Health Care: Migration Is Often a Matter of Survival
Chuuk immigrants attend a church service in Dededo, Guam. Photo by Mark Edward Harris
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On the first floor of the Rongelap town hall on Majuro, several Marshallese women sit on the tile floor or in plastic chairs. They’re wearing the long, flower-print dresses common in the islands as a professor from Japan is asking them to trace their hands onto a tapestry that will be shared with her students.

One of the women, Nerje Joseph, points to a large photo on the wall.

It’s a picture of a Marshallese girl who can’t be older than 6 or 7. Her eyes are cast down beneath thick, dark eyelashes while the hair on part of her scalp is burned away. An inset photo shows the skin on her feet blackened and peeling.

The girl in the photo is Nerje Joseph, who is now in her 60s with short, graying hair. It was taken after the radioactive fallout from the March 1, 1954, Bravo test on Bikini Atoll fell over Rongelap. At the time, Bravo was the largest nuclear device ever detonated — 1,000 times more powerful than the bomb that fell on Hiroshima, Japan, in 1945. Weather reports had predicted that winds the day of the test would not carry radiation over inhabited islands like Rongelap, which is only 90 miles from Bikini. They were wrong.

Nerje Joseph holds a photograph her as a young girl, taken in 1954 when radioactive ash from Bikini fell on her home atoll of Rongelap.
Nerje Joseph holds a photograph of herself as a young girl, taken in 1954 when radioactive ash from Bikini fell on her home atoll of Rongelap. Mark Edward Harris/Civil Beat

Before its irradiation, Rongelap was a postcard tropical atoll. Joseph says she remembers waking up early on that long ago March 1 morning and seeing a rainbow.

“It was all colors, pink, blue, all kind colors,” she says.

“Then I saw the light. My hair,” she says in broken English, pointing to the photo of her burnt hair, “and then after my skin, sick, throw up, diarrhea, skin really burn.”

Within hours of the explosion, a white ash fell on Rongelap, landing on people, drifting into houses and dissolving into water supplies. Thinking it was snow, children played in it, tasting it and rubbing it in their eyes.

View Larger MapMany Marshallese suffer from high rates of diabetes and other noncommunicable diseases. High rates of cancer are linked to the nuclear testing of the 1940s and 1950s in the region.

Two days later, Joseph and dozens of other Rongelap islanders were relocated by U.S. authorities to Kwajalein, where the U.S. military still has a base, for treatment. They spent the next three years on Ejit in Majuro Atoll before returning to Rongelap in 1957.

It wasn’t until 1985 that concerns were raised about long-term health effects from the nuclear fallout. Rongelap residents moved again, settling mostly on Mejatto and Ebeye islands in Kwajalein Atoll and on Majuro.

Like many Marshallese exposed to the testing, Joseph is still regularly monitored by U.S. medical personnel for thyroid problems directly attributed to the fallout. She points to a scar on her neck, saying she had surgery in 1970, and reaches in her bag to show several vials of medications prescribed to relieve pain and help low calcium levels that the thyroid gland is intended to regulate.

Joseph now spends time at the town hall on Majuro because she can’t go home. Soil-remedial actions and resettlement efforts have been underway since the 1990s to make Rongelap inhabitable again.

Over the course of 12 years, the total explosive power detonated in the Marshalls equaled more than one Hiroshima-size bomb detonated every day. Many Marshallese and their advocates believe the radiological damage continues to contribute to high levels of cancer, diabetes and other health problems for the islanders.

The Fallout

While it is not possible to prove conclusively that a specific person’s health condition is related to the nuclear tests, research in 2002 by Neal Palafox, a Honolulu doctor, “found that cervical cancer mortality in Marshallese women is sixty times higher than in United States women, male liver cancer rates thirty times U.S. levels, breast and gastrointestinal cancer rates five times the U.S. rate, and lung cancer threefold higher.”

Bikini town hall on Majuro Atoll.
The Bikini town hall is located on Majuro Atoll, hundreds of miles from Bikini. That’s because Bikini is largely uninhabitable. Mark Edward Harris/Civil Beat/2015

Jessica Schwartz, an assistant professor of musicology at UCLA and co-founder of the nonprofit Marshallese Educational Initiative in Arkansas, where there’s a sizeable Marshallese population, reports that the surge in cancer was so profound that survivors of Rongelap sang songs about the experience, lamenting “the unwanted inheritance.”

“When will I be released from my sufferings,” one song ends, “that I still now do not understand?”

A church on Majuro.
The church is central to Micronesians, as seen in this worship service on Majuro. Mark Edward Harris/Civil Beat

Indeed, the experience of radiation was so foreign to the Marshallese that, as Holly Barker wrote in her 2013 book “Bravo for the Marshallese,” they had to translate English words to describe what they were experiencing — “radiation doctors,” for example.

“A unique radiation language,” Barker explains, helps survivors communicate their experiences to each other.

Barker also describes the horrific phenomenon of “jellyfish babies” — pregnancies that resulted in severe abnormalities — that many Marshallese women have reported.

“Some babies that were born resembled bunches of grapes,” Barker writes. “Another was said to have a horn-like protrusion on its forehead making it look like the image of Satan we see in books.”

One woman who got pregnant after the testing reportedly gave birth to a baby with two heads. “One was on top of the other,” the father told Barker. “There was one head that was smaller than the other head…. It breathed for just a short time when it was born. Maybe an hour, only some minutes. It was alive, but it wasn’t doing so well.”

Dr. Wilfred Alik, a Marshallese physician who works in Hawaii, still flies to the Marshall Islands regularly with the U.S. Department of Energy to treat “downwinders” from the 1954 nuclear tests, part of an ongoing cancer-surveillance program.

“It’s still going on, until the last person dies,” says Alik, speaking of the residents of Rongelap and Uterik atolls who were exposed to radiation.

Hundreds of Bikinians today live on Kili, a remote island far to the south of Bikini. Alik says many of the relocated islanders find life hard on the formerly uninhabited island. It has no lagoon and rough surf makes fishing difficult.

“These people can no longer live on their lands,” he says. “They can’t farm it, they can’t drink from the water — that was the old ways. They cannot go back to Bikini and Rongelap.”

The Nuclear Legacy

While the U.S. nuclear weapons testing only directly affected four atolls, the consequences of both the detonations and the relocations have been far more widespread.

A billboard on Ebeye.
The Marshallese government relies on U.S. aid to help islanders with a range of health concerns. Chad Blair/Civil Beat

Changes in the Micronesian way of life combined with the fallout from so much radiation has led to serious health problems in many island communities. The lack of adequate health care facilities and vital treatment in Micronesia is helping fuel the exodus to the U.S.

After more than a century of colonization — first with the Germans, then the Japanese, and finally the Americans — many Micronesians were already losing their cultural and traditional practices. Relocation and fear of nuclear-contaminated marine life further exacerbated that problem, fundamentally changing the environment, language, economy, politics and social organization of the Marshall Islands specifically and Micronesia more broadly.

The radiation, after all, didn’t only affect people, but the environment as well. Many islanders became “nuclear nomads,” and for many, it was never clear what was safe and what wasn’t.

“I have been longing to go back,” Isao Ekniang, a native of Rongelap, said from his office in the Rongelap town hall on Majuro.

Mark Edward Harris/Civil Beat

ListenIsao Ekniang longs to return to his home on Rongelap.

“It’s very hard for us to go back because we are afraid of the radiation there. No one is ever telling us the truth about the radiation on Rongelap. Sometimes Americans said, ‘It’s OK. Crystal clean, you can go back.’ But some said, ‘Ah, don’t go back. You cannot live there.’ It’s been 28 years now since I live Rongelap. Twenty-eight years.”

A 2012 study in the Social Medicine Journal argues that the displacement and social disruption of the Marshallese by the nuclear testing diminished reliance on traditional staples like fish, taro and breadfruit.

Coconut crabs, for instance, are considered a delicacy in the Pacific islands. Since the nuclear testing, however, the crabs are contaminated with a radioactive isotope.

As a result, many Marshallese turned to Western diets heavy on imported processed foods and canned meats such as Spam. The items were considered safer because there was no fear of contamination.

“Much of Micronesia has witnessed a breakdown of traditional cultural values and an increased prevalence of obesity and alcohol, tobacco, and other drug use,” the Social Medicine Journal study observed.

Many Micronesians suffer from health problems and contend with environmental issues, largely the result of Western influence.
Many Micronesians suffer from health problems and contend with environmental issues, largely the result of Western influence. Mark Edward Harris/Civil Beat

Noncommunicable diseases, notably diabetes, became rampant.

A study this year in the American Journal of Health noted that, “The prevalence of type 2 diabetes in the Marshallese is among the highest of any population in the world,” with 25 percent to 50 percent of Marshallese adults diagnosed with diabetes compared to 8.3 percent of the U.S. population and 4 percent worldwide. That’s three to six times more than in the U.S.

The Marshallese also have disproportionate rates of hepatitis B, tuberculosis, and Hansen’s disease (commonly known as leprosy), and Marshallese mothers in the U.S. have high rates of low-birth-weight infants. 

photograph Cory Lum/Civil Beat
Dr. Neal Palafox and Dr. David Derauf treat COFA citizens who have immigrated to Hawaii for health reasons. Cory Lum/Civil Beat

While research shows increased incidence of diabetes in places exposed to radiation, “the science around causation of diabetes by ionizing radiation at the current time is soft,” according to Palafox, a Honolulu doctor who has done extensive work in the islands.

But, he notes, “the evidence is growing.”

“Let’s face it,” says Dr. David Derauf, a physician at Honolulu’s Kokua Kalihi Valley community clinic, which treats Compact of Free Association patients, “stress plays a huge role in the development of this disease though not completely understood.”

And, as the region’s food supply faces the new and very serious threat of climate change, which is devastating coral reefs and the abundance of fish and flooding crops, dependence on imported, Western foods seems destined to continue.

America’s Role

Perhaps the only thing more staggering than the health statistics of Micronesians is the lack of health facilities to treat them.

Despite the high diabetes rates, there are no dialysis centers in Chuuk or the Marshalls, the COFA regions that have the greatest out-migration. (There is dialysis in Pohnpei and Palau.)

In 2014, the U.S. government was assessing whether it was possible to establish more dialysis facilities in the COFA nations, but the medical programs proved too expensive to operate, and too difficult to staff and maintain quality care.

“It’s not sustainable in these areas, and they will tell you that,” says Palafox. “In the United States the best-run dialysis machines, if you don’t look at a (kidney) transplant, will keep people alive seven or eight years. In Pohnpei it’s three years. That shows you the difference in quality.”

The lobby of the hospital on Ebeye.
The lobby of the hospital on Ebeye, where posters offer advice on diabetes, tuberculosis and leprosy. Chad Blair/Civil Beat

Palafox says the per capita cost was sucking up so much money from the rest of the health system that, for the foreseeable future, it’s not feasible to treat diabetes in the one place in the world where it is most needed.

Cancer victims are similarly out of luck. A 2006 Harvard Law report found that basic treatment for nearly all radiation-related cancer victims is discretionary and arbitrary because the Marshalls lack the facilities to treat the patients.

“Without U.S. support, cancer victims with five-year survival rates below 50 percent are refused funding for treatment and left with no chance of being cured,” the law students wrote.

“Negative effects of the testing directly attributable to the U.S. testing have not yet been rectified,” they concluded. “Most notably, some Marshallese are still unable to return to their homelands because of contamination, and many victims stricken with radiation-related cancers will receive partial compensation or no compensation at all.”

The 2012 Social Medicine Journal study puts the onus on the U.S. even more bluntly.

The health effects of exposure to radiation from nuclear weapons, it said, “involved gross violations of the human rights of people in the Marshall Islands. In all likelihood, fallout from U.S. nuclear weapons testing in the Pacific was deposited on other Micronesian islands.”

Lacking proper medical treatment, it’s no surprise that many Micronesians capitalize on the “free association” element of the COFA agreement and migrate in droves to Hawaii,  Guam and cities on the U.S. mainland.

The Joseph Bates Outreach Clinic in Springdale, Arkansas, where thousands of Marshallese have settled, sees more than 100 Micronesian patients a week. With the floors painted “Pacific blue” and Marshallese handicrafts displayed in every room, the clinic is designed to tackle some of the more intransigent health problems facing the community.

“The objective is to get the word out there,” says Sandy Hainline, nurse coordinator at the clinic. “In the Marshalls and most Pacific Island communities, word does not travel by TV, radio or newspaper but coconut wireless — word of mouth.”

A Marshallese dental assistant, at right, with a dentist at the Community Clinic in Springdale, Arkansas. January 2015
A Marshallese dental assistant, at right, with a dentist at the community clinic in Springdale, Arkansas. Mark Edward Harris/Civil Beat

Health care professionals like Hainline have come to understand cultural differences that often impede Marshallese patients from seeking health care.

“We are a rude culture,” Hainline says of Americans. “We get right in your face,” noting that most routine questions at health centers — like if you have an appointment or if you have a bill due — may embarrass Micronesians and turn them off from the experience.

She also says many Marshallese do not have “the mindset” to go to the doctor for minor pain and sickness, preferring to wait until a crisis forces them to. Derauf, the Kokua Kalihi Valley doctor, sees this often in Hawaii, where, he says, the majority of his patients had no other choice but to immigrate for help.

“The decision to come to Hawaii was often a life or death decision,” he says. “It was a decision that all of us can understand, no matter what people’s positions are about this.”

“What would you have done if it was your mother in their shoes? What would you have had her do?,” he says. “Would you have told her, ‘Sorry, Mom, that’s all we can do’? No, you would have gotten on the first plane you could get on to come to Hawaii.”

To Heal The Body

Manuel Sound migrated to Hawaii about 10 years ago. Originally from Chuuk, he had worked for that state’s education department for decades and later served as lieutenant governor.

His daughter, Innocenta Sound-Kikku, doesn’t remember when he was diagnosed with diabetes, but she knows that he was already receiving insulin treatment when he was lieutenant governor, which was from 1997 to 2005.

With no dialysis in Chuuk, and with limited medical facilities elsewhere in Micronesia, Manuel Sound made the decision to move to Honolulu. Sound-Kikku followed in 2007 in order to be with him.

Mark Edward Harris/Civil Beat

"We were colonized by so many, and that affected the way we live."
— Virginia Luka

We're All Different

Virginia Luka, originally from Palau, is a student and academic adviser at Portland State University in Oregon.

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Leaving Chuuk meant leaving home, especially the family’s home atoll of Lukunor, located about 164 miles southeast of the main Chuuk islands — a place so remote that it takes two plane rides and a boat to get there from Hawaii. Sound-Kikku calls Lukunor “enchanted … anyone who comes to Lukunor falls in love because it is so beautiful.”

In Honolulu, Manuel Sound found the care he needed at Lanakila Health Center in the neighborhood of Kalihi, where many COFA citizens live in public housing. His diabetes required several medications and he visited the health center sometimes 10 times in a single month.

His medical services were covered by Med-QUEST, a state program that granted low-income adults and children access to medical coverage. Even though many COFA immigrants pay U.S. taxes and into Social Security, the federal welfare reform law of 1996 repealed Medicaid eligibility to COFA migrants.

Nuclear Weapons Yields in the Marshall Islands, Nevada and World War II

Source: Harvard Law Student Advocates for Human Rights, 2006.
Source: Harvard Law Student Advocates for Human Rights, 2006. Click to enlarge. 

Covering COFA migrants under the Med-QUEST program seemed like the next best option, but in 2009, citing cost burdens, the state announced COFA migrants were no longer covered under the program. Then-Republican Gov. Linda Lingle said the state paid as much as $100 million in 2007 to cover COFA migrants, or 10 times the amount reimbursed by the federal government for Compact Impact Aid.

The costs are similarly shocking in Guam, where the territory absorbed $30 million in unpaid emergency room bills last year. Uninsured COFA citizens, Guam officials say, use the hospital like a clinic.

With no indication of an increase in Compact-Impact Aid, Hawaii decided to transfer COFA citizens to a new program, Basic Health Hawaii, which came with considerably reduced benefits.

The new plan would allow people like Manuel Sound just 12 visits a year to a doctor and four medications a month. Sound testified in 2009 before lawmakers at the Hawaii State Capitol, telling them that the forced switch from Med-QUEST to the basic plan amounted to a “death sentence.”

Sound was not alone in this problem.

Dakleen Salla originally from Chuuk receives a handshake welcoming her aboard the Health Connector at St. Elizabeth's church for a recruitment drive. 7 feb 2015. photograph Cory Lum/Civil Beat
Dakleen Salla from Chuuk, at right, successfully enrolled in the Hawaii Health Connector at St. Elizabeth’s Church recruitment drive. The program is now being enrolled into the Affordable Care Act. Cory Lum/Civil Beat

Some 7,500 Micronesians living in Hawaii were taken off Med-QUEST in 2009 and enrolled in Basic Health Hawaii. That same year, lawyers for a group called Lawyers for Equal Justice (now known as the Hawaii Appleseed Center for Law and Economic Justice) and two Hawaii law firms sued the state, calling the switch discriminatory.

The legal battle lasted five years, with much back and forth, until finally, in 2014, three Micronesians living in Hawaii asked the U.S. Supreme Court to hear their case about being denied health benefits by the state. But the high court decided not to take up the issue, thus validating the state’s authority to determine the health care coverage provided to non-U.S. citizens ineligible for Medicaid.

But by then it no longer mattered. Micronesians had a new health care system to deal with thanks to the Affordable Care Act, also known as Obamacare.

A ceremony marking Disability Week is held in early December on Ebeye in the Marshall Islands.
A ceremony marking Disability Week is held in early December on Ebeye in the Marshall Islands. Mark Edward Harris/Civil Beat

The state announced that adult COFA migrants — as long as they were not pregnant, aged, blind or disabled — would be automatically enrolled into the Hawaii Health Connector, the state’s private health insurance exchange, by March 2015.

The change was disorienting for many Micronesians, and in addition to keeping up with the utterly dizzying policy changes, not all COFA citizens could easily produce the required documents to select a new plan on the Connector. There were also concerns about the copay under the Connector plans, which ranged from $750 to $2,250. Bills to have the state of Hawaii pick up the copay for COFA migrants died in the Legislature earlier this year.

Nonetheless, nonprofit groups like COFA CAN (Compact of Free Association Community Advocacy Network), Micronesians United – Big IslandWe Are Oceania and the Micronesian Community Network launched an aggressive outreach campaign to enroll COFA citizens into the Connector, and by July, 8,500 COFA migrants had enrolled in insurance plans.

The switch is expected to save the state $29 million, but health and other expenses for COFA citizens continue to cost taxpayers, especially those in Hawaii. In 2014, the state spent $163 million, with costs for health care and human services comprising about 42 percent.

Mark Edward Harris/Civil Beat

"There are a lot of people who are suffering, they’re seeking opportunity here in the states."
— Kianna Angelo

Educating Local Communities

Kianna Angelo, a Marshallese living in Vancouver, Washington, is executive director and founder of the nonprofit Living Islands.

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The Department of Human Services reported spending $66.7 million in state funds for the residents. The total cost was actually $78 million but Hawaii gets $11 million from federal taxes through Compact-Impact Aid that offsets some of the state’s expenses.

Temporary Assistance for Needy Families, Aid to the Aged, Blind, or Disabled and general assistance cost Hawaii $10.6 million, and the Department of Health spent $5.4 million in state funds for both community-based and direct health care and health-related education to COFA residents. High on the list was care related to tuberculosis, Hansen’s disease (leprosy) and other communicable diseases, which are over-represented within the COFA population.

For Hawaii doctors who see Micronesian clients, however, the state is being penny wise and pound foolish.

They describe the switch from Med-QUEST, which provided better care and coverage, to Basic Health Hawaii and then to the Hawaii Health Connector as impractical and short-sighted.

Dr. Wilfred Alik.
Dr. Wilfred Alik, a Marshallese doctor working in a Big Island clinic. Mark Edward Harris/Civil Beat

“The reason for doing that was to save money for states,” says Alik, the Marshallese doctor who works in Hawaii, “but if you think about it, really analyze their proposal, if they’re going to cut care to a marginal population that is in need of care, then they end up flooding the emergency room.”

The decision is actually counterproductive, agrees Palafox, the Honolulu doctor who works closely with Micronesians.

He argues that the greater economic cost is not taking care of a population in need.

“It’s like you float all boats or you sink all boats,” he says. “The fleet goes only as fast as the slowest ship.”

Big health disparities hurt America, he says, because they also cause disparities in poverty, education and jobs. If you don’t get the slow ship to pick up speed, Palafox contends, “It hurts all of us. You don’t want that in any form.”

A Marshallese boy on Ebeye.
Watch Slideshow In many ways, Ebeye and Majuro are still feeling the effects of nuclear testing that devastated the Marshall Islands decades ago. Mark Edward Harris/Civil Beat

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