Micronesian migrants struggle to access health care in Oklahoma and Arkansas.
Ernest and Lenwa Joab outside their rental home in Enid, Oklahoma.
Lenwa doesn’t speak much. She had a stroke a few years ago, and has high blood pressure, diabetes, and poor vision. Her family worries that the coming winter will be hard on her, as it is on most elders who grew up without winter; who came to the United States to get better but are dying instead. Few imagined they’d die here, in a foreign land with Ford trucks in driveways and leaf blowers in yards. Soon, snow will shiver through the bare branches. Lenwa isn’t receiving any medical care.
The Joabs came to Oklahoma in 2007 from the Republic of the Marshall Islands, a tiny nation in Micronesia in the middle of the Pacific Ocean. Several of their seven children were already working in the United States, and after Ernest retired they came to join them for a while. Long journeys are nothing new for the Marshallese—the tiny islands they call home are scattered across vast distances of ocean, and for hundreds of years trade and marriage and war necessitated lengthy voyages in outrigger canoes. Moving is part of their culture.
Colonization in the 20th century only strengthened these skills. During World War II, when the Marshall Islands were occupied by the Japanese, battles and bombs forced many Marshallese off land they’d lived on for generations. After the war, the archipelago was ceded to U.S. control, and nuclear testing began: Between 1946 to 1958, the United States dropped the equivalent nuclear power of nearly 7,000 Hiroshimas on the Marshallese islands of Bikini and Rongelap. Dozens of families were permanently displaced from their lush homelands and resettled on barren islands that lacked reefs for fishing and land for growing taro and other staple crops.
Without access to traditional food, displaced families turned to the few imports available: white rice, canned tuna, SPAM, corned beef, refined sugar. Diabetes skyrocketed. Meanwhile, as more people crowded into urban centers with poor sanitation and access to clean drinking water, diseases like leprosy and typhoid spread. And Marshallese exposed to nuclear fallout experienced increased rates of birth defects and thyroid cancers.
Today, a Compact of Free Association that the Marshall Islands signed with the United States shortly before it gained independence in 1989 means that these health problems have arrived in places like Enid, Oklahoma.
The compact allows the United States to operate a large military base in the Marshall Islands, and in exchange any Marshallese citizen can live in the U.S. indefinitely, without a visa, green card or health screening upon entry.
When it was signed, only a handful of Marshallese had emigrated to “Amedika.” But as the government of the Marshall Islands struggled to provide jobs and healthcare for its citizens, many citizens who could manage to save the $1,500 for a plane ticket to the U.S. left home—sometimes as a permanent move, sometimes with the goal of getting better healthcare or an education and returning to the islands. The most obvious stopping place was Hawaii, just over 2,000 miles away. But though Hawaii’s climate and culture is familiar, the cost of living is high. Many Marshallese migrants go on to the lower Midwest, where there are plentiful jobs in meat processing plants and the lower cost of living allows workers to save enough money to send home.
Today, northwest Arkansas has the largest Marshallese population outside of the Marshall Islands, and Oklahoma isn’t far behind. In all, more than a third of Marshallese residents—some 25,000 people—have now emigrated to the United States. Some, like Lenwa Joab, are too sick to return home, and too poor to get better.
In early November, Enid is still warm, and Lenwa is barefoot, her feet broad and flat against the footrests of her wheelchair, her hair combed back with coconut oil. In a voice barely louder than a whisper, she says in Marshallese that she’s tired—i mok—and needs to lie down. Her son wheels her inside toward a dark back room. Ernest settles into an armchair. I lived in the Marshall Islands for a year after college, and he’s politely amused by my attempt to interview him in Marshallese.
In a mix of Marshallese and English, Ernest tells me that when they first arrived in Enid several years ago, his wife was well. But in 2014, she suffered a stroke and was briefly hospitalized. Her bill was $3,000—low by American standards but a fortune to the Joabs, who have no source of income. Their son Frederick works at the Oklahoma City airport an hour to the south and needs every cent of his paycheck to support his own three kids, pay rent, and buy food for both families. “People call all the time,” Frederick says, of Lenwa’s medical bills. He pauses to search for the right word in English: “Collections.”
Lenwa needs insulin for her diabetes, medicine for her high blood pressure, and perhaps other medical care. But like many other Marshallese elders, Lenwa is ineligible for Medicare and Medicaid and is thus uninsured. The family doesn’t see a doctor because it’s too expensive.
Terry Mote, who moved to Oklahoma in 2007 and serves as the Micronesian community health coordinator for the Garfield County Health Department in Enid, later confesses that he doesn’t think Lenwa will live much longer without medical care. He’s seen it before—there are a lot of people like Lenwa in Arkansas and Oklahoma’s Marshallese communities, he says, quietly suffering behind closed doors. Although Marshallese migrants are here legally and pay taxes that support federal programs like Medicaid, they’re barred by law from receiving Medicaid benefits. And because the health disparities that plague the Marshall Islands have followed migrants here to the United States, many are in desperate need of health care.
In Arkansas, for instance, Marshallese suffer from tuberculosis at a rate of roughly 50 cases per 100,000 people, compared to 3.6 per 100,000 people in the general population. From 2001 to 2005, researchers from the Arkansas Department of Health and Human Services found that 68 percent of Marshallese with tuberculosis were uninsured, and 65 percent had delayed seeking medical diagnosis or treatment for two months or more, possibly aiding the spread of the disease. Marshallese also have higher rates of communicable diseases like syphilis, and last summer, a mumps outbreak among vaccinated Marshallese migrants raised questions about whether the islands’ nuclear legacy may be impacting immunity in ways not yet fully understood. Some health professionals are also concerned that the islanders’ shared historical trauma—the years of nuclear testing and the current threats posed by rising sea levels—may be impacting mental health. Yet few Marshallese seek treatment, either because of cultural mores or because it’s too expensive. “Access to health care is a huge issue,” says Micheal Duke, an anthropologist at the University of Memphis who studies health disparities among Micronesian migrants. Although migrants who work full time may receive health insurance through their employer, many are surprised that the insurance only covers their legally recognized spouse and children. “The concept of what a family is very different in the Marshall Islands,” Duke explains: Parents often raise children who aren’t biologically their own, and aunts, uncles, and cousins can be virtually indistinguishable from mothers, fathers, and siblings. “Often people will make sacrifices to get family health insurance only to realize that their parents or cousin aren’t eligible,” Duke says.
Two other states with large Micronesian populations—Hawaii and Oregon—have passed state legislation giving Marshallese access to state-funded health benefits similar to Medicaid. But though several bills aimed at providing similar benefits have been introduced in Oklahoma, none have passed. “It’s frustrating,” says Duke. “Even though the Marshallese are a big drain on health care costs because so many are uninsured, there’s still this concern about immigrants getting something for nothing.”
Or as Arkansas Representative Billy Gaskill said in 2007, in response to the disparities that make health care access especially pressing for Marshallese migrants: “A nuclear bomb don’t cause syphilis, and it certainly don’t cause leprosy.”
Still, Terry Mote and other health workers believe it’s only fair that legal, tax-paying residents have access to the services they help pay for. Since 2001, more than a dozen bills seeking to expand health care access to Micronesian migrants have been introduced to the United States Congress, including the latest, the 2017 The Covering Our FAS Allies (COFA) Act, written by Hawaii’s congressional delegation.
If Marshallese and other COFA migrants were to receive access to Medicaid, it would increase federal spending by about $200 million over a 10-year-period. That’s $20 million a year—a tenth of the $183 million that the U.S. Department of Defense spends annually to maintain its military base in the Marshall Islands.
Marshallese families in Enid aren’t totally without options. Pregnant women are covered by a state program, and a volunteer-run clinic tries to fill in the gaps by offering uninsured Marshallese some primary care and help with prescriptions. Terry Mote translates for Marshallese migrants, helps them navigate Oklahoma’s health care system, and advocates for change in the state legislature.
A month after I met Lenwa Joab, though, she was again hospitalized for complications related to her diabetes. She began visiting the Enid Community Clinic to receive help with insulin, but it proved to be too little, too late: On May 5, 2017, Lenwa died. Her funeral was held at the Assembly of God church on a clear day, the sky overhead stretching on forever, achingly blue.
Krista Langlois is a freelance journalist based in southwest Colorado. She taught English on a remote atoll in the Marshall Islands from 2006 to 2007, and has also built trails in Idaho, led sea kayaking trips in New Zealand, and guided teenagers in the Alaskan wilderness. You can see more of her work at kristaleelanglois.com. Reprinted from The New Territory (Issue 4), a new quarterly magazine that tells stories of the Lower Midwest’s land, people, and possibilities.