Letters from Majuro
An Upside Down System
From Koror to Majuro and just about everywhere in between, the majority of health funding is spent for costly off-island medical referrals. Instead of investing in equipment and laboratory needs, for example, that would make it possible to spend less while treating more people locally, millions of dollars are spent so a few hundred patients can be sent to hospitals in Hawaii, Guam and the Philippines.
“The triangle of need is opposite of the budget funding” from the Legislature, is the way one Palauan doctor assessed the situation, a description that fits most islands. Almost without exception, big money goes into so-called “tertiary” — off-island — care, while primary health services at the village level are severely under-funded, and hospitals that provide secondary care don’t fare much better.
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Most politicians who vote on health budgets are well meaning, but largely uninformed about why vastly increased amounts of money need to be going into primary health care. Preventing the environment that causes dengue fever or cholera — outbreaks of which have hit many islands in the region — is a lot cheaper than trying to treat the aftermath of the illnesses. The same goes for HIV/AIDS, family planning, immunization and non-communicable diseases such as diabetes.
But it’s not only funding for and action by preventive health services that is needed. Many other developments have a significant impact on the health of island populations: road designs, access to beaches for fishing, foods that businesses sell or promote, pollution of fresh water and the ability to exercise at work are just a few that come to mind. In one island, for example, 25 percent of high school students are overweight, so health policies about physical education at school are critical to dealing with the problem.
One might say the “Ministries of Health” in the islands are a misnomer. “We deal with disease OK, but not well with health,” says one island doctor. Indeed, one look at the number of patients with amputated limbs — a consequence of advanced diabetes — attempting to exercise at Majuro Hospital’s physical therapy facility underscores that point.
The impending onslaught of HIV/AIDS, however, may finally bring the message home about the need for prevention — though for many islands, it will be like trying to close the barn door after the animals have gone. It seems almost inexplicable that the Pacific Forum leaders haven’t addressed this issue head on — but then, neither has the leadership of many island nations, where “national AIDS prevention” is left to a couple of dedicated, but overworked and under-funded health staff.
What will the leaders say to their younger relatives 10 to 15 years from now when the lethal path of AIDS spreads far and wide? “We couldn’t talk about it because it involved sex?” It’s not much of an excuse. The reality is, of course, that to treat even a handful of patients with AIDS will essentially bankrupt the budgets of hospitals in many of the islands.
Whether it’s TB, leprosy, or AIDS, or some outbreak of an opportunistic disease like cholera, they are all cheaper to prevent than to treat. It just appears simpler to spend money on a travel authorization to send a patient to Hawaii than it is to fund programs dealing with the intangibles of behavior change. But as this issue’s health focus points out, a change in status quo thinking from island legislatures and parliaments is an essential ingredient to improving the health of Pacific Island populations.
