complications of CAD, HTN, stroke, ESRD, pneumonia, other infections

• Alcoholism in adult males, suicide in teen males• Ebeye residents are the most dependent upon imported

food sources in all of the RMI (2006)

http://www.wpro.who.int/countries/mhl/16MSIpro2011_finaldraft.pdfHawaii J Med Public Health. 2013 May; 72(5 Suppl 1): 77–86.



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Questions

• Why is there so much TB and diabetes on EbeyeIsland?

• What impact will a 3-month TB case-finding project have on public health on Ebeye Island?

• What sustains conditions of poor health on EbeyeIsland?

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The Legacy of U.S. Nuclear Testing

• After a church service on Bikini Atoll in 1946, the U.S. Army asked residents of Bikini Atoll to relocate “For the good of mankind”

• Between 1946 and 1958 the U.S. tested 67 nuclear bombs on Bikini and Enewetak atolls

• Subsequent relocations and diaspora

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The Legacy of U.S. Nuclear Testing

Source ‐ http://www.atlasobscura.com/places/cactus‐dome



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“This dome in the Pacific houses tons of radioactive waste – and it's leaking”

https://www.theguardian.com/world/2015/jul/03/runit‐dome‐pacific‐radioactive‐waste

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Kwajalein Island: Ronald Reagan Ballistic Missile Defense Test Site (U.S. Army)

Source ‐ http://www.bechtel.com/projects/kwajalein‐test‐range/

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Test Missile Fired Over Pacific Ocean (CA)

Source ‐ http://missiledefenseadvocacy.org/advocacy/memorials/ronald‐reagan‐missile‐defense‐site‐vandenberg‐afb/



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Anti‐Missile Defense Testing (RMI)

Source ‐ http://www.bechtel.com/projects/kwajalein‐test‐range/

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“U.S. May Not Be Able To Shoot Down North Korean Missiles, Say Experts” (NBC News, 4/19/2017, 5:35 am ET)

http://www.nbcnews.com/news/us‐news/u‐s‐may‐not‐be‐able‐shoot‐down‐north‐korean‐n748046

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Global Warming and a Rising Sea



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Relationship Between Kwaj and Ebeye

• Kwaj occupied by U.S. Army since WWII• Strategic military importance to U.S. for anti-missile

defense of the U.S. mainland• Kwaj leased by U.S. from Marshallese landowner(s)• Clearance required for all visitors/workers on Kwaj• Approximately 1,000 Marshallese travel by ferry daily

from Ebeye to work on Kwaj; with few exceptions, no Marshallese are permitted to live on Kwaj

• “Perk” for Marshallese workers is access to potable water to carry on ferry to Ebeye

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Questions

• Why is there so much TB and diabetes on Ebeye Island?• What impact will a 3-month TB case-finding project have

on public health on Ebeye Island?• What sustains conditions of poor health on Ebeye Island?• Who is responsible today for improving public health on

Ebeye and throughout the RMI?

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What are “social determinants of health”?

• The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.

• These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.

Source ‐ http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/



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Social Determinants of Health

• Dahlgren and Whitehead, 1991. Policies and strategies to promote social equity in health. Stockholm Institute of Futures Studies

• What is missing?

Graphic Source ‐ https://nacchocommunique.files.wordpress.com/2015/08/sdoh.png

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Recommended Viewing

“Unnatural Causes:Collateral Damage”

http://www.unnaturalcauses.org/episode_descriptions.php?page=6

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Acknowledgements

• Richard Brostrom, MD• Joaquin Nasa, MD• Feliciano Noriega, MD• Glorine Jeadrik – Asst.

Secretary of Health, RMI• TB program staff: Mareta,

Marcello, Ruthann, Limanman, Noah, Rose, all of the “CHOWs” and the hospital staff

• WHO Staff:▫ Eunyoung Ko▫ Subash Yadav▫ Jonathan Malo▫ Kerri Viney

• Ministry of Health, RMI• Gates Foundation



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Volunteers

Team A Team B Team C

• Sandra Chai • John Bernardo • Andrea Ayers

• Yusuke Kobayashi • Sally Cook • Carolyn Bargman

• Angela Largen • Elizabeth Foy • Kenny Boaz

• Connie Okilong • Candace Kugel‐Zuroweste • Jennifer Dillaha

• Camy Retzl • Janice Louie • Mark Durand

• Orlando Salazar • Courtney Radcliff • Mayleen Ekiek

• Lana Tyer • Randall Reeves • Sandra Hainline

• Jon Warkentin • Emily Tholen • Karen Martinek

• Nash Witten • Mark Wohlman • Monica Pecha

• Seiji Yamada • Ed Zuroweste

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A Word From Dr. Richard Brostrom to“TB‐Free Ebeye” Volunteers

(4/19/2017, 1:28 am)

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In Honor ofDr. Richard Brostrom



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THANK YOU

Documents

General Session II 03 Warkentin 04-19 · (4/19/2017, 1:28 am) 57 In Honor of Dr. Richard Brostrom. General Session II ‐Jon Warkentin April 19, 2017 2017 National TB Conference,