The real ‘South Pacific’
SMHS alum Dr. Don Person tells the story of the world’s longest running humanitarian telemedicine program.
“The longest running humanitarian telemedicine program in the world.”
This is how UND School of Medicine & Health Sciences Class of 1961 Bachelor of Science in Medicine grad Dr. Don Person described the Pacific Islands Health Care Project (PIHCP) he founded with the U.S. Army at Tripler Army Medical Center (TAMC) in Honolulu, Hawaii, in the late-1980s.
“We cared for at least 10,000 patients and contributed to the training of hundreds of medical students, residents, fellows, and staff physicians at TAMC,” smiled Person from his home in San Antonio, Texas. “Dozens of Indigenous medical officers from Micronesia and American Samoa and expatriate physicians from the Philippines, nurses, PAs, and other health care providers have benefited from the program.”
After thirty years and tens of thousands of patient encounters, the PIHCP closed its doors in 2023, another victim, said Person, of the SARS-CoV-2 pandemic.
Re-upping
The story of how this program both came to be and paved the way for today’s telehealth technologies is both amazing and almost unknown, said Person.
That’s why the Fargo, N.D., native, now in his ninth decade, wants to make sure the PIHCP story is finally told.
After receiving his M.D. from the University of Minnesota and serving a rotating internship at the Hennepin County Hospital, Person entered active military duty in July 1964 as part of the so-called “Doctors Draft.” Assigned as Chief of Preventive Medicine, Aviation Medicine, and Professional Standards in the U.S. Army Southern Command in Panama Canal Zone, Person led medical civic action teams serving Indigenous peoples in Honduras, Panama, Columbia, Bolivia, Paraguay, and Brazil.
Following active duty, he completed a fellowship in microbiology/virology at Mayo Clinic. He accepted a position at Baylor College of Medicine and was appointed assistant professor in the Departments of Internal Medicine and Virology & Epidemiology. Following pediatrics training, he joined Baylor’s peds team, where he practiced through the 1980s.
Then, almost by chance, an opportunity arose for Person to return to active duty, he said. In November 1987, Person joined the staff at TAMC in Honolulu, serving as chief of pediatrics, chief of clinical investigation, senior scientist, and, eventually, medical director PIHCP.
“With our previous time in Panama and nearly 20 years of active reserve, my military record was continuous,” he said. “We stayed in Honolulu for the next 21 years, and at retirement I had accumulated more than 49 years of creditable service!”
The real South Pacific
Person stayed active because, as he quickly learned, there was a tremendous unmet need for medical care among the inhabitants of the remotest of Pacific Islands, which until the late 1980s had been under the aegis of the United States Government.
It was here that the PIHCP was born.
After all, the situation in the region at the time was more desperate than either the stage or film versions of South Pacific suggested.
Following the end of the World War II, the Pacific Islands, formerly controlled by the Empire of Japan and consisting of some 500,000 people living on hundreds of islands and atolls, were divided up among the Allies for rebuilding and strategic defense. In addition to reestablishing control over its own territories in the region (Guam, American Samoa, Northern Marianas), the U.S. was “responsible” for several other islands in Micronesia, including the Marshall Islands, Palau, and the Federated States of Micronesia. (These former U.S. Trust Territories are now known as the U.S. Associated/Affiliated Pacific Islands.)
Unfortunately, postwar development proceeded slowly in the Islands. Many residents were without electricity, running water, transportation, or basic infrastructure – and remained so for years after the war. Even more, some of the islands had been used as nuclear test sites from the 1940s-60s. The Johnston Atoll, for example, was used for nuclear and biological weapons testing and as a dump site for chemical weapons. The Bikini, Enewetak, Rongelap, Utirik atolls in the Marshall Islands remain uninhabitable due to radiation contamination.
When many of the islands, whose economies were based on subsistence fishing and farming, were released from American jurisdiction in 1986, they soon found themselves struggling to meet their peoples’ health needs. Conditions like meningitis, rheumatic fever/rheumatic heart disease, tuberculosis, and leprosy were afflicting – and sometimes killing – many Pacific Islanders.
By federal law, medical care at a federal hospital can only be provided on a reimbursable basis, said Person. But even if a Pacific Islander managed to get to TAMC as “Secretary of the Army designees,” it was highly unlikely that they could pay for the care they might receive, or for transportation to and from Honolulu.
Given that Tripler’s medical residents needed robust training, though, Person and his colleagues, including Tripler’s Commander, Major General Girard “Jerry” Seitter, M.D., began to devise a cost-sharing plan that could address both problems – the Army’s need for resident training and the islands’ need for care – at once.
“So, we decided that if we could talk to the folks in Congress, then Washington might somehow help us try to figure this out,” Person continued. “We approached Hawaii’s Senator Daniel Inouye, who was very much interested in not only Hawaii, but the entire Pacific.”
According to Person, who knew a thing or two about rural landscapes, Inouye (who died in 2012 and was studying medicine at the University of Hawaii when Pearl Harbor was attacked) loved the idea of using U.S. Army medical residents to provide care for these “rural” patients living on far-flung islands in the Pacific. He proposed funding through Congress to the tune of $500,000 for the first year to transport patients to and from their home islands to Tripler in Hawaii.
Federal monies came through, smiled Person, and the first island patients were admitted to Tripler in early 1990: “It was amazing – we began to admit patients and transport them from the Pacific to Tripler, treat them, and return them home restored to health.”
Honolulu calling
But after operating for a few years under the patient transport model and caring for some 2,500 patients, the cost of the program was getting to be too much. Given the speed with which telecommunications were developing in those years, the PIHCP team began to experiment with other ways of providing care at a distance.
Enter telemedicine, a broad term describing the diagnosis/treatment/triage of patients by a distant consultant using some form of telecommunication. Still in its infancy at the time, none of the many experiments in “virtual” healthcare had really taken off by the late 1980s.
Person and his team hoped to change that. So they partnered with Tripler’s Project AKAMAI (“Akamai” being Hawaiian for “clever”), a Sen. Inouye-sponsored Department of Defense medical research and development program designed to apply and assess the value of telemedicine technologies in the Pacific region for humanitarian purposes. Multiple projects were sponsored by AKAMAI, said Person, including teleradiology, hyperspectral diagnostic imaging (cancer screening), Theater Telemedicine prototype development, the Alaskan Native Health Services, and the Pacific Island Health Care Project.
Of the handful of AKAMAI projects developed, the PIHCP was the only one to survive.
“We tried everything in those early days—fax, long distance telephone, even diplomatic pouch—to connect island patients and health providers,” said Person.
At one point they even tried using a new AT&T-made device called the “PICASSO” phone, which allowed users to “transmit broadcast-quality pictures over ordinary phone lines” as one ad for the device from the early 1990s put it.
“It was very effective, but out in the Pacific long-distance telephone calls and faxes cost eight to 10 dollars per minute!” Person recalled, still astounded. “Those jurisdictions couldn’t support that sort of thing. And you had to have someone available at both ends to make sure the technology was working. So, we kept experimenting with various approaches, trying to find out what would work best.”
As Person explained, what worked best to diagnose, treat, and facilitate patients at a distance evolved with the technology. Digital photography, email, dial-up internet, and other asynchronous technologies all came along slowly to help the team build capacity for “store-and-forward” file systems (which acquire, store, and transmit medical data electronically to a consultant for later review and assessment offline) and care for more people more quickly.
But even as virtual care improved, the obstacles were monumental for teams connected to the U.S. military.
Store-and-forward technology “was restricted because in the 1990s nobody at military hospitals was allowed access to the internet for a variety of security concerns,” said Person. “Plus, out in the Pacific, by the time we got the internet and were able to use it, we had only dial-up technology. I had referrals from the western Pacific that took all night just to load up for maybe one-page worth of written text and one or two photos. It would take hours and hours, at considerable expense.”
The challenge was to develop a telemedicine methodology that would be simple and workable in the austere, remote geography, said Person. And it had to be done in a way that was acceptable to the Army and the physicians at Tripler.
Making all of this even more difficult was the fact that the islands in question often didn’t have the necessary supplies to treat patients in the way TAMC physicians recommended. Person recalls, for example, x-ray machines without film or developer chemicals, sterile gloves that were reused, laundered rags used in operating rooms, and few or no medications.
Palliative care
But the program evolved such that by 2014, when Person published a paper on the PIHCP in Frontiers of Public Health, 9,000 Pacific Islanders had been cared for either remotely or at TAMC. A large part of this success was due not only to the dedication of Person and his colleagues, but the local, Indigenous medical officers who were being trained to care for their compatriots.
Combining local providers with the tools of telehealth has been the key, Person suggested, noting that until the COVID-19 pandemic arrived on the scene he had been running PIHCP continuously since 1997. Despite retiring in 2008 and moving back to Texas, Person has continued to work with the program directly, having been named PIHCP Director Emeritus by the Surgeon General of the U.S. Army in 2009.
Sadly, said Person, the program is over.
“It was highly successful, but many of the islands have had to drop out because they don’t have the resources to provide food, housing, transportation, translation services for their patients in Hawaii,” he said, noting how changes in medical practice from inpatient to outpatient care, the challenges of the global political economy, and growing concerns over cybersecurity have markedly affected the program. “These impoverished countries of subsistence fishers and farmers have lost their fishing rights, having sold them to Korea, Japan, and China. Some of the outer islands still don’t have electricity or running water. So, they are in desperate straits.”
That, said Person, is why he remained so committed to the program.
Indeed, Person suggested, it’s likely difficult for the 21st Century reader to appreciate how revolutionary and innovative the program truly was at the time.
“These islands have unique and incredible history,” he concluded, stressing that being forced to work with few resources can lead to innovations. “Their stories are amazing and little known.”
Sen. Inouye agreed, entering into the Congressional Record a tribute to Person on July 9, 2008.
“I would like to recognize a great American and true military hero who has honorably served our country for 49 years,” noted Inouye. “His performance reflects exceptionally on himself, the U.S. Army, the Department of Defense, and the United States of America. I extend my deepest appreciation to Colonel Person on behalf of a grateful Nation for his more than 49 years of dedicated military service.”
Not bad for a Fargo boy.
