Back home, bikeless

I'm back from a few days in Guam. Most of my friends in America don't have to get on a plane to see an orthodontist, but that's the way it is on Saipan. I took Arman over for some orthodontic work, and Nava tagged along. We had a nice time staying with our friends, the Johnson's, and had a chance to get together with many old friends, as well as eat some fantastic Persian food.

We bought bikes for the two older kids, and I found out that if you want to put a bike on a plane, you have to have a box for it (or buy one from the airlines for $30); you have to be able to put the bike in the box which requires having the tools to take off the pedals and the front wheel; and you have to pay another $30 to get it on the plane. Given this combination of impediments (we rode the bikes up to the checkout counter), the bikes are still in Guam.

Branding Saipan... er, the CNMI... um, the Commonwealth

Here's my column from today's Saipan Tribune

***

Every time I travel and meet new people, I’m at a loss when they ask “Where do you live?” I can’t quite figure out what to call this place, nor where we are. It seems to be a common problem. At the last general membership meeting of the Marianas Visitor’s Authority, the ad hoc committee on branding acknowledged the difficulty in naming ourselves, and thus branding ourselves.

Officially, we’re the Commonwealth of Northern Mariana Islands. That’s a mouthful. And if you try to abbreviate it, “CNMI”, that doesn’t really mean anything to anyone who isn’t from Micronesia.

So, I propose it’s time for a name change. Name changes can be painful. I went through one myself. I grew up in a coal-mining town in the Appalachian mountains of Kentucky. There, before the era of “political correctness,” no one wanted to make the effort to learn the name of some foreign kid, so in the first grade the principal called the immigrant family into his office and told us that my name, the one my parents had given me when I was born, “just wouldn’t do in these parts. Pick another.” David is the name I picked. As it turns out, in America, “David” is a much more marketable name than the one I was born with.

Our group of islands, what is commonly now known as the Commonwealth of Northern Mariana Islands, ought to be known either as “The Mariana Islands” or “Saipan.” And we need to boldly state that we’re located in the “South Pacific.”

Here is my reasoning.

For option A – Mariana Islands – it’s part of our current official name. The word “Commonwealth” doesn’t really add anything to our brand identity. It’s a political designation, but a confusing one. Guam doesn’t market themselves as the “Territory of Guam,” California doesn’t call itself the “State of California,” and members of other commonwealths, like the “Commonwealth of Kentucky” or the “Commonwealth of Virgina” don’t include that in their designation. With branding, the shorter the better.

I also suggest that it’s time to drop “Northern” from our name. Where are the “Southern” Mariana Islands? Is that Guam? Is that how we define ourselves – the place north of Guam?

I don’t think that the word “North” has any role in the name of a tropical island. When people want to know where we are, I say, the “South Pacific.” I am well aware that we are north of the equator, but the equator isn’t the only frame of reference. Alabama is also north of the equator, but it’s in the “South,” even the “deep South.” Most of our tourists and business partners hail from regions north of us. The North Pacific sounds like a cold, even inhospitable place -- maybe somewhere up around Alaska or Vladivostok. Say “South Pacific” and people think palm trees, warm breezes, sandy shores and swaying hips. That’s us! If I’m talking to a cartographer, I’ll say “just north of the equator.” The South Pacific is a concept and we’re conceptually in the South Pacific.

Now someone is sure to squawk that Guam is part of the Mariana Islands also, so we can’t usurp the name for ourselves. Sure we can. Guam doesn’t need the name. And there is precedence. A few years ago, what used to be known as “Western Samoa” changed its name to “Samoa,” much to the chagrin of the people who live on “American Samoa.” The implication is that Western Samoa is the real Samoa. I think the same can be said for us in relation to the Mariana Islands. If someone asks, “Isn’t Guam part of the Mariana Islands too?” we simply say, “They’re the Southern Marianas, we’re the Marianas.” They’ll live.

There is of course, also, option B – change the name of the island chain to “Saipan.” Or the “Saipan Islands.” Think of Hawaii. The archipelago is called Hawaii (or the Hawaiian Islands), and each island has its own name, including one of the islands which is known also as Hawaii (or more commonly as “The Big Island”). The same would work well here. There are two disadvantages to the “Saipan” designation. First, for some reason people think Saipan sound’s Asian, maybe because it sounds a bit like Taipan or Taipei or Sampan, and so they think we’re part of the continent of Asia. So that may not be the best idea. Why change one confusing name into another confusing name. Also, it might be better for us to go by Mariana Islands, and just ruffle the feathers of the folks in Guam, rather than go by Saipan and upset the people in Tinian and Rota and the Northern Islands.

I’m from the Mariana Islands. It’s in the South Pacific. I live on the island of Saipan. I just wish it were official.

Medical Care in the CNMI & Saipan

A few people have recently come across this column in Google searches for CNMI's health care. I wrote the column two years ago for the Saipan Tribune. It was picked up by the Pacific Report out of the University of Hawaii and distributed through them. I'm posting it here as a supplement to Jeff's recent post.

I’ve always said that our health care system in the CNMI is among the best in the region, and that the overall quality of physicians here is as high as in other rural communities anywhere in the United States. Yet our population is medically under served. The resources for care, though good, are limited. There are not enough doctors to serve our population. The public health care facilities are often short of supplies and specialists. On the operating room wall there hangs a quotation from Dr. Howard Tait, who served as the CNMI’s orthopedic surgeon for many years. Speaking to other surgeons, he said, “If you have to have everything you need to do the case, you probably shouldn’t be here.” Strangely, these are the very reasons that many of us choose to practice medicine here. We get personal satisfaction from making a difference to the people we serve, and we learn from the challenges of not having everything we need.

The US Department of Health and Human Services routinely evaluates the access to care in all US jurisdictions and gives each geographic area a Health Professional Shortage Area (HPSA) score. This HPSA score is an indication of how badly doctors are needed in an area. The scoring system used by the Department of Health and Human Services takes into account such factors as the number of doctors available for the population, and the travel times to the nearest available source of care. The higher the score, the worse off a region is, and the more badly doctors are needed. A HPSA score of 25 is bad, 1 is great.

How do you think the CNMI ranks on this list? Well, it’s pretty bad – in fact, among the worse. For non-metropolitan areas in Region IX, the highest shortage award goes to the FSM, with a HPSA score of 25. There is no other area in the entire US with a greater need for doctors. This is followed by a few Indian Reservations in Arizona, California and Nevada that have HPSA scores between 21 and 19. Next comes American Samoa with a HPSA score of 20. And then, the CNMI with a HPSA score of 18. A HPSA score of 18 is bad. It is an indication that despite having one of the best hospitals in the region and having great doctors on the island, we are among the most under-served areas in the entire country. Guam fares much better than we do, with a score of 8. Many Indian Reservations have better HPSA scores and less of a doctor shortage than we have.

Areas that have doctor shortages typically do everything possible to bring in more doctors. There are tremendous challenges in bringing in new doctors to the CNMI. After all, the area is underserved for a reason. If it were considered a great place to practice medicine, there wouldn’t be a shortage in the first place. This is one of the reasons that our public facility is constantly short of doctors and specialists. There has to be a compelling reason for people to move half-way across the world, to an unknown land, far from their families, and take a pay cut to work under challenging circumstances.

In my case, I had always wanted to work in an under-served area and to feel like I was making a real difference to the people I served. When I arrived in the CNMI 12 years ago (now 14 years ago) as a government employee, I thoroughly enjoyed establishing the first eye care services at CHC. It was a challenge, and I was able to make a big difference quickly. We saved the government hundreds of thousands of dollars in referral costs, and I had the privilege of making life better for my patients. After five years at CHC, my wife and I decided to make the CNMI home and realized that this would be difficult to do while working for the government. Each year there were questions of whether or not funding would be available for my position and whether or not my contract could be renewed. I had also reached the limit of what I could build under the government system. I came from one of the best training centers in the US, and I wanted to bring in the best eye care technologies to the CNMI. The emphasis of CHC was rightfully on providing primary care to as many people as possible with the limited resources available, so it just wasn’t possible to spend money on the more advanced technologies I was requesting. For these reasons, and with the enthusiastic support and encouragement of the administration I entered the private sector. And this is where I believe the future of improving health care in the CNMI lies. We will always need a government supported hospital. But one of the keys to addressing our poor HPSA score, and building a stable medical community is to encourage the development of private medical practices.

Most of us in private practice came to the CNMI as government employees. Dr. Tony Stearn’s venture into private medicine resulted in the establishment of FHP (now PacifiCare), and more recently of Marianas Medical Center. Dr. Hocog and Dr. Aldan built Saipan Health Clinic. Dr. Ahmad Al-Alou established Pacific Medical Center. Tony Glad built Island Medical Center. And most recently, Dr. Norma Ada has opened Medical Associates of the Pacific. Together, these practices, along with my own, remove the burden of some 60,000-76,000 office visits from the shoulders of the government facility each year. Private practices provide stability and continuity of care. The average number of years that each of the physicians in private practice has served in the CNMI is somewhere between 10-15 years. We put down roots. Those of us in specialty care like myself, provide support to other physicians, like those in the emergency room, when complex cases arise. Private medical offices are more likely to invest in the most advanced technologies which raise the level of care for the whole population. It was Dr. Al-Alou at PMC who had the vision and the means to bring the first CT scanner into the CNMI. Marianas Eye Institute brought in technologies that most eye care practices in the US mainland don’t even have. Private medicine raises the level of care available to you.

I share these benefits because I believe that stimulating the development of private medical practices can be more actively pursued in the CNMI. In Guam, we see that the entire medical care system, like that in every other developed jurisdiction in the United States, is built upon a strong and healthy private practice model. We need to actively attract doctors into private practice. As a community and a government we may wish to consider the big picture of health care, and of our severe physician shortage, and consider which legislation, policies and regulations -- which decisions -- will move us closer to addressing our doctor shortage, and which will take us further away. Quality health care for the greatest number of people is a guiding principle that can serve as a touchstone when considering the impact of various decisions.

Being medically under served is just part of the reality of living on a remote tropical paradise with a relatively small population. It's as much a function of geography and demographics as anything else. Sure, things could be better, but people will still die for reasons that would not exist in LA. There are trade-offs for everything. If you live in LA there are certain trade-offs. I'm raising four kids here, by choice, and I'm intimately familiar with the shortcomings of the health care system. Yes, something might happen out here that results in a worse outcome than if I were living in LA. But overall, I'm okay with it. For most of us here, where we live is a choice. For me, Saipan wins out over LA (and Aukland and Honolulu and Sydney and Tumon and every other spot on the face of the earth.) This is where my heart is.

More on the blood situation later.

A good sign

I was in Guam over the weekend. I went over on Thursday, and spent Friday morning at Island Eye Center with Dr. Margie DeBenedictus. She's an expert at blepharoplasties (cosmetic lid lifts) and I'm an expert at an advanced type of cataract surgery (phaco chop), so we spent the morning teaching and learning in the operating room. The rest of the weekend I was at the National Convention of the Bahai's of the Mariana Islands.

When I got back, I looked at Arman, and not having seen him for a few days, I'm pretty sure that the lumps have gotten smaller. A few other people who hadn't seen him over the weekend said the same thing. I'm hoping it's not just our wishful thinking that helps us see a smaller lump. But I don't think so. I think it really is smaller. Smaller would be a very good sign.