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

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.

-----------------------------------------------------------------------

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]

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