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The Marshall Islands' struggle to defeat tuberculosis once and for all

Micro Waves By Jack Niedenthal

Third and final in a series: This is the continuation of our Q&A with Dr. Frank Underwood, who currently serves as the Marshall Islands director of public health, a position he began during the initial stages of the Covid-19 pandemic

in 2020 based on his experience in communicable disease control after serving in a national advisory position in Fiji on TB control.

Pacific Island Times: You have an immense amount of experience in dealing with TB, tell us what some of the issues are from your perspective.

Dr. Frank Underwood: With regard to TB, the Marshall Islands has some of the highest rates in the USAPI, FSM also has high rates of TB, but not quite as high as RMI.

In our region we have a number of risk factors for getting TB as an infection, overcrowding is one of them, and having infectious people in the community for a long time is another because diagnostic delays cause issues in controlling TB. In addition, because of our climate, there's heavy use of air conditioning, which creates a lot of space for the transmission of TB within those households.

PIT: Discuss some of the characteristics of TB.

Dr. Underwood: There are different risk factors for getting sick with TB. This is because you can have what we call latent or “sleeping” TB, and you can have this form of TB for a long time. You get sleeping TB when you're initially infected, but your body's natural defenses keep the TB under control, it doesn't kill the bacteria, so it sort of goes to sleep. The time between having the infection and the disease can be as long as 50 to 60 years, though it can be much shorter if your immune system is weakened. When a person with sleeping TB becomes ill or has a health issue, this can trigger your immune system to become undermined.


PIT: Could you give some examples of diseases that typically trigger a weakening of the immune system?

Dr. Underwood: In our older population, health issues associated with diabetes cause TB to “wake up” faster. In our younger population, malnutrition is a large contributing factor to issues with sleeping TB, which is the reason why many of our children come down with full-blown TB infections.

PIT: In 2017 and 2018, with the help of our international partners, we did mass screenings for TB and leprosy in both of our urban population centers, first on Ebeye and then on Majuro, and now we have moved to the outer islands for screenings, discuss where we are in these operations and what transitions have been made to localize these efforts.

Dr. Underwood: What we accomplished on both Ebeye and Majuro involved a global change in our approach that began with getting organized and then actively going out into the communities to find cases of TB. These first two mass screenings were an international collaboration, we had our partners and experts, including CDC officials, on island to help us. Additionally, our partners came through with the funding for these operations. Subsequently, it's become a local effort. During the mass screenings, there was a tremendous amount of collaboration with outside experts, and that led to a skills transfer to our own on-island healthcare workers.


PIT: It’s rare in this part of the world when skills get transferred to locals during this kind of operation, discuss this a bit more.

Dr. Underwood: I admire what we have been able to do with the neighboring island mass screenings because we are doing it ourselves. We now have the ability to perform locally based screening efforts because of better technology, which reduces the cost of operations, though it is still not cheap. We completed Arno Atoll in 2019-20, we’ve also finished Jaluit and Wotje Atolls, and recently we concluded the screening on Ailinglaplap Atoll. There, we discovered 108 new cases of active TB, 55 percent of them were smear-positive or bacteriologically confirmed infectious cases, this is remarkable for just one jurisdiction, so we say it's a hyper-endemic there.

PIT: Did the other atolls you screened have so many active cases? Are you surprised by these numbers, or were they expected?

Dr. Underwood: Arno Atoll had high rates, Jaluit Atoll had relatively high rates, though Wotje was not as high as we expected, but Alilinglaplap was certainly very, very high. These results were surprising in a way, but not so surprising in another way. We know that TB is in the neighboring islands, we have done a risk stratification based on people with TB diagnosed in our urban centers, so we know the majority of the cases are coming in from the outer islands. This occurs because we know that health services on the outer islands are very basic. They only have health assistants and health centers with minimal technology and equipment.

PIT: When a person has active TB, does it go away on its own if you don’t get treatment?

Dr. Underwood: If you don’t treat an adult who has active TB, 50 percent of them will die, and 50 percent will continue to live with a debilitating disease that can potentially be transmitted to their families and to the community. With intervention, which involves six to nine months of treatment, you get a high cure rate. The treatment success rate in the Marshall Islands is in excess of 90 percent, so a lot of people do very well, and that's what we're trying to promote and accomplish.

PIT: So where do we go from here with regard to eradicating TB once and for all?

Dr. Underwood: Because of our high rates of diabetes and malnutrition, the way forward is to treat the latent, sleeping TB with medications and aggressively finding and treating the active cases. That's the only way. Treating active cases can be challenging. People don't want to come in for treatment, people don't want to take the medicine, and there's still some stigma, though that aspect is getting better. Prior to the 2017-18 mass screenings, the stigma associated with TB was a problem. But with the public education during that time, with everyone taking part, most people had someone in their family with sleeping TB, so the stigma lessened. People here came to understand that TB is not a curse because it's curable. And once you're cured of the disease, the prognosis is excellent. The key here is quick diagnosis and treatment.

PIT: Are there any plans to do more mass screenings in Majuro or Ebeye? That's going to take some funding, right?

Dr. Underwood: I am hoping within a couple of years. And yes, it's going to be expensive, but it's a worthwhile investment. On the outer islands, we send “teams” of healthcare workers, so we do the TB screenings, but we also screen for leprosy, NCDs, and we do vaccinations. We're also instituting maternal and child health services, women's health and family planning. Because of the limited health services on the outer islands, these teams who go out stay for a two to three-week period, so there's great value for the money in the services they deliver.

Jack Niedenthal is the former secretary of Health Services for the Marshall Islands, where he has lived and worked for 42 years. He is the author of “For the Good of Mankind, An Oral History of the People of Bikini,” and president of Microwave Films, which has produced six award-winning feature films in the Marshallese language. Send feedback to

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