[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

[[Page 29129]]

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]
BILLING CODE 6450-01-P