Ebeye Community Health Center
In operation since 1986 on the island of Ebeye, the health center is located in the Kwajalein Atoll of the Republic of the Marshall Islands. A population of 11,000 people lives on the islands of Kwajalein Atoll, of which about 9,000 are on Ebeye Island, which is less than one mile long. Ebeye is one of the most densely populated places in the world, with a population density of 66,750/square mile (contrast this with New York City, which is the most densely populated city in the US, at 26,403 per square mile, or with Bombay, India at 70,241 per square mile). This service area has been identified as a Medically Underserved Area (MUA) as well as a Medically Underserved Population (MUP).
Ebeye CHC provides services through a clinic operated in conjunction with the outpatient department of the Ebeye Hospital, school-based health centers, and satellite clinics on neighbor islands. Ebeye Community Health Center (Primary Health Care and Preventive Services) and Ebeye Hospital (Curative Services) are institutionalized under the RMI Ministry of Health as the Kwajalein Atoll Health Bureau. The two divisions share a common facility where the health center occupies the majority of the bigger first floor area while curative and in-patient care (maternity, medical, surgical, pediatric, delivery and neonatal care, ICU, and surgical theater) occupying the second floor. The two divisions have learned and have almost perfected the system to co-exist – benefitting the patients and the community’s residents the most. This system ensures the continuity of care from primary to curative – and both emphasizing the importance of prevention. Medical staffs from the primary health care division may admit cases in the hospital. At the same time, medical staffs of the curative division, with their specialties, are utilized part-time in the CHC. Also, both divisions have access to referral programs for patients who may need tertiary care.
Kwajalein Atoll/Ebeye CHC’s primary mission is to improve the health of its residents by providing affordable access to quality and comprehensive health care.
The Governing Board has ultimate responsibility for the operations of the health center. The Governing Board selects the Executive Director (CEO) and defines his/her responsibilities. The Executive Director is accountable to the Governing Board for the operation and execution of policies and activities of the health center. The health center is a public entity being under the RMI Ministry of Health – and as such, the Governing Board and the Ministry of Health work together as co-applicants to create and sustain the health center.
The main clinic of Ebeye Community Health Center is a one-stop shop. It is open 24 hours a day seven days a week. Primary health care and out-patient services are available Monday – Friday from 8AM to 5PM. Some specialty services are also available in the afternoons. A dental department is also a part of the main health center. It provides various types of oral health care services including preventive and restorative procedures. Emergency Room services is open and staffed with nurses and one physician 24 hours and 7 days a week. Almost all of the ER staffs are certified BLS and ACLS providers. Other services include Laboratory, Radiology, Pharmacy, and a Rehabilitation Unit. There is an ambulance available for emergency cases 24 hours 7 days a week, including a boat to transport patients from the outer-islands who may need acute care in the main health center or to Ebeye Hospital.
Currently, patients of the health center have access to various specialists locally. Specialty services available include family medicine, public health, internal medicine, pediatrics, obstetrics-gynecology, general surgery, orthopedics, and general dentistry. However, some patients may require higher health care services (diagnostics and/or curative services) that are not available in Ebeye. The health center has access to various referral programs in such cases: (1) RMI outer-island services for patients who need to be sent to Majuro (capital of RMI) for special diagnostic procedures or specialty care, (2) RMI National Medical Referral Program for patients who may need care off-island such as in Philippines and Hawaii, (3)Tripler Army Medical Center in Hawaii which provide free complete medical and surgical services to Micronesians mainly based on GME value, and (4) Shriners Hospital for Children in Hawaii which provides complete free surgical services to kids with orthopedic needs. Medical providers need to present the cases and justify merit and need of referral before being approved. Additionally, the health center also coordinates with Canvasback Medical Mission – a non-profit organization who provides free medical supplies and specialty services to areas of need in the Pacific. The Taiwan government also at times sends specialty teams in the RMI to provide free services that are otherwise unavailable .
In addition, outer-island Dispensary Units were established several years ago within the service area. These are the Santo (Ennibur) Dispensary Clinic, the Guegeegue Dispensary Clinic, and the Ebadon/ Mejatto Dispensary Clinic. The island of Santo is about 50 miles from Ebeye and has a population of more than 1,200 that is rapidly growing. The island is right beside the Roi-Namur Base (a satellite base of the Ronal Reagan Test Missile Site). Meanwhile, Guegeegue is connected to the island of Ebeye by a causeway. The causeway is a rough road. On the average, transport between Ebeye and Guegeegue will take about 30-45 minutes. The community has one public and one private school. Its current population is about 400 people. Ebadon and Mejatto are the farthest islands within the atoll. It is about 70 miles from Ebeye. Life in Ebadon is simple. The air is clear and people live off the land. Their population is around 200 people. Unlike in the past when Santo Clinic is just being manned by health assistants – the clinic is now manned by a physician and a health assistant through the American Recovery and Reinvestment Act grant. The other dispensary units however are still being staffed with only health assistants. The clinics are almost open all the time where patients can come in at any time. Public health programs are delivered in these communities through the dispensaries and through the outreach teams. Radio communication is available to the main health center.
The three main outer-islands (Santo, Guegeegue, and Ebadon/ Mejatto) are visited by the outreach teams at least once every three months. Outreach teams are composed of at least one doctor and dentist, health educators, and public health program nurses. The services to be provided for each outreach trip is based on the priority needs of a particular community – this may mean sending several staffs from various programs such as Prenatal, NCD Prevention, STD Prevention, TB Prevention, Immunization, Mental Health, Substance Abuse Prevention, and even Cancer Prevention. Health promotion and education is almost always a part of the activity in every visit. The ARRA Increased Demand for Services grant has significantly improved the outreach services. The number of outreach visits has significantly increased; and primary care initiatives in the communities were strengthened. More and more outer-island residents are being served and the number of encounters has almost tripled for the past year alone.
The Health Center’s School-Based Health Program maintains a clinic in three of the seven schools on Ebeye, but also provides visit services in all other schools. Each school clinic is open for about 2 hours a day, providing primary healthcare and counseling services to the students, teachers, and sometimes even parents. The SBHP is an integral component of the Ebeye CHC. Services include annual physicals, oral health care, audiometric screening, nutritional status assessments, and primary health care consultations. Through annual physicals we are able to detect a wide range of illnesses from minor health problems to other serious health issues such as cardiac and respiratory problems, and ensure that they are referred to services within or outside of RMI. Children with bone and joint deformities were also diagnosed; and most were referred to Shriners Hospital in Hawaii that provides free orthopedic surgeries for Micronesians.
About the Community
87% of the population resides on the tiny island of Ebeye, which is less than a mile long. Overcrowding and limited housing are therefore serious problems. Ebeye is considered one of the most densely populated areas in the world given its small land area. A typical Ebeye household consists of several families living together, in one overcrowded, aging, single-storey wooden structure. Based on household surveys, the average number of people living in a single household is 20. It is not unusual to find a two-bedroom house with more than 30 occupants. Some households have their family members sleep in shifts as there are no adequate floor space for all its members. Cultural factors also contribute to overcrowding. Marshallese culture dictates that if a relative(s) show up at your doorstep looking for a place to stay – you are expected to take him/her in whatever the circumstances are. Overcrowding remains as one major contributor to poor health outcomes and spread of communicable diseases. The prevalence of water-borne and respiratory illnesses have remained very high over several years. Running water is unavailable in some households. Water quality is below par and is usually unsuitable for drinking. Residents must either use rainwater catchments or haul large containers of water from the water treatment plant or from the Kwajalein Missile Range base. Electrical services are subject to power outages whenever the island’s power plant runs out of fuel. Waste and sewage management also needs to be improved. All food must be brought in on a monthly barge and is thus very expensive. Fresh food produce such as fruits and vegetables are available sporadically when they are shipped-in monthly and there are no local agricultural programs available. Only about half of the residents complete a high school education; and only around 5% have obtained higher education. The low education and literacy rates impact the health center both in terms of recruitment of local staff and the health literacy of its patients.
The remaining 13% of the population are scattered across several outer- islands, accessible only by boat, making access to healthcare services heavily reliant on the service capacity of the CHC’s health dispensary units and outreach visits by the health center’s clinical providers. Health disparities exist within the outer island communities which have higher rates of non-communicable disease complications and poorer outcomes for perinatal Care. Mejatto, one of the outer-islands, poses unique challenges. Most of this island’s residents were originally from Rongelap Atoll which is one of the four atolls in the Marshall Islands that were heavily affected by radiations posed by the nuclear bombs that were tested on the nearby Bikini and Enewetak Atolls. The Rongelapese were relocated to Mejatto Island in the 80’s and have stayed on this island since then. Working with this population is very challenging as they have unique health problems such as higher rates of thyroid and cervical cancers.
The traditional Marshallese island lifestyle is still evident in small rural outer-island communities where families live together and survive off the land through fishing and agriculture. Family and social relationships are of primary importance. As the western presence in the Marshall Islands has brought more jobs, migration has also increased from the outer-islands to Ebeye. The increased population, overcrowded conditions, and migratory lifestyle resulted in the breakdown in the nuclear family. The influence of western culture has altered the traditional lifestyle into a strange hybrid of Marshallese culture and western materialism. The western influence has been integrated through clothing, music, entertainment and most notably in diet preference – but without the benefit or capacity of a western standard of living. Diet and lifestyle changes from traditional to western preferences – have led to the rise of Non-Communicable Diseases. Diabetes, Cardiovascular Diseases, and Cancers now rank as the top three causes of adult mortality not just in Kwajalein Atoll but in the entire Marshall Islands.
Recent estimates suggest that 99% of the population is under the 100% poverty level. Many Ebeye residents are migrants from the outer islands to this urban community in search of jobs and education. Unfortunately, employment opportunities are scarce. Around 70% of the adult population is unable to find jobs. A Compact of Free Association between the United States and the Republic of the Marshall Islands (RMI) allows for federal funding opportunities. The residents, however, are ineligible for Medicaid and Medicare benefits. All healthcare services are subsidized by the RMI National Government through the Ministry of Health and from the Community Health Center grants.
Health Status and Indicators
Between the periods of 2007-2009, the average Diabetes-related mortality in Kwajalein was 18.33 deaths per year. This accounts on the average 38.77% of all recorded deaths and around 51.7% of all recorded adult mortalities. With adjustment based on the estimated population of 14,000 residents in the area – Diabetes Mortality rate was computed at 130.95/100,000 population for the past 3 years. This is extremely high compared with the 22/100,000 rate in the
United States. Recent comprehensive STEPS-survey done by the WHO revealed that close to 30% of the RMI adult population has Diabetes. The same survey also revealed high rates of predisposing factors to Diabetes and other NCDs such as obesity, low physical activity, smoking, alcohol intake, and poor dietary habits. On this same survey, the prevalence of hypertension is 10.5% (+/- 3.5) with 11.6% for males and 9.3% for females. Meanwhile, percentage of adult users in the center diagnosed with hypertension is around 5.4%. In spite of establishing comprehensive prevention efforts in the entire country – NCDs namely Diabetes, CVD, and Cancer remain consistent as the top 3 causes of deaths in the population.
The Republic of the Marshall Islands has declared last year a state of health emergency against Tuberculosis. Confirmed cases of Multi-Drug Resistant Tuberculosis and the continuous rise in the prevalence of Tuberculosis have triggered the Ministry of Health to launch a major campaign towards elimination of the disease. With the assistance of health agencies and funding programs – the Ministry is putting a lot of work to control the spread of the disease. The health center pilots the initiatives and strategies of the Ministry in the service area which comprises around one-third of the Marshall Islands’ total population. This is a significant development in the service delivery.
Ebeye Community Health Center
Kwajalein Atoll Health Care Bureau
Ministry of Health
P.O. Box 5219
Ebeye, MH 96970
Phone: (692) 329-8030/8029 x 269
Fax: (692) 329-3385/3206