“The health of the community depends in large part on our lab being able to test for all significant diseases….” Director Philip Dauterman, MD

CNMI CHCC Lab staff

​Photo: CNMI lab staff (from l to r) Christopher Boone, Juan Duenas, Wilma Moran, Sherine Corotan, Philip Dauterman, Gaydee Comparativo, Editha Welle and Noel Biglete. Photo by Albert Ichirhara

by Nancy Maddox, MPH, writer

The tropical limestone and volcanic islands were first settled by Southeast Asian migrants, whose descendants are now known as Chamorros. A few thousand years later, the explorer Ferdinand Magellan landed here and the archipelago became Spanish territory from 1521 to 1898, when Guam was ceded to the US at the end of the Spanish-American War and the remaining islands sold to Germany. Following Germany’s defeat in WWI, Japan administered the islands. Just 26 years later, the fierce WWII Battle of Saipan forcibly ended Japanese rule, and the United States became the most recent legal administrator. After Guam rejected offers to reunify with the Northern Marianas, the islands’ residents approved a referendum to become a US commonwealth, a change that took effect March 1976.

Today, the CNMI—about 2.5 times the area of Washington, DC, and across the International Date Line from the rest of the US—is mostly uninhabited. About 48,000 people live on Saipan, and about 2,000 each on the islands of Tinian and Rota. The population is about half Asian (including Filipinos, Japanese, Chinese, Koreans and others) and about 35% native Pacific Islanders (including Chamorros, Carolinians, Native Hawaiians and others). The commonwealth has two official languages, English and Chamorro, and the predominant religion—a vestige of Spanish rule—is Roman Catholic.

Although the CNMI has a small agricultural and seafood industry— producing coconuts, breadfruit, melons, ornamental plants, livestock, poultry and fish—just 2% of its land area is arable; most of the remainder is forested mountainside or volcanic rock. Instead, tourism drives the economy, with visitors drawn by casino gambling, world-class golf courses, clear blue waters and brilliant coral reefs. The Annual Flame Tree Arts Festival, timed to coincide with the blossoming of the vibrant arboreal flowers, showcases local artists, musicians, dancers and craftspeople.

Philip Dauterman, MD, director of the Commonwealth Healthcare Corporation Laboratory, describes the islands as “very relaxing . . . beautiful beaches, beautiful scenery, friendly people, a slow pace of life.”

“A Seamless Transition from Public Health to Hospital”

With a small population and small local government, the CNMI has no freestanding public health department. The Commonwealth Healthcare Corporation (CHCC), said Dauterman, is “America’s only combined municipal hospital/public health department incorporated as a public corporation.” Similarly, the CHCC laboratory is a unique hybrid, filling the roles of both public health and hospital laboratories. Each year, its full time microbiologist, seven clinical laboratory technicians and two clinical laboratory scientists report out results for an impressive 1.25 million chemistry tests, plus 200,000 additional tests. Since a separate laboratory handles drinking water testing for the islands, the CHCC devotes all of its resources to clinical analyses, including hematology assays, coagulation tests, blood bank tests and more.

Dauterman said, “The greatest advantage [of the CHCC hybrid model] is free sharing of information, supplies and other resources, such as electronic health records; there is a seamless transition of a patient from public health to hospital.”

The hospital, known as the Commonwealth Health Center (CHC), opened in 1986 and is the CNMI’s sole provider of comprehensive healthcare services. It is located in the main village of Garapan, about a mile inland on Saipan and overlooking the downtown area. The 86-bed in-patient facility has two floors, and the 2,344-square-foot, BSL-2 laboratory occupies space on the top floor, between the cashier’s office and hemodialysis unit.

“The lab has expanded several times in its history,” said Dauterman. “We would like to become a BSL-3 facility to be able to test TB cultures, but that is dependent on funding from CDC. If we got funding, we would have to build [a BSL-3 suite] off-site, because there is no room here.”

The CHCC laboratory, Dauterman said, “is the only moderate or high complexity testing laboratory on Saipan; there are other labs on the island, but they offer waived testing only. As a result, the CHCC laboratory provides acute care testing for hospital patients and also acts as a referral lab for all outpatient testing on Saipan that needs STAT results that can’t wait for [specimen] shipping to off-island labs,” in Guam or Hawaii.

The main healthcare problems on the islands tend to be non-communicable in nature, including one of the highest diabetes rates in the world, at upwards of 20%. High blood pressure is also prevalent. As a US commonwealth, the CNMI is not subject to the provisions of the Affordable Care Act and access to health care is problematic for some segments of the population.

As in any mainland hospital, the laboratory’s highest volume procedures are complete blood counts and Chem-7 and Chem-12—two metabolic test panels that assess blood chemistry and proteins. Technicians use Cepheid’s GeneXpert System for molecular detection of a number of pathogens, including those responsible for tuberculosis, chlamydia and gonorrhea. Most HIV testing is performed at point-of-care public health clinics. Leptospirosis—a mostly tropical bacterial disease, spread through the urine of infected animals—is an occasional concern here, and the sentinel CHCC laboratory has capability to detect it.

Testing in a Typhoon

Being in a relatively isolated location has its advantages and disadvantages. On the plus side, Dauterman said, “The mosquitoes that transmit dengue, Chikungunya or Zika aren’t here, and there are no direct flights to Africa, so Ebola is not a major concern.” Still, Dauterman would like to implement Zika testing, since importation of the virus by travelers is always a possibility.

On the minus side, the remote locale has caused issues “related to transportation.” Dauterman said, “We have had repeated problems with proficiency test specimens received warm, delayed arrival of shipments of critical supplies, etcetera.”

Last year, the commonwealth, which straddles notorious Typhoon Alley, was buffeted by Typhoon Soudelor, the first Category 3 storm to hit the archipelago in nearly 30 years. According to Wikipedia, the National Weather Service anemometer at Saipan International Airport broke after recording a gust of almost 100 mph. Hundreds of homes were damaged or destroyed and a state of emergency declared. Dauterman said the laboratory—which is open 24/7, 365 days a year—suffered extensive disruptions to its supply lines due to temporary closure of the airport and impassable roads, but “was able to remain operational and did not suspend testing.” Fortunately, the laboratory sustained no structural damage.

In addition to its laboratory technicians and scientists, the CHCC laboratory employs seven phlebotomists and is actively recruiting to fill two phlebotomy vacancies. “Anyone interested can contact the CHCC human resources department through our website,” said Dauterman.

The laboratory director has ping-ponged back and forth from the South Pacific to the Western Hemisphere. He was born in Columbus, OH, grew up on Guam and studied at the University of Guam, where he earned a BS, and at Ross University School of Medicine in the Caribbean island nation of Dominica. With MD in hand, Dauterman moved to the US East Coast and spent four years completing a residency program at Eastern Virginia Medical School in Norfolk. From there, he traveled north to Brooklyn, NY, for specialty training in anatomic physiology at the State University of New York.

Dauterman then crossed continents again, this time relocating back to Guam, where he spent 16 years as a pathologist at Guam Memorial Hospital. In 2013, he quit Guam for a year of advanced anatomic pathology work at the Veteran’s Hospital in Muskogee, OK—the farthest he has ever lived from the ocean. He accepted his current position as head of the CHCC laboratory in December 2013.

Said Dauterman, “I trained as both a pathologist and lab director and am board certified in both anatomic pathology and clinical pathology. The first 22 years of my career, I was working mostly in anatomic pathology, looking at glass slides. After 22 years, this work seemed repetitive and routine. I decided to change to being primarily a lab director.”

Dauterman, who manages a $2 million annual budget coming largely from public and private health insurance, has one chief goal for the future: to increase the number of clinical tests offered in-house, and especially the number of infectious disease tests, such as human papil- loma virus and Zika assays.

Dauterman said, “The health of the community depends in large part on our lab being able to test for all significant diseases, both communicable and non-communicable. We will strive to provide the people of the CNMI with the best healthcare possible.”