[Federal Register Volume 62, Number 103 (Thursday, May 29, 1997)]
[Notices]
[Pages 29125-29131]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-14027]
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DEPARTMENT OF ENERGY
Office of Environment, Safety and Health; Draft Notice of
Availability of Funds and Request for Applications for the Department
of Energy Medical Program in the Republic of the Marshall Islands
AGENCY: Office of Environment, Safety and Health, Department of Energy.
ACTION: Request for comments on the draft notice of availability of
funds and request for applications.
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SUMMARY: The Department of Energy (DOE) Office of Environment, Safety
and Health (EH) is requesting comments on a draft Notice of
Availability of Funds and Request for Applications to provide special
medical care to a specific group of citizens of the Republic of the
Marshall Islands (RMI). EH is especially interested in receiving
comments on program requirements. This draft Notice of Availability of
Funds and Request for Applications is a follow on to a more general,
annual notice of potential availability of grants and cooperative
agreements for epidemiology and other health studies published in the
Federal Register on October 16, 1996.
DATES: By this Notice, DOE is requesting comments on the draft Notice
of Availability of Funds and Request for Applications. Formal
applications are not requested and will not be accepted at this time.
DOE intends to hold a public meeting in San Francisco, California, in
July 1997, to provide a forum for discussion of the DOE special medical
care program in the RMI and this draft Notice of Availability of Funds
and Request for Applications. Parties interested in attending the
public meeting should notify the EH information contact listed herein
as soon as possible but no later than 2 weeks after publication of this
Notice of their intent to attend and/or make an oral presentation at
the public meeting. DOE will advise actual location, date and time of
meeting by letter to respondents.
COMMENTS AND ADDRESSES: Formal written comments on this draft Notice
may be submitted to EH via Neil Barss, Office of International Health
Programs (EH-63), U.S. Department of Energy, 19901 Germantown Road,
Germantown, Maryland 20874-1290, not later than thirty (30) days after
the public meeting. DOE will consider and may utilize all information,
recommendations, and suggestions provided in response to this Notice.
Respondents should not provide any information that they consider to be
privileged or confidential or which the respondent does not want
disclosed to the public. DOE does not intend to respond to comments,
either to individual commentors or by publication of a formal Notice.
After reviewing these comments, DOE may modify the draft Notice and
formally publish it in the Federal Register as a Notice of Availability
of Funds and Request for Applications To Deliver Special Medical Care
in the Marshall Islands.
This draft Notice should not be construed (1) as a commitment by
the Department to enter into any agreement with any entity submitting
comments in response to this Notice, (2) as a commitment to issue any
award concerning the subject of this Notice, or (3) as a request for
Applications. The mailing address for applications will be specified in
the future formal Notice.
FOR FURTHER INFORMATION CONTACT: All correspondence in response to this
Notice should be directed to Neil Barss, Office of International Health
Programs (EH-63), U.S. Department of Energy, 19901 Germantown Road,
Germantown, Maryland 20874-1290; telephone: (301) 903-4024; facsimile:
(301) 903-1413; or [email protected].
SUPPLEMENTARY INFORMATION:
Table of Contents
I. Purpose
II. Background
III. Program Requirements
IV. Applications
V. Application Instructions
VI. Award Information and Application Format
VII. DOE's Role
VIII. Applicants
I. Purpose
DOE provides a special medical care program for a specific group of
RMI citizens in accordance with Section 103(h) of the Compact of Free
Association Act of 1985, as amended, which mandates that the United
States ``shall continue to provide special medical care and logistical
support thereto for the remaining * * * members of the population of
Rongelap and Utrik [sic] who were exposed to radiation resulting from
the 1954 United States thermonuclear `Bravo' test, pursuant to Public
Laws 95-134 and 96-205.'' Section 104(a)(4) of Public Law 95-134,
enacted in 1977, directed the Secretary of the Interior to provide for
the populations residing on Rongelap and Utirik Atolls on March 1,
1954, ``adequate medical care and treatment * * * of any radiation
injury or illness directly related to the [``Bravo''] thermonuclear
detonation * * *'' Section 104(a)(4) goes on to state that, ``The costs
of such medical care and treatment shall be assumed by the
Administrator of the Energy Research and Development Administration,''
a precursor agency to DOE. Pursuant to this congressional mandate, DOE
is required to provide a special medical care program consisting of:
Medical screening, diagnosis and treatment for radiation-
related diseases, illness or injuries (see Appendix A for definition)
in an economically disadvantaged tropical environment in the central
Pacific.
Medical care and treatment of other diseases or injuries
as time and resources permit.
Administrative management, cognizance and oversight of
patients and patient records, clinical referrals and followups as
medically appropriate.
DOE is currently seeking ways to more effectively and efficiently
deliver special medical care services in the Marshall Islands to an
aging population, and to spend more of the allocated budget on medical
services rather than logistical support .
DOE intends to award one (1) cooperative agreement in support of
the RMI special medical care program by late first quarter fiscal year
(FY) 1998. The cooperative agreement award will be for a one (1) year
budget period, and may be negotiated and renewed annually as
continuation awards for up to four (4) additional years.
[[Page 29126]]
The current funding level for the implementation of the medical
program is $1.1 million annually.
II. Background
As a result of the 1954 United States' thermonuclear ``Bravo'' test
in the Marshall Islands, approximately 253 Marshallese people
(hereinafter referred to as patients) on Rongelap and Utirik Atolls
were exposed to high levels of radioactive fallout. Since 1956, DOE and
its predecessor agencies have provided medical care to these patients.
Within DOE, this special medical care program is currently administered
by the Office of International Health Programs for the Assistant
Secretary for Environment, Safety and Health.
Currently, there are three programs providing medical care in the
RMI. The first is provided by the RMI Ministry of Health for the
national primary medical care of approximately 60,000 people. This care
is delivered by means of primary and secondary care facilities on Ebeye
and Majuro islands, with smaller facilities in the remote outer islands
that function as first aid stations, providing limited primary care and
pharmaceutical capabilities (see Appendix B for details). Two-way radio
is the primary means of inter-atoll communications, and medical
emergencies are transported by air from the outer islands to Ebeye or
Majuro.
The second is known as the 177 Health Care Program (177 HCP),
described in section 103(j) of the Compact of Free Association Act of
1985 as the Four Atoll Health Care Program. This program provides
medical care for the people of the Atolls of Bikini, Enewetak, Rongelap
and Utirik who were affected by the consequences of the 1946-1958 U.S.
nuclear testing program in the northern Marshall Islands, and their
descendants. The program is administratively overseen by the Department
of the Interior (DOI), is funded by the Congress through the DOI, and
is currently implemented by Mercy International, Inc., under contract
to the RMI Ministry of Health. The program serves approximately 10,600
individuals (which includes the non radiation-related medical needs of
the current DOE patients) and provides primary medical care, secondary
referrals to the hospitals at Ebeye and Majuro, and tertiary referrals
to the Queen's Medical Center and Group in Honolulu, Hawaii.
The third is the special medical care program provided by DOE to
approximately 238 patients in the Rongelap and Utirik communities.
DOE's special medical care program currently provides biannual
medical screening visits and full medical care for radiation-related
conditions for the remaining 131 members of the original patient
population, as well as medical treatment for approximately 107 people
in a comparison group. From the inception of DOE's program, medical
treatment has been delivered biannually by teams consisting of
Brookhaven National Laboratory (BNL) employees supplemented with
volunteer medical specialists. Logistical support for DOE's medical
missions has also been provided by a contractor, which is currently
Bechtel Nevada Corporation.
Those DOE patients with medical conditions that can be effectively
managed in the Marshall Islands are either treated by the BNL medical
personnel at the U.S. Army hospital on Kwajalein island, or are
referred to the 177 HCP. Since 1986, patients have been referred to the
177 HCP for continued care during the time between BNL screening visits
and for non-radiation related disease or injuries. Currently, the 177
HCP has not been able to adequately meet all the medical needs of the
DOE patients.
Those DOE patients with radiation-related medical findings that
cannot be managed in the Marshall Islands are referred to Straub
Hospital and Clinic in Honolulu for tertiary evaluation and treatment.
In 1995, DOE started to transition from biannual vessel-based
medical missions to biannual land-based medical missions. Vessel-based
missions were handicapped by the inability to keep a vessel equipped
with state-of-the-art medical equipment. The land-based approach has
improved the quality of medical care delivery for the patient
populations in Rongelap and Utirik and will also affect cost
efficiencies. This approach makes available, at existing medical
facilities in the Marshall Islands, more sophisticated diagnostic
equipment and improved laboratory capabilities, for example: use of
ultrasound equipment; ability to perform immediate fine needle
aspiration or thyroid surgery; availability of certified mammography
equipment at Kwajalein and other medical equipment that permits
immediate followup, additional tests, and surgery when needed.
As with vessel-based care, the land-based system includes visits to
infirm patients in their homes at Mejatto and Utirik. Land-based
medical assets have also added the ability to provide full diagnostics
and tests of samples taken right after the visit to these remote
islands, rather than (as previously) shipping such samples for analysis
to the U.S. mainland.
In January 1997, the RMI requested the DOE to compete the current
special medical care program due to problems being experienced by the
177 HCP and the RMI's desire to spend more of the allocated budget on
medical care rather than logistical support services.
III. Program Requirements
A. General
The awardee will be required to execute a high quality special
medical care program within DOE requirements and budget; provide
continuity with the medical program conducted since 1956; and operate
in a highly visible international political environment and under
rigorous oversight by the U.S. Congress.
Applications should be based on a budget of $1.1 million annually
over a 5 year period. In preparing applications to deliver DOE's
special medical care program in the RMI, potential applicants should
consider innovative ways to:
(a) Provide full time medical services in the Marshall Islands to
the Rongelap and Utirik communities, sufficient to cover the medical
needs of the effected Marshallese citizens.
(b) Collaborate or coordinate medical care delivery with local
Marshallese health care providers.
(c) Use telemedicine and other electronic technologies that enhance
professional communications and maximize cost savings.
(d) Use recruited volunteer medical professionals to maximize cost
savings.
(e) Use current DOE contractor support (i.e., Bechtel Nevada
Corporation, the Straub Hospital and Clinic, and the U.S. Army Hospital
at Kwajalein) or propose a replacement for the services provided by
these contractors (see Appendices C, D, and E, respectively, for
currently provided services). Applications that propose replacement
services should emphasize more dollars being spent for medical care
rather than logistic support, but may provide a cost estimate that
exceeds $1.1 million annually.
B. Project Description
For the approximately 238 patients, whose general medical and
demographic information is summarized in Appendix F, the awardee shall
either itself implement or use subcontractors for the following special
medical program requirements:
The DOE Clinical Medical Program
For this program element:
(a) Conduct and implement a special medical care program for
patients with
[[Page 29127]]
radiation-related diseases, illness or injuries in a tropical and
under-developed area of the world that includes treatment of as much
non radiation-related disease as medically indicated. The special
medical care program should be implemented by primary care medical
professional(s) augmented by physicians with specialties in oncology,
diagnostic radiology, gynecology, internal medicine, and endocrinology,
as appropriate.
(b) Provide the services of other medical specialists, as indicated
by patient condition, including but not limited to the fields of:
allergy/immunology, cardiology, dentistry, dermatology, emergency
medicine, family practice, gastroenterology, geriatrics, hematology,
infectious diseases and parasitology, nephrology, neurology, nuclear
medicine, obstetrics, ophthalmology, pathology, physical medicine,
pulmonary medicine, rheumatology, surgery, tropical medicine and
therapeutic radiology.
(c) Provide, in addition to the physician services specified in
this section, nursing, pharmacy, radiology (including nuclear
medicine), clinical laboratory, histology and pathology, inpatient,
outpatient and technical medical support services.
(d) Institute appropriate ethical safeguards that include obtaining
the express written consent of any patient for participation.
(e) Provide appropriate gender medical personnel to accommodate
Marshallese cultural sensitivities.
(f) Conduct medical examinations in accordance with medical
screening recommendations, published guidelines or standards (e.g.,
American Cancer Society, American College of Physicians, U.S.
Preventive Services Task Force of the Department of Health and Human
Services, etc.).
(g) Provide radiology services that include:
(1) Mammography utilizing a unit that is certified by the American
College of Radiology and complies with U.S. Food and Drug
Administration regulations.
(2) Diagnostic equipment that has been inspected for radiological
safety and approved for operation (e.g., chest x-ray, nuclear medicine
imaging or therapy, mammography).
(3) Therapy as clinically prescribed for the treatment of cancer.
(h) Conduct examinations of the thyroid gland including:
(1) Thyroid ultrasound measurements.
(2) Palpation of the thyroid by a physician skilled in such
technique.
(3) Appropriate blood and chemistry tests of thyroid function
(e.g., TSH, T3, T4).
(i) Provide diagnostic and clinical laboratory services, as
appropriate.
(j) Utilize laboratory testing capabilities and services that
comply with the requirements specified in the Clinical Laboratory
Improvement Amendments of 1988 (documentation required).
(k) Provide appropriate immunizations, as indicated by patient
needs.
(l) Provide pharmaceuticals based on the needs of the patients.
(m) Provide pathological services for the identification of cancer.
Logistical and Administrative Support
For this program element:
(a) Obtain insurance (and documentation thereof) for medical
malpractice and comprehensive general liability, for $1 million per
occurrence and $3 million aggregate for each insurance type.
(b) Implement non-medical administrative functions in support of
the special medical care program, which shall at a minimum include the
following:
(1) Provision of non-medical personnel and administrative staff
services to adequately support the medical personnel and services.
(2) Unless the current contractors and subcontractors are replaced
by either the awardee or the awardee's subcontractors, the awardee will
be required to:
(i) Establish and maintain a working programmatic relationship with
Bechtel Nevada Corporation which not only currently provides the
logistic needs of the medical program, but also DOE's radiological and
environmental monitoring programs.
(ii) Establish and maintain a working programmatic relationship
with the current secondary or tertiary referral facilities (U.S. Army
Hospital at Kwajalein and Straub Hospital and Clinic in Honolulu). DOE
currently has a Memorandum of Understanding and a contract,
respectively, with these facilities to provide the services.
(3) As applicable, establish and maintain a working programmatic
relationship with existing medical providers in the Marshall Islands
and/or the 177 HCP using the capabilities listed in Appendix G, to help
implement the DOE special medical care program.
(4) Provide current state-of-the-art methods for the consolidation,
storage, management and retention of current and historical patient
medical records and medical program operational records. This will
include receipt from the current DOE provider of approximately 30 cubic
feet of all hard copy medical records, a similar volume of records
compressed onto compact discs and an Oracle
database of current patients.
(5) Protect the confidentiality of patient medical information and
records.
(6) Implement a continuing quality control and assurance program
for all clinical medical and recordkeeping aspects of the program
necessary to maintain compliance with applicable medical standards.
(7) Develop and implement a transition phase with Brookhaven
National Laboratory.
Direct Marshallese Involvement
For this program element:
(a) Interface, establish and maintain a working relationship with
Marshallese appointed spokespersons and/or citizen advisory committees
in the Rongelap and Utirik communities to:
(1) Consult and inform before implementing any changes in the DOE
special medical program.
(2) Establish a regular process that receives community and patient
input and feedback on DOE special medical program activities.
(3) Recommend improvements in the care delivery.
(4) Inform DOE of Marshallese concerns and work with DOE to
accommodate the concerns within a framework of DOE's legal mandate,
funding and sound medical practice.
(b) Develop and implement a Rongelap and Utirik community health
outreach educational program that:
(1) Reflects DOE and Marshallese community representative input on
Marshallese history, language, culture and the experience of DOE or its
predecessors for the past 45 years (e.g., development of videotapes,
brochures and handouts for health care provider briefings and use).
(2) Helps patients and their family members learn about medical
program activities and findings by distributing and explaining an
annual report.
(3) Utilizes Marshallese public health educational materials and
brochures.
(4) Augments Marshallese public health and educational materials
where germane to the medical care being provided by the awardee (e.g.,
provision of handouts, brochures or videotapes for Marshallese use).
(5) Advises on the known relationships between radiation dose and
health effects.
(c) Develop and implement a training program for Marshallese
medical and
[[Page 29128]]
para-medical, and/or technical support professionals for the special
medical care program that includes:
(1) A needs assessment as to the types and number of professionals
(physicians, physician assistants, nurses, support service
technicians).
(2) Recommendations on how to meet needs using the indigenous
Marshallese population.
(3) Means to provide training and ``on-the-job'' practical
experience in the Marshall Islands.
(4) Consideration of available regional educational resources to
meet these objectives.
(d) Develop and implement a plan to build an infrastructure in the
Marshall Islands with respect to:
(1) Partnerships with local health care providers.
(2) Facilitating the training of Marshallese professionals.
(3) Acquisition and use of medical equipment.
Development of Documentation
At the time the special medical program is implemented, the
following will be required:
(a) Written protocol(s) and/or manuals describing procedures and
associated forms to be used by the medical professionals for medical
examinations, patient referrals, and overall administrative
implementation of a special medical care program that includes:
(1) Identities, qualifications and biographies of medical or
medical program experience for all persons providing medical,
technical, nursing and administrative support services.
(2) The awardee's selection and qualification criteria for all
personnel who will participate in or implement the program.
(3) Involvement of local Marshallese medical, health and support
personnel, including:
(i) Participation of medical and other health care or technical
professionals.
(ii) As applicable, selection and qualification criteria by which
these personnel will be made eligible to participate.
(iii) Provision of bilingual Marshallese/English speaking
individuals for adequate communication, translation and the
interpretation of examination results and meaning between the patients
and the care providers.
(4) Frequency and types of patient examinations.
(5) Method(s) of patient examinations and treatments that afford
personal privacy.
(6) Method(s) by which patient informed consent and medical release
will be obtained for any medical examination or treatment modality that
ensures patient understanding in Marshallese.
(7) As applicable, method(s) by which a program physician will
interface with existing medical care providers in the Republic of the
Marshall Islands and the Pacific region and provide referrals as
needed.
(8) Method(s) by which medical services will be provided to those
patients (approximately 25) who habitually reside in the United States,
such as other medical care insurance options in lieu of awardee
provided medical services.
(9) Method(s) by which the program referring physician will consult
with and remain continually cognizant of the medical condition and
results of a patient referred to another medical professional or
organization identified in items (7) or (8).
(10) Method(s) to inform all patients (or their designated
guardians) in Marshallese of individual medical results and any
additional followup actions necessary.
(11) Method(s) by which pharmaceuticals will be obtained,
inventoried, managed and dispensed.
(12) Method(s) for retaining, storing, maintaining, or releasing
(to honor a lawful request), patient tissue samples and specimens used
for pathological classification of disease.
(13) Method(s) by which the awardee will implement the working
programmatic relationships with any contractor or regional health care
provider.
(b) An annual summary report (in English and Marshallese) on the
following:
(1) Program activities, medical conditions and statistical analyses
of the findings.
(2) Number of individuals remaining in the patient and comparison
populations.
(3) The overall health of the two populations and the
identification of any special risks to their health.
(4) Identification of all medical, nursing, technical practitioners
and support personnel that performed provider services.
(5) Identification of patient related medical problems with
recommendations for improvement or resolution.
(6) Progress made on strategic plan initiatives.
(7) Recommendations to improve programmatic functions.
(c) A strategic plan which proposes and details ways to:
(1) Achieve partnership and coordination with the RMI medical and
health organizations.
(2) Evolve medical partnerships and coordinate awardee's resources,
to the greatest extent possible, with local Marshallese or U.S. Federal
resources, to:
(i) Strengthen local healthcare delivery.
(ii) Involve local personnel in medical activities.
(iii) Share new skills and technical knowledge.
(iv) Strengthen local land based assets such as radiologic,
pathologic and laboratory support services.
(3) Maintain a cost effective medical program as the patient
population ages and incurs greater needs for medical services.
(4) Use other local or regional health care and/or logistical
support capabilities or services to supplement and maximize the above
objectives conducted in the Marshall Islands.
(5) Use other clinical referral options outside the Marshall
Islands.
Cost Reporting Requirements
(a) The awardee shall implement cost containment measures,
maximization of financial savings, and negotiation of subcontracted
services to maintain a high quality special medical care program in
accordance with applicable medical care standards and DOE budgetary
constraints. At a minimum, the cost reporting requirements that will be
required under the cooperative agreement will include but not be
limited to providing:
(1) Budget, financial and programmatic activity reports. The
contents and formats are to be specified and revised as necessary by
DOE.
(2) A monthly report of all program expenditures.
(3) Fiscal planning and budget information in the format prescribed
by DOE.
(4) A separate itemized price list (detailing both direct and
indirect costs) for all clinical medical examinations, treatments,
services or supplies to conduct and implement the medical program for
any anticipated medical referrals.
(5) A separate itemized price list for the direct and indirect
medical program and non-clinical administrative and program management
aspects, salaries, and supplies for the proposed support services.
(6) A separate itemized price list for any service that is
anticipated to be subcontracted.
(7) A separate itemized price list for any capital equipment that
must be
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purchased to implement the medical program.
(8) The formula or estimated cost for each of the following non-
priced listed items:
(i) Special DOE requests (e.g., record duplication, statistical
analysis of medical findings, special topical reports in response to
RMI or congressional inquiries).
(ii) Non-stocked medical or administrative items and supplies.
(iii) Cost of any other service or expense that the provider
intends to charge but does not appear on a price list.
IV. Applications
This Notice of Availability of Funds and Request for Applications
is issued pursuant to DOE regulations contained in 10 CFR part 602:
Epidemiology and Other Health Studies Financial Assistance Program, as
published in the Federal Register on January 31, 1995 (60 FR 5841). The
Catalog of Federal Domestic Assistance number for 10 CFR part 602 is
81.108, and its solicitation control number is EOHSFAP 10 CFR part 602.
10 CFR 602 contains the specific requirements for applications,
evaluation, and selection criteria. Only those applications following
these specific criteria and forms will be considered. Application forms
may be obtained at the address previously cited. Applications will be
peer reviewed by evaluators apart from DOE employees and contractors as
described under section 10 CFR 602.9(c), and submission of an
application constitutes agreement that this is acceptable to the care
provider(s) and the submitting organization.
V. Award Information and Application Format
A. General
The application shall contain two volumes, technical and cost.
Technical Applications shall be no more than one hundred (100) pages in
length; resumes of key personnel should be submitted as an appendix to
the technical application and will not be counted against the page
limit. Cost proposals have no page limit.
The cost proposal will be structured to include a five (5) year
project period consisting of five one (1) year budget periods. A
cooperative agreement will be awarded for the first budget year only
and may be negotiated and renewed annually as continuation awards for
up to four (4) additional years based on the availability of funds and
the awardee's continuation application, which will be submitted not
later than 120 days before the end of each budget period.
It is left to the applicant to determine how best to structure the
proposal. However, the application shall include a detailed project
description that discusses and demonstrates the applicant's ability to
successfully conduct the RMI special medical care program in general,
and to specifically perform the activities described in the draft
project description in section III.B. including the technical and cost
reporting requirements. The applications shall not merely offer to
perform work in accordance with the draft project description but shall
outline the actual work proposed as specifically as possible.
B. Specific Application Instructions
Applications must include the following information that:
(a) Demonstrates that the applicant has the experience and
capability to plan, organize and manage the special medical care
program.
(b) Demonstrates the competency of personnel and the adequacy of
resources.
(c) Identifies technical and administrative staff, and detail their
professional experience as well as their level of program involvement.
In the event that any of the proposed personnel are not currently
employed by the applicant, letters of commitment from those individuals
shall be submitted.
(d) Itemizes the medical diagnostic or laboratory equipment that
the applicant intends to use for this program, and how the applicant
will integrate such equipment with the Government provided equipment
listed in Appendix H.
(e) Specifies the location(s) where services will be obtained. The
applicant is free to propose referral locations of its choosing within
or outside of the Marshall Islands, provided that all services are made
available to the entire patient population.
(f) Identifies the recommendations or standards to be used to
satisfy the requirements of section III.B., paragraph (f) and any
reason for exception(s) taken by the applicant to those standards.
(g) Contains initial concepts for the training program development
requirements of paragraph (c) under Direct Marshallese Involvement.
(h) Contains initial concepts for the development and
implementation of the applicant's plan to meet the Marshall Islands
infrastructure requirements of paragraph (d) under Direct Marshallese
Involvement.
(i) Contains a short-term plan detailing milestones and deadlines
stating:
(1) Applicant's requirements for a transition phase with BNL.
(2) When independence will be achieved to implement all aspects of
the medical program.
(j) Contains initial concepts for the strategic plan required by
paragraph (c) under Development of Documentation, that includes
milestones and deadlines for implementation.
(k) Provides a cost proposal for the first budget period year (year
1) detailing expenses associated with the following:
(1) The clinical medical aspects of implementing the special
medical program.
(2) All non-medical administrative staff functions to implement the
special medical program.
(3) The logistical support of the special medical program and
services in the Marshall Islands.
(4) The transportation of patients within or outside the Marshall
Islands.
(5) The use of any current DOE contractor.
(6) The use of any other alternative instead of the existing DOE
contractors to provide any of the required services for any of the
budget years.
(l) Contains estimated cost information supporting the applicant's
project description for budget years 2 through 5.
VI. Application Review and Evaluation Criteria
Formal applications will be subjected to formal merit review (peer
review) and will be evaluated against the following criteria, in
descending order and codified at 10 CFR 602.9:
(a) The medical and technical merit of the proposed special medical
program.
(b) The appropriateness of the proposed program.
(c) Competency of the program personnel and adequacy of proposed
resources.
(d) Reasonableness and appropriateness of the proposed budget.
Formal applications will be peer reviewed by evaluators apart from
DOE employees and contractors as described in the EH Merit Review
System (57 FR 55524, November 25, 1992) and at 10 CFR 602.9. Submission
of an application constitutes agreement that this is acceptable to the
investigator(s) and the submitting institution.
VII. DOE's Role
In order for DOE to utilize a cooperative agreement for this
medical program, there must be substantial involvement between DOE and
any awardee(s). DOE established the core requirements for this program
and
[[Page 29130]]
prepared this Notice of Availability of Funds and Request for
Applications. DOE will conduct the selection and award process, which
will include evaluations by persons outside the Federal Government. DOE
will utilize the results of these evaluations and make one initial
award. Continuation awards may be made based upon the availability of
funds and other DOE performance criteria that will be set forth in any
initial award. DOE will consult with program medical professionals and
coordinate joint provider(s) and Marshallese community meetings. DOE
will consult with representatives from the RMI national and local
governments, the Department of the Interior, the Department of State
and the Department of Health and Human Services on the medical program.
Finally, DOE will monitor and evaluate the performance and delivery
of the medical program by conducting program reviews and the patients'
level of satisfaction to determine adequacy of program delivery.
VIII. Applicants
Applicants for the cooperative agreements could include domestic or
international nonprofit and for profit organizations, universities,
medical centers, state or local government health care organizations,
labor unions and other employee representative groups, small, minority
and/or women-owned businesses or other domestic or international health
care organizations. Consortiums of interested organizations are
encouraged to apply. Awardee(s) for the medical program will work
cooperatively with Marshallese health care providers, current DOE
contractors (as applicable), other regional health care providers and
designated Marshallese community representatives.
Issued in Washington, DC, on May 22, 1997.
Paul J. Seligman,
Deputy Assistant Secretary for Health Studies.
Appendix A--Definition of Radiation Related Disease, Illness or Injury
For the purposes of this program, applicants shall consider the
following to be radiation related diseases, illness or injury:
(a) Any thyroid cancer, other tumor or thyroid nodule that has
been found as a result of medical evaluation.
(b) In accordance with Public Law 101-426, ``Radiation Exposure
Compensation Act'' (October 15, 1990), the following are considered
latently expressed diseases attributed to radiation:
(1) Leukemia (other than chronic lymphocytic leukemia).
And the following diseases, provided onset was at least 5 years
after the first exposure to radiation:
(2) Multiple myeloma.
(3) Lymphomas, other than Hodgkin's disease.
(4) Primary cancer of the thyroid, provided that the initial
exposure occurred by age 20.
(5) Primary cancer of the female breast, provided that the
initial exposure occurred prior to age 40.
(6) Primary cancer of the esophagus, provided low alcohol
consumption and not a heavy smoker.
(7) Primary cancer of the stomach.
(8) Primary cancer of the pharynx, provided not a heavy smoker.
(9) Primary cancer of the small intestine.
(10) Primary cancer of the pancreas.
(11) Primary cancer of the bile ducts.
(12) Primary cancer of the gall bladder.
(13) Primary cancer of the liver, except if cirrhosis or
hepatitis B is indicated.
Appendix B--RMI Medical Program Information:
Available RMI Medical Facilities and Services for DOE patients:
(a) Local dispensaries at Utirik and Mejatto provide limited
medicine and first aid, and are staffed by medical personnel with
MEDEX level training and experience (i.e., between a regional nurse
and nurse-practitioner). Short-wave radio communications are
maintained between the dispensaries and the off-island medical
health care providers (up to 300 miles distant) to discuss serious
medical conditions.
(b) A small 34 bed community hospital is available with limited
capabilities in a community of 12,000 living on Ebeye (an island of
approximately 4 square miles located 2 miles from Kwajalein island
where the U.S. Army contractor-operated hospital facility that
serves the base personnel is located).
(c) A 75 bed hospital is available with limited capabilities to
serve 29,000 living on the capital island of Majuro. This hospital
also receives referrals from the entire national population of
60,000.
Appendix C--Bechtel Nevada Corporation Medical Support Capabilities
(a) Provides all logistics to transport and support medical
program personnel to the Marshall Islands twice a year, which is
currently limited to travel, lodging and per diem costs west of
Honolulu.
(b) Provides all logistics to transport and support ambulatory
patients and their authorized medical escorts to medical facilities
at Kwajalein.
(c) Provides all logistics to transport medical personnel for
subsidiary home visits to non-ambulatory infirm patients at Mejatto,
Ebeye, Utirik and Majuro.
(d) Provides transportation and support to RMI medical personnel
assigned to participate in the DOE special medical program.
(e) Operates and provides all logistics and support services for
patients referred to the Straub Hospital and Clinic located in
Honolulu, Hawaii by Brookhaven National Laboratory. The services
provided include:
(1) Bilingual Marshallese/English speaking escorts to accompany
patients.
(2) Coordination of patient travel and medical appointment
schedules.
(3) Lodging and per diem arrangements and expenses.
(4) Coordination between Brookhaven National Laboratory and the
Straub Hospital and Clinic on medical services, as required.
(f) Conducts market research on the availability of marine
assets in the U.S. and Central Pacific Area to support a limited,
sea-based medical program.
(g) Issues and monitors the Straub Hospital and Clinic medical
services subcontract.
(h) Administers and manages the DOE's interagency agreements
with the U.S. Army at Kwajalein and Hickam Air Force Base at
Honolulu.
(i) Implements terms and conditions, including the making of
payments and collections under DOE's agreements with other agencies,
and instrumentalities of the RMI.
(j) Implements requirements as directed by DOE during the course
of the year.
(l) Interfaces and coordinates with the U.S. Army at Kwajalein
to provide the following in accordance with a Memorandum of
Understanding between DOE and the U.S. Army:
(1) Marine craft (currently a LCU) used to transport patients to
and from Mejatto.
(2) Hospital services as delineated in Appendix E.
(3) Trailer rentals for medical use (currently 2, each 660
square feet).
(4) Housing, lodging and dining facilities for patients and
medical team members.
(5) Maintenance of facilities and equipment.
(6) Aircraft services limited to within Kwajalein Atoll at no
cost.
(7) Automotive services used to transport patients at Kwajalein.
(8) Recreational services for medical team use.
(9) Public services used to announce medical team activities at
Kwajalein.
(10) Ferry services between Kwajalein and Ebeye at no cost.
Appendix D--Services Provided by the Straub Hospital and Clinic Located
in Honolulu, Hawaii
(a) Complete and comprehensive medical services for DOE patients
that have radiation-related diseases.
(b) Refers diseases diagnosed as non radiation-related back to
the 177 HCP.
(c) Provides certified and accredited medical personnel.
(d) Provides price list as basis for charges.
Note: Straub Hospital and Clinic is accredited by the Joint
Commission for Accreditation of Hospital and Health Care
Organizations.
Appendix E--Medical Services Provided by U.S. Army Hospital at
Kwajalein in the RMI
In accordance with a Memorandum of Understanding between DOE and
the U.S.
[[Page 29131]]
Army, the following medical services are provided at the U.S. Army
Hospital in Kwajalein:
(a) Laboratory Services
(b) Mammography Screening
(c) X-ray Screening
(d) Proctosigmoidoscopy
(e) Limited Surgery (e.g., appendectomy, amputations for
advanced diabetic conditions)
(f) Professional Services (physicians, nurses, technicians)
(g) Safety inspection and certification of mammography and x-ray
equipment by Trippler Army hospital technical staff
(h) Inpatient care and treatment
Note: Brookhaven National Laboratory is responsible to ensure
that proper and current certification for the special medical
equipment and services are in place prior to receiving services.
Appendix F--DOE Medical Program Information
1. Summary of Clinical Findings
After 41 years of medical monitoring, the most prevalent health
effect has been related to thyroid function and the appearance of
thyroid-related nodules and cancer. There has been one case and
death due to radiation-related leukemia, two pituitary tumors and
two cases of basal cell carcinoma. The major non radiation-related
diseases seen in the Rongelap and Utirik people have been Type II
diabetes, hypertension, cardiovascular diseases, and their
associated complications.
The above information has been summarized from the report
entitled, ``Medical Status of Marshallese Accidentally Exposed to
1954 Bravo Fallout Radiation; January 1988 Through December 1991'',
by Brookhaven National Laboratory/Department of Energy, DOE/EH0493
and BNL-52470, July 1995.
2. Patient Population Description
------------------------------------------------------------------------
Age range Male Female
------------------------------------------------------------------------
30-39................................................. 1 1
40-49................................................. 57 59
50-59................................................. 28 35
60-69................................................. 15 19
70-79................................................. 8 12
80+................................................... 1 2
------------------------------------------------------------------------
3. Summary of Patient Location
Patients in the Rongelap and Utirik populations are combined in
the table below and represent approximate estimates of total
patients in each location:
------------------------------------------------------------------------
Location Female Male Total
------------------------------------------------------------------------
Ailinglaplap.................................... 1 1 2
Ailingnae....................................... 2 0 2
Arno............................................ 1 0 1
Ebeye........................................... 40 33 73
Hawaii.......................................... 9 4 13
Kili............................................ 1 0 1
Lib............................................. 1 0 1
Mainland USA.................................... 4 2 6
Majuro.......................................... 41 46 87
Mejatto......................................... 19 12 31
Mejit........................................... 1 1 2
Ujae............................................ 1 1 2
Unknown......................................... 1 0 1
Utirik.......................................... 6 8 14
Wotje........................................... 1 1 2
-----------------------
Total..................................... 129 109 238
------------------------------------------------------------------------
Appendix G--The RMI 177 Health Care Program (HCP)
(a) Currently implements DOE patient care in absence of Brookhaven
National Laboratory.
(b) Provides all non radiation-related care of DOE patients.
(c) Provides general medical care for the people of Rongelap,
Utirik, Enewetak and Bikini. Serves a total population of approximately
10,600 (which includes the 238 DOE patients).
(d) Refers its non-DOE patients to the Queen's Medical Center and
Group in Honolulu, Hawaii. Current services provided to the 177 HCP by
Brookhaven National Laboratory:
(a) Assists and provides consultations to 177 HCP medical personnel
for non-DOE patients.
(b) Provides access to DOE patient medical records. Current
services provided to the 177 HCP by Bechtel Nevada Corporation:
(a) Utilization of DOE mission aircraft and sea charters when
possible.
(b) Facilitates entry and exit clearances for 177 HCP staff at
Kwajalein.
Appendix H--DOE Equipment Used by Brookhaven National Laboratory
(a) Johnson & Johnson, Ektachem DT60 II-DTSC II Module Chemistry
Analyzer, K-Number 339 4116, Serial Number 60029378
(b) Kodak-Ektachem DT60 DTSC Module Chemistry Analyzer, K-Number 337
0137
(c) Ektachem DT60 Module Chemistry Analyzer, K-Number 322 1695
(d) Calposcope
(e) Ultramark 4 Plus with transducers
(f) Nikon Microscope
(g) Sereno Baker 9118c Blood Analyzer Machine
(h) Ektachem DT60II System
(i) Biorad Micromat Model 415
(j) Beckman TJ6 Centrifuge
(k) Portable defibrillator
(l) Hoag-Streit Slip Lamp system
(m) Sun computer workstation
[FR Doc. 97-14027 Filed 5-28-97; 8:45 am]
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