STATE OF THE ISLAND: Healthcare Revolution

 
Guam faces many challenges when it comes to the health of its community. These challenges include Guamanians’ access to healthcare, protecting the community from diseases brought in by travelers and migrants, the preventable non-communicable diseases that threaten Guamanians and the unhealthy diets and lifestyles of the people. Fundraisers for medical treatment or surgeries have become a normal part of Guam’s community. Healthcare and healthy initiatives have become a priority for GovGuam.
 
Access to Healthcare                                               
Helping Guamanians access quality healthcare is important. Access to healthcare means that people are able to use healthcare resources to preserve or improve their health and the health of their families.
 
Changing medical practices and new technologies have drastically increased the cost of healthcare in the United States. Without health insurance, families may have difficulty affording health care services. In 2010, almost 82,000 Guamanians had access to health insurance. Average premiums for private sector subscribers ranged from $2,130 to $2,711. Also in 2010, only one insurance company was willing to insure GovGuam employees, retirees and their dependents.
 
Today, almost 91,000 people are insured. An average premium for private sector insurance plans range from $2,522 to $2,734. In 2013, GovGuam gave their employees healthcare insurance options. They were able to choose from a group of three insurance providers. Each plan put forth by insurance providers was competitive, allowing Guamanians to choose the best plan for their family’s healthcare needs and financial restraints. Insurance now costs less for GovGuam employees than it did before. In fiscal year 2011 active employees paid an average of $180.46 each pay period on the 2000 Plan or $4,691.96 a year. In fiscal year 2013, active employees paid an average $135.46 on the same plan, or $3,521.96 anually. GovGuam employees have access to over 70 different clinics and services, fitness centers, and other services that promote healthy living.
 
Guamanians with low incomes and limited financial resources, who live below the poverty line, may access publicly funded programs for healthcare. Medicaid coverage and the Medically Indigent Program (MIP) help this specific population receive medical treatment and preventive care. Through Medicaid and MIP, 48,000[1]Guamanians have access to inpatient, outpatient, dental, optical, pharmacy, and off-island medical services.
 
Guamanians who cannot afford insurance, are not insured by their employer, or are simply not eligible for publicly funded healthcare coverage are burdened with paying for their medical treatment out-of-pocket. These people are not always able to afford to go to the doctor for annual physicals and regular check-ups. These routine doctors’ visits are used to determine how healthy one is, to catch the onset of disease, to address minor illnesses, or to treat health ailments that are not visible to the naked eye. Without these checkups, these people may wait to the eleventh hour to seek medical care–where drastic measures may be taken and the treatment is costly and unaffordable.
 
Guam Memorial Hospital                                                                  
Guam Memorial Hospital Authority, Guam’s only public hospital, provides healthcare services for the civilian population and visitors of Guam. Patients are given medical attention regardless of their ability to pay, without hesitation or delay. Although this puts a severe financial strain on GMH’s operation, patients that need acute care, urgent care, long-term care, and skilled nursing services are never turned away.[2]  On average, GMH provides care to 26,000 uninsured or self-pay patients annually. Uninsured/self-pay patients account for almost 20% of GMH’s patient charges, and for approximately 35% of GMH’s “open” receivables. Many uninsured or indigent people seek healthcare services when their condition requires hospitalization.
 
The Department of Public Health and Social Services (DPHSS) estimates 66,870 people are uninsured or underinsured, costing the hospital $30 million a year.[3]
 
Despite GMH’s financial challenges, they continue to provide services to every patient who seeks their help. In 2013, GMH completed the expansion of their Emergency Room and Intensive Care Unit. These improvements allow GMH to accommodate the growing patient population and the almost 30,000 patients who visit GMH’s emergency room each year.
 
Why do we need more healthcare? What is the health of our community?
 
Health of our Community                                          
According to DPHSS, Guam has been facing a health crisis. The youngest person diagnosed with diabetes is five-years-old. Children are exposed to second hand smoke that can lead to cancers in the future. Guam’s diet promotes obesity through the prevalence of fast food, processed food, high sugar, high salt, and trans fat and highly saturated foods, and people dying early from non-communicable diseases.[4]
 
From data collected from 2008-2011, Guam’s top five leading causes of death are heart disease, cancers (i.e. tumors, abnormal growth of tissue), cerebrovascular disease (i.e. hypertension, stroke), diabetes and septicemia (i.e. life-threatening infections.) The diseases listed above account for 58.8% of Guam’s overall death rate[5] during that time frame. Guam’s death rate is 810.6 people for every 100,000 people, which is 8.5% higher than the United States, which is 747 people per 100,000 people.
 
Guamanians are dying from hypertension and strokes, heart disease, and diabetes at rates significantly higher than the United States.
 
The data below shows the difference in death rates between Guam and the United States.

Guamanians are dying from hypertension and strokes at a rate 83.1% higher than the United States, from heart disease at a rate 42.3% higher than the U.S., and from diabetes at a rate 78.4% higher than the U.S. Heart disease, cancer, stroke, and diabetes are preventable. Research shows that these health issues are caused by alcohol abuse, tobacco use and exposure, physical inactivity, unhealthy diets, and obesity.  
 
According to the 2012 Behavioral Risk Factor Surveillance System (BRFSS) Survey, 32.4% of Guam’s population is considered overweight and 29.1% of Guam’s population is obese. This is attributed to the lack of fruits and vegetables consumed and poor overall diet and the lack of physical activity.  In 2012, BRFSS reported 33.3% of Guam adults did not participate in any physical activity during the past month. In 2009, only 24% of Guamanians were eating five or more fruits and vegetables a day.
 
Although trends show a decline in tobacco use, it continues to affect the health of our community. Heart disease, cancer, stroke, and diabetes are caused or worsened by the continued use of tobacco. In 2011, 30.5% of Guamanian adults and 21.9% of Guamanian youth were smoking.
 
The need for more Healthcare                                        
 
There is a need for us to address the issue by increasing access to preventive care and education measures and policies that help Guamanians lead healthier lifestyles and prevent these diseases from killing them.
 
Preventive care is essential to track the progression and onset of illnesses. If all Guamanians went to the doctor for their routine check-ups they can begin making necessary changes to their lifestyles or start receiving treatment. It’s in these doctor’s visits that men and women also learn how to recognize the symptoms of heart disease, cancer, hypertension and diabetes–they also learn how to avoid it.
 
If we can decrease the amount of investment that goes into treating diseases like heart disease, cancer, hypertension, and diabetes we can use these savings to invest in improving our environments to promote healthy living. Guam can invest in medical professionals and technology so patients don’t have to bear the expense of off-island treatment or simply living without it.
 
 
Improving the health of our island                                                   
GMH and DPHSS have been gearing up to address the healthcare needs of our community. GMH published their 2013 Strategic Plan to improve the healthcare services they provide.  The strategic goals center around helping GMH achieve financial stability, establish and sustain safety and quality, assess training and education, implement and plan for capital improvement projects, and develop their leadership team.[6]
 
The Department of Public Health and Social Services has also developed a strategic plan to combat Non-Communicable Diseases through health protection and promotion. The NCD strategic plan will drive healthy public policy, legislation and enforcement, advocacy systems and environmental change, supportive environments, health services, and community engagement. Their goal is to reduce premature non-communicable disease by 25%.
 
 
Infectious diseases brought to Guam & Immunization                    
Guam’s economy relies heavily on the number of visitors who come to Guam. With over a million visitors a year, the chances of diseases are high. In 2010, 1.2 million people visited Guam, followed by 1.1 million visitors in 2011, and a banner year in 2012 with 1.3 million visitors.[7] During these years, cases of cholera, dengue fever, and other diseases were diagnosed from people who traveled to other countries and from visitors.
 
In 2010, two cases of mumps were associated with visitors from Japan. That year 502 cases of mumps were recorded which was the highest on Guam since 1958.[8]
 
In 2011, one case of cholera was diagnosed from a patient who provided false contact information preventing true identification of the origins of the disease and three cases of dengue fever from the Philippines and Yap.⁸
 
In 2012, we saw more diseases imported to Guam from other areas.⁸

• Three cases of dengue fever were diagnosed in persons who traveled to the Philippines, Thailand and Palau.
• Three cases of Hepatitis B from people traveling from the U.S. mainland and Yap.
• Two cases of Hepatitis C from the CNMI.
• Twenty-four cases of Influenza A from Japan.
• One multi-drug resistant case of pneumonia from the CNMI.
• One case of MRSA (staph-infection) from the CNMI.
• And two cases of the contagious skin-infection scabies from the CNMI and Chuuk.

 
Over the next 10 years, Guam will expand its visitor markets overseas and the military buildup will bring thousands of military personnel and their families to our island. As migration increases, primary and specialist healthcare providers can expect to be faced with challenges to recognize, diagnose, and manage diseases that originate outside of Guam. With more people coming to Guam it is increasingly important for Guam to prepare for possible infectious diseases. Customs and Quarantine, DPHSS, and GMH are at the forefront of preventing a widespread outbreak of diseases our population is not prepared to handle.
 
The DPHSS preliminary Community Health Assessment Report shows that our immigrant population accounts for the highest incident rate of Hepatitis A, B and Varicella–all vaccine preventable diseases. However, the elevated hepatitis A and B rates may also be partly accounted for by in-migration from the other Pacific islands and Asian countries, where these diseases are highly endemic, with subsequent diagnosis made in Guam. In addition, the hepatitis B vaccine was introduced into Guam in 1988-1989 for targeted groups (infants, contacts of known cases); thus, individuals born prior to vaccine introduction would not have been immunized.
 
 
Currently, DPHSS has immunization vaccines available for eligible clients of all age groups:

• Tetanus
• Meningococcal Vaccine
• Influenza
• Human Papilloma Virus
• Hepatitis A
• Measles, Mumps, & Rubella
• Hepatitis B
• Polio
• Chicken Pox
• Hemophilic Influenza Type B
• Diphtheria Tetanus & Pertussis

 
Education and Outreach                                                                    
In 2007 all government agencies went smoke free and in 2009 smoking was banned in areas 20 ft. from public buildings. DPHSS statistics show a decline in smoking prevalence between 2007 and 2009. In 2010, P.L. 30-80 increased taxes on cigarettes and since then the Department of Revenue and Taxation reports a decline in cigarette sales. These policies have helped reduce the smoking prevalence rate on Guam.  In 2011 the prevalence of smoking on Guam for adults was 30.5%  (approximately 1 in 3 people) while the prevalence rate of the United States was 21.2%. In  2012, the prevalence of smoking decreased to 25.8% (approximately 1 in 4 people).
 
Tobacco Cessation programs on Guam include: [9]

• Guam Behavioral Health and Wellness Center 
  Mr. Peter J. Cruz, Cessation Facilitator
  (671) 477-8861
• Department of Public Health and Social Services
  Tobacco Prevention and Control Program
  Educational print and video materials                                                                      (671) 735-7334 / 303                                                                                                 Tobacco Free Guam Quitline Cessation Facilitation / Counseling by phone or on-line, Educational Material,  Free Sample of Nicotine Replacements (ie: gum and patches) 1-800-QUIT-NOW (1-800-784-8669); www.quitnow.net/guam
• Guam Memorial Hospital
  Ms. Renee Veksler
  (671) 647-2350
• U.S. Naval Hospital Guam 
  Mr. Luis K. Martinez
  Health Promotion Section                                                                                           Cessation Program for military personnel and dependents
  (671) 344-9124
• SDA Wellness Center
  Comprehensive healthy lifestyle program
  (671) 647-7521 to 24
• Sanctuary, Inc.
  Cessation program for youth
  (671) 475-7102
• FHP Health Center
  Smoking Cessation Class
  (671) 646-5825 
• University of Guam Student Health Center
  Cessation Program for UOG Staff and students
  Ms. Gloria Balajadia, (671) 735-2225 / 226

The NCD Strategic plan outlines a Tobacco Prevention and Control Action Plan with a goal to reduce the tobacco prevalence rate to 18% by the end of 2018. The NCD Strategic Plan uses policy changes and cessation resources to reach their objectives. Their three objectives are:

• Increase taxes by 100% on all tobacco products by December 2018
• Remove all exceptions in tobacco control mandates by December 2018
• To include Brief Tobacco Intervention (BTI), Cessation and ACS Freshstart program (online facilitator training) resources as part of Worksite Wellness Program by January 2015.

The plan’s strategies are to use guidance from the success of P.L. 30-80, engage community organizations, and strengthen and amend certain policies.
 
The outreach component consists of educational campaign tool kits, student talks, multi-lingual educational resources, social media campaigns, events, contests, and other public awareness campaigns targeting village organizations, schools, worksites, and clinics.
Aside from high tobacco rates, Guam struggles with obesity. The preliminary community health assessment shows trends of higher incidences of heart attacks, strokes, and cardio vascular disease in people with annual salaries of $24,999 or less. Let’s face it: processed foods are more affordable than healthier options. Guam families eat what they can afford–a can of luncheon meat is cheaper than a head of lettuce. Although the high cost of food plays a role in accessibility and the availability of healthy foods on our island, the root of obesity on Guam stems from poor eating habits as well as the lack of physical activity. 

 
For such a small island, Guam has a large issue with obesity.  The adult obesity rate for Guam is at an alarming 61.2% which is right behind the national average of 63%.  What is even more alarming is that based on a BMI study conducted by the Guam Department of Education in 2010 showed that 38.5% of GDOE students were overweight or obese compared to the national average of 32%.  Physical activity in adults on Guam is similar to the physical activity reported in the United States. However, reports show that only 37.4% of Guam youth get at least 60 minutes of physical activity a day for 5-7 days in comparison to 49.5% of youth in the United States.
 
The 2011 Guam Youth Risk Behavior Survey (YRBS) indicates that 15% of Guam’s high school students were obese, compared to 10.5% in 2001.  The YRBS almost shows that 59% of youth surveyed did not attend physical education (PE) classes in an average week when they were in school and 91% did not attend PE classes 5 days in an average week. The YRBS identified that better health education; more physical activity programs and healthier school environments would help reduce the obesity rate in Guam’s students.
 
One of the solutions, identified by the CDC, to improve the health of Guam’s children is to change the environments they are exposed to. Because students spend one-third of their time at school, the Department of Education recognizes that not every family has access to nutritious foods and not all students eat well-balanced nutritious meals at home. In 2010, GDOE started to make changes to the foods that were served and offered to students as well as started to look at ways at increasing physical activity in schools.  As a result of the Healthy Hunger-Free Kids Act of 2010, GDOE implemented a new meal plan to ensure that the food their students were exposed to were nutritious and healthy.
 
The New Meal Pattern sets specific requirements for the amount of fruits, vegetables, grains, meat/meat alternate, and milk. These requirements, determined by the United States Department of Agriculture, are designed to meet the nutritional and caloric needs of the elementary, middle, and high school students. (See chart)

A similar meal pattern is also available for the students who eat breakfast at school. In the month of October 2012, GDOE provided 161,303 free and 4,529 reduced breakfast meals, and 291,258 free and 12,893 reduced lunches. The meal patterns also have strict nutrient requirements for calories, trans-fat, saturated fat and sodium.
 
The following are guidelines used by GDOE to prepare lunches for their students:

• Vegetables must include
  • Dark greens (e.g. broccoli, collard greens, spinach)
  • Red/Orange (e.g. carrots, sweet potatoes)
  • Beans/Peas (e.g. kidney beans, lentils)
  • Starchy (e.g. corn, green peas, white potatoes)
  • Other (e.g. onions, green beans, cucumbers
  • Vegetables preparation:
    • Fresh, frozen, and canned products
    • A variety of no salt added/lower sodium products
    • Fruits
      • A daily serving at lunch
      • Can be fresh, frozen without added sugar, canned in juice/light syrup, or dried fruit options.
        • No more than half of the serving may be in the form of juice
        • 100% juice only
        • ¼ cup dried fruit=1/2 cup fruit
        • Grains
          • Schools must offer the daily and weekly serving ranges of grains
          • By 2015 all grains offered must be whole grain-rich (“Whole grain-rich” foods must contain at least 50% whole grains)
          • Grain based desserts (Only two creditable grain-based desserts allowed per school week)
          • Meats/Meat Alternates
            • At a minimum, 2 oz. daily for students in grades 9-12
            • At a minimum, 1 oz. daily for younger students
            • A variety of meat/meat alternates encouraged
            • Milk
              • Allowable milk options
                • Fat-free (unflavored or flavored)
                • Low-fat (unflavored only)
                • Fat-free or low-fat (lactose-reduced or lactose-free)
      • Schools must offer at least two choices of milk.

 
GDOE is also creating more avenues to encourage students to choose and eat more nutritious meals.  GDOE has incorporated one salad bar at Okkodo high schools which has increased student participation in the School Lunch Program.  Efforts are also in the works to provide salad bars for 5 elementary schools.  On top of providing more nutritious meals to students, the GDOE is also updating its current policies that affect the school environment to reflect the most current guidelines set forth by USDA.  Currently, GDOE has in place Board Policy 705 that mandates that any foods sold within the school environment or at any school sanctioned event must meet healthy nutrition standards.  This policy is now being reviewed by an advisory committee composed of GDOE partners and stakeholders to make suggestions to update it.
 
Aside from focusing on nutrition, GDOE is also taking an active role in encouraging schools to provide more avenues for students to increase physical activity within the school day.  School teachers and assistants are being trained to incorporate physical activity into the existing school curriculum.  For example instead of having students simply sit at their desk and learn about mathematics, teachers are incorporating movements like jumping jacks or squats into their subject matter.  Whether it’s structured physical activity in the classroom or playground, early morning calisthenics, or even organizing walk or bike to school programs, GDOE is actively encouraging all schools to increase ways for students to be more active.
 
Through the school meals programs, GDOE’s 31,000 students and their parents are being encouraged and taught to eat more vegetables, fruits, and whole grain-rich foods–foods that some families do not have regular access. If our students are not well fed and physically healthy, we cannot expect them to succeed.  GDOE understands the importance that nutrition and physical activity plays in relation to increasing academic performance of its students.  We want our students to go through the education system and learn how to live a healthy and active lifestyle–one that promotes increased academic performance for all our students.
 
 
The education system is just one component of teaching Guamanians to live healthy lifestyles. Adults spend most of their time in work. In 2010, DPHSS conducted random blood pressure screenings for a sample size of 1,400 employees. These screenings identified that 43.6% of participants had elevated blood pressure levels and most of them were not aware they did. A separate survey collected data on cholesterol levels, and nearly half of the group surveyed did not know they had elevated borderline cholesterol level. These screenings prompted the establishment and enhancement of a wellness program they could implement at work. GovGuam re-established the Worksite Wellness Program (WWP) in 2012 to encourage employees to get active, their goal was to get at least 10% of the 10,000 Government employees and their families to engage in wellness activities.
 
The program rewards employees for the length of time they are physically active throughout the workweek. It also designates time during the workday for exercise. In 2010, an estimated 6% of GovGuam employees were participating in a worksite wellness program, and has increased to 8% in 2013. The WWP anticipates increasing the participation throughout the government to 16% this year.[10]
 
In 2014 the WWP partnered with three insurance providers to conduct Health Risk Assessments on all the participants, and included a “counseling” station to help employees understand and interpret their assessment. This will help many decide how to take meaningful actions to improve their health. In 2014 more community organizations reached out to the WWP to become vendors at their screening events.   This year other new additions includes a “Pop Up” message that appears on all GovGuam workstations at the typical employee break times, 10 a.m. and 3 p.m. This message links them to website with exercise options suitable for office areas.
 
Islandwide activities through the NCD Consortium include the “Adopt-A-Park Project” with the Islandwide Beautification Task Force to help provide safe areas for children and adults to engage in physical activities.  NCD is working on the pilot “Safe Paths to School” project to encourage school children to walk to school.
 
Other indicators of an overall increase or peaked interest in physical activity is the rising number of participants in Guam’s major 5k’s, the opening of new fitness gyms, and the establishment and success of the Guam International Marathon and Ko’Ko Road Races. This may be attributed to the fitness benefits negotiated with insurance companies and employers offering free or discounted gym memberships at various gyms throughout the island. Guam has a total of 16 fitness gyms registered with the Department of Revenue and Tax–this means for every two miles of Guam there’s a fitness gym.
 
In 2011, Guam’s physical activity rate indicated that only 37.4% of Guam’s youth met the physical activity guidelines which is at least 60 minutes of physical activity a day, 5-7 days a week. The NCD strategic plan sets a goal of improving the amount of youth meeting the minimum physical activity guidelines to 47.4% by 2018 through their educational outreach programs.
 
Conclusion                                                                                         
The health issues on Guam will not be solved overnight. However, a clear vision, realistic goals, and practical methods will improve the overall health of the youth and adults on Guam. The solution is providing access to healthcare services, nutritious food, and physical activities. A part of our community does not have access to these things because they are not able to, financially. If more Guamanians can access preventive care, exercise programs or sports activities, we will see a decrease in the numbers of death by non-communicable diseases. Educating and exposing young children and their families to healthy and nutritious meal options are vital to the success of improving the health of our island.
 
It is too soon to measure the success of the recent policy changes for smoking and smokeless tobacco, the school lunch program, and worksite-wellness on the overall health of our island. However, these policies are changing the lives of Guamanians. The NCD Strategic Plan, school curriculum, and advocates for health have made tremendous strides in communicating the importance of maintaining a healthy lifestyle.
 
In the next year, the Guam Regional Medical City will help alleviate the burden that GMH faces by offering a second option to healthcare services. GRMC will be the first private hospital to open its doors on island.  GRMC will bring advanced-technology and medical expertise, which will augment existing services at GMH. These services include:

• Cardiology
• Oncology
• Endocrinology
• Pulmonology
• Neurology
• Orthopedics
• Opthalmology
• Ear, Nose and Throat
• General Surgery
• Ob-Gynecology, including high-risk OB
• Anesthesia
• Pediatrics, including Neonatology
• Infectious Disease
• Emergency Medicine
• Ambulance Services
• Laboratory
• Radiology
• Physical Therapy
• Pharmacy

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