Micronesians who were hospitalized in Hawaii were significantly younger than other racial and ethnic groups, a new study has found.

The severity of the illnesses also was higher for Micronesians than for whites, Japanese and Hawaiians when it comes to cardiac and infectious disease.

Micronesians were hospitalized at higher rates for cancer and endocrine issues (relating to the bloodstream and glands) compared with whites and Japanese, and recorded a higher rate for substance abuse compared with Hawaiians.

The study — “Younger and Sicker: Comparing Micronesians to Other Ethnicities in Hawaii” — was published last month in the American Journal of Public Health. It says that the results and conclusions may help researchers, governments officials and hospitals, medical providers and health systems help “this vulnerable group.”

Much of the population of Ebeye in the Marshalls is under 18 years of age, and the island is largely impoverished.

Much of the population of Ebeye in the Marshalls is under 18 years of age, and the island is largely impoverished.

Mark Edward Harris/Civil Beat

One of the authors of the study says she was surprised by the results.

“We were really shocked to find out how much younger this population was compared to other groups,” said Megan Inada, a doctoral student in public health at the University of Hawaii at Manoa. “For some reason, they are getting the same diseases as older people in other groups. So that means they are either dying younger or living a longer time with serious conditions.”

Seiji Yamada, another study author, said the results bolster arguments in favor of better access to health care in Hawaii for immigrants from Compact of Free Association islands. Under COFA, residents of Palau, the Marshall Islands and the Federated States of Micronesia are permitted to live and work indefinitely in the U.S. and its territories without a visa.

“If we believe that health is a human right, we must advocate for access to health for those who are most sick.”—Dr. Seiji Yamada, UH medical school

“One of our arguments calling for access to health care for COFA migrants has been our contention that when there are financial barriers to primary care access, people will receive less preventive and primary care, and end up more sick,” said Yamada, an associate professor of family medicine and community health at UH’s John A. Burns School of Medicine, said via email.

The new study does not provide sufficient data to compare periods when COFA migrants were on Med-QUEST (the state’s Medicaid program) and when they were forced by the state and courts to enroll in an inferior program called Basic Health Hawaii.

Chuukese, like these girls on the main island of Weno, have access to only limited health care.

Chuukese, like these girls on the main island of Weno, have access to only limited health care.

Mark Edward Harris/Civil Beat

The move started in 2009 under Republican Gov. Linda Lingle and continued under her Democratic successor, Neil Abercrombie, in 2010. Legal challenges followed, but the state’s action was ultimately upheld. Courts cited congressional welfare reform in 1996 that removed COFA migrants from Medicaid eligibility.

Advocates for COFA citizens living in Hawaii believe the 1996 law and the subsequent court rulings have been detrimental for Micronesians. Some 7,500 COFA citizens in Hawaii were forced to enroll in the state’s troubled private insurance exchange, the Hawaii Health Connector, in 2015.

When the Connector collapsed under financial strain and technical woes with the online enrollment system, Gov. David Ige, a Democrat, moved to have the Micronesians enroll under the federal Affordable Care Act.

Yamada believes Hawaii’s government has fallen short in helping Micronesians in the islands. As he put it, “If we believe that health is a human right, we must advocate for access to health for those who are most sick.”

Like her colleague, Inada hopes that the new research could help inform policy decisions.

“Especially during this time, with so much going on with insurance and the U.S. Congress, we have to be very careful before making decisions to cut access to health care and making it harder to get,” she said. “It is the last thing that you want to do, because it is going to have a big impact.”

Health Care Drives Migration

As Civil Beat reported in its series The Micronesians, Marshallese, Chuukese and other islanders flock to Hawaii because of inadequate health care at home.

They have higher rates of diabetes, cancer and tuberculosis. Their illnesses are tied to the effects of colonialism and loss of culture, U.S. nuclear testing and the rapid adoption of unhealthy Western diets. Their challenges are compounded by high rates of poverty and language barriers.

In 2014, the cost to provide health, education and social services to Micronesians living in Hawaii totaled more than $160 million. But the federal government only compensates the state $11 million annually for what’s known as compact-impact aid.

The “Younger and Sicker” study comes at a time when two other recently published studies about Micronesian health in Hawaii reach similar conclusions about the dire condition of the islanders. They include Yamada as a co-author. 

One, “Inpatient Hospitalization Costs: A Comparative Study of Micronesians, Native Hawaiians, Japanese, and Whites in Hawaii,” concludes that Micronesians have higher unadjusted hospitalization costs overall, and specifically for several disease types.

“It is important to find the root causes of these apparent health inequities so that we may not only lower healthcare costs but decrease suffering,” wrote the authors.

The inpatient hospitalization study was published last year in the International Journal of Environmental Research and Public Health.

Ethical Responsibilities

The third study, “Ethical Responsibility for the Social Production of Tuberculosis,” by Yamada, Sheldon Riklon and Gregory Maskarinec, was published last year in the Journal of Bioethical Inquiry. Like Yamada, Riklon and Maskarinec are associated with the UH medical school; Riklon is also Marshallese.

The tuberculosis study found that one in 200 people in the Marshall Islands have active TB, and it details the widespread social and ecological destruction from nearly 70 nuclear tests conducted in the region in the late 1940s and ’50s.

The study concludes that “there were certain junctures at which decisions were made by particular individuals at military headquarters or in corporate boardrooms that were harmful to Marshallese people” — in this case, a TB epidemic.

The people who made the decisions — namely, individuals at military headquarters or in corporate boardrooms — that led to what the study refers to as “personal violence” are not likely to be held accountable. But the study said there remains an ethical responsibility on the part of persons “in positions of power” to address the TB epidemic in the Marshalls.

Yamada said it was “sort of a coincidence” that the three studies were published at about the same time. But he said there is a burgeoning interest in the health of Micronesians, not only in Hawaii but also in Guam and Arkansas, where tens of thousands of Micronesians now make their homes.

Drs. Sheldon Riklon and Gregory Maskarinec talk about their visit to a Marshallese community in Arkansas, held at the UH medical school in March 2015.

Drs. Sheldon Riklon and Gregory Maskarinec talk about their visit to a Marshallese community in Arkansas, held at the UH medical school in March 2015.

Cory Lum/Civil Beat

With attention now focused on the impact of climate change on the COFA nations, which will almost certainly lead to greater outmigration, Yamada said it is important to understand COFA, the U.S. history in Micronesia and the ongoing and growing crisis with health care needs of Micronesians in Hawaii.

It’s a very timely issue, he said.

Referring specifically to the inpatient hospitalization study, Yamada wrote in an email:

“In these times, when we see a presidential candidate who advocates deporting millions, building walls, and banning the entry of Muslims, leading in the the polls — we want to be careful that the findings in our article are not used to buttress arguments to bar the entry of COFA migrants or deny access to care.”

Inada, co-author of the “Younger, Sicker” study, hopes the new research will put a human face on the crisis.

“I think I am too touchy-feely, but people seem to have more empathy,” she said. “It’s not easy to just move 7,500 COFA migrants on to a new health care program. I want people to see that these are people just like you and me who want to be healthier, but for some reasons they are sicker. And because of that they are in Hawaii now. We should take care of them like our family.”

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