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

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. U.S.-affiliated Pacific Islands 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):

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

7. THE CREATION OF THE U.S. TRUST TERRITORIES OF THE PACIFIC ISLANDS 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

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. OUTCOMES 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 ofDr Wilfred Alik, Marshallese Physician, at the 2005 Pacific Global Health Conference

10. A LEGACY OF MISTRUST 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

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

12. 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. Forging a new type of relationship with the U.S. – the Compact of Free Association 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.

14. Pacific Islanders in U.S. Armed Forces Highest Fatality Rates in Iraq Conflict through March 26, 2008 Source: Time Magazine, April 7, 2008

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

16. Challenges for CFA Population in Hawaii 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%

17. Burden of healthcare costs for Hawaii • 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

18. Micronesian Homeless in Hawaii

19. Biennial Pacific Global Health Conference

20. Micronesian Voices Conference, April 2008 • 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.

21. www.hawaiipublichealth.org 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!