Photo: View of the Republic of the Marshall Islands from above. Dr. Nash Witten Photo.
The unique “hands-on” effort integrated multi-disciplinary teams of experienced volunteers, including a UH medical student, resident, and faculty members
Special to UH Med, contributors to this story: Arcelita Imasa, MS4; Nash Witten, MD; Seiji Yamada, MD, MPH
Members of the University of Hawaiʻi (UH) spent their summer in Majuro, the capital of the Republic of Marshall Islands (RMI) to participate in the “TB and Leprosy Free Majuro” project. This project is the largest screening and treatment campaign for active and latent tuberculosis (TB) in the contemporary era.
“It was an experience of a lifetime to have become a part of this global effort,” said Arcelita Imasa, MD 2019 candidate from the John A. Burns School of Medicine (JABSOM).
The project, which will last from June through September 2018, is a collaboration between RMI Ministry of Health workers, the U.S. Centers for Disease Control and Prevention (CDC), and World Health Organization (WHO).
“It gave me an understanding of where the Marshallese patients that I meet in our facilities in Hawaii are coming from in socioeconomic terms, but I definitely need to learn more about the healthcare system in the Republic of the Marshall Islands (RMI),” Imasa added.
People came from all over the world to take part in the project, including volunteer clinicians, nurses, and public health workers, largely recruited from the membership of the National TB Controllers Association.
Volunteers in Majuro. Photo by Dr. Nash Witten.
Along with Imasa, other JABSOM members involved in the project include Nash Witten, a second-year UH Family Medicine resident; Dr. Seiji Yamada, UH Family Medicine and Community Health faculty; and Dr. Kelly Withy, Hawaiʻi Pacific Basin Area Health Education Center (AHEC). AHEC supports efforts to train future healthcare workers for Hawaiʻi and the Pacific and helped fund the team’s transportation to and from Majuro.
Dr. Richard Brostrom, CDC Regional TB Field Medical Officer and JABSOM clinical faculty is the external project coordinator and visionary of the strategy to reduce the disease burden of TB and enhance the capacity to address TB in the Pacific Islands.
Dr. Brostrom is facilitating the program throughout its. The multi-year effort started in Ebeye, the second population center of RMI, in 2017.
“I am extremely grateful to UHFMRP, Hawaiʻi Residency Programs, Inc., and Dr. Brostrom for allowing me to participate in this visionary project during residency,” said Dr. Witten.
He adds, “It was a privilege to be able to work with the amazing team of volunteers from across the globe, but even more so to work with the passionate and committed local staff. I am continually impressed with the multitude of careers that are possible as a family physician, including organizing this novel project at a country scale.”
TB in Majuro
Majuro is home to approximately 28,000 Marshallese. The goal of the project is to screen 80% of the population. It is expected that more than 150 active TB cases and up to 7,000 cases of latent TB infection (LTBI) will be identified. Active TB cases are being treated by the RMI Ministry of Health TB program, while the project is treating the latent TB cases with short course of TB preventive therapy. The project also screens for Hansen’s disease among children and adults who receive chest x-rays, as well for diabetes among active and latent TB patients.
TB, mainly a lung disease but can also manifest in other organs of the body, is a bacterial infection that is treatable. The bacteria can be spread from a sick person through aerosols in the air via coughing, spitting and sneezing. A person with latent TB does not spread the disease.
While there are 2.8 TB cases per 100,000 in the U.S., the RMI’s incidence rate is staggering 422 per 100,000, and is considered the highest among the U.S.-affiliated Pacific Islands nations, which include American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Palau and RMI.
In RMI, the high prevalence of diabetes is a driver of the high rates of TB. It is estimated that diabetes triples the risk for developing TB. Also, the overcrowding found in Majuro, where one household can have more than a dozen individuals, compounded by poor ventilation, contributes to TB transmission. RMI also has a burden of other non-communicable diseases (NCDs) such as heart disease, stroke and cancer, a consequence of the unhealthy food supply and the lack of resources available to the healthcare system in RMI, all influencing the high burden of TB.
In particular, these volunteers took part in different lines of work of the Project including PPD placement and reading, x-ray screening, active TB referrals to local TB facility, LTBI treatment initiation, medication packaging, NCD counseling, and local healthcare workforce training. Roughly one hundred Marshallese were hired for the duration of the project to work as community health outreach workers (CHOWs) in order to package medications, deliver medications for LTBI, and to assist with PPD placement.
“The Marshall Islands,” said Dr. Yamada, “with a mean elevation of two meters, is highly vulnerable to sea level rise. By making the human habitation of remote atolls more precarious, climate change drives people to migrate to population centers such as Majuro. Such population shifts exacerbate the TB epidemic, but under Dr. Brostrom’s leadership, projects such as ‘TB Free Ebeye’ and ‘TB and Leprosy Free Majuro’ are helping to reduce the burden of disease.”
Dr. Yamada said, “Climate change is also contributing to migration out of RMI toward Hawaiʻi and the Continental U.S., however, those who participated in the project are not motivated by a desire to stop TB at the borders.
He adds, ”We are motivated by the spirit of aloha and a belief in the human right to health. Next year, TB-Free Chuuk!”