Health for the Marshallese

Despite being more than 1,500 miles from the Pacific Ocean, Arkansas holds the distinction of serving as home to the largest population of Marshall Islanders in the continental United States, with as many as 6,000 residing in the state. Although the number of Marshallese Arkansans may seem small, they represent approximately 9 percent of the entire population of the Republic of the Marshall Islands. The vast majority reside in Springdale, where they contribute greatly to the local economy and the region’s cultural life.

Although they are legal residents and pay U.S.

taxes, the Marshallese are ineligible for many federal safety net programs. Their exclusion from these services not only threatens the health of Marshall Islanders and their neighbors but has resulted in a substantial financial hardship for health care facilities in Springdale and its surrounding communities.

The Marshall Islands consists of a series of widely dispersed coral islands and atolls located about 2,400 miles southwest of Honolulu. Due to the Compact of Free Association (COFA) treaty signed in 1986, Marshall Islanders-as well as citizens of the Federated States of Micronesia and the Republic of Palau-can live and work in the United States without a visa or green card.

In exchange, the United States enjoys exclusive military rights over the more than 2 million square miles of ocean encompassing these three countries. In addition, the U.S. maintains a large military base on Kwajalein Atoll, which includes the strategically important Ronald Reagan Ballistic Missile Defense Site.

Many Marshallese in Northwest Arkansas work in the region’s vast poultry industry, in retail, and in food service. Most who are employed full time are eligible for health insurance. However, for many workers, the cost of covering their spouses and children can be prohibitively expensive. Due to their complex lineage system, Marshallese employees may also be responsible for relatives not typically covered in family health insurance plans like cousins, parents, or their siblings’ children.

Unlike those families, though, U.S.-based Marshall Islanders are ineligible for most federal health care programs like Medicaid, Medicare, and Social Security. Although the original treaty permitted eligible COFA migrants to apply for these programs, welfare reform legislation signed by President Bill Clinton in 1996 explicitly barred them from receiving these benefits. Nonetheless, Marshallese workers continue to subsidize these programs through payroll deductions and income taxes.

Marshall Islanders share some of the same health problems facing other low-income populations in the U.S. Type 2 diabetes, for example, has reached epidemic proportions among Marshallese Arkansans. Likewise, Marshallese suffer from unusually high rates of a variety of cancers. They are also susceptible to ailments that are less common among the general population including tuberculosis, eczema, and Hansen’s Disease. The reasons for this susceptibility are complex but likely include their adopting a Western diet, overcrowding and poor sanitation in the Islands’ urban centers, and a lack of comprehensive health care on the nation’s many far-flung islands and atolls.

However, the ecological and genetic impact of nuclear weapons testing in the Marshall Islands may play a disproportionate role in explaining these health problems. Between 1946 and 1958, for example, the U.S. military detonated 23 hydrogen bombs in the Marshalls, some of which were 1,000 times more powerful than the atomic bomb dropped on Hiroshima, Japan.

Because so many Marshallese lack health insurance and none are eligible for federal health care programs, they tend to avoid seeking treatment until their condition has greatly deteriorated. This not only places the individual’s health at risk, but once he finally seeks help, the illness can be both difficult and expensive to treat.

Marshallese Arkansans’ inability to receive Medicaid, Medicare, and other health assistance places an undue financial burden on local health-care providers, and ultimately on the state of Arkansas as a whole. Between 2006 and 2012, for example, a local out-patient health care provider absorbed over $595,000 in outstanding balances from its Marshallese patients, who represent just 6 percent of its client base.

When the Compact of Free Association was ratified, Congress assumed that its impact would be limited to Hawaii and to U.S. Territories such as Guam and American Samoa. The treaty specifically states that the agreement is not intended “to cause any adverse consequences” to those localities. But Arkansas, like Hawaii, has faced a substantial financial burden in addressing the health-care needs of Marshall Islanders residing in the state, which can negatively impact health care delivery for everyone. The Marshallese, and all Northwest Arkansas residents, deserve better.

To address these concerns, Senator Mazie Hirono (D-Hawaii) recently introduced an amendment to the Border Security, Economic Opportunity, and Immigration Modernization Act currently being debated in Congress. This amendment, if approved, would restore Medicaid coverage for U.S.-based Marshall Islanders and other Compact of Free Association migrants. Meanwhile, her colleague in the House of Representatives, Colleen Hanabusa (D-Hawaii), filed a bill in March called the Compact Impact Aid Act of 2013 (HR 1222), which would for the first time provide mainland U.S. states like Arkansas with special grant funding to reimburse public spending on Marshallese and other COFA migrants. (Currently, Hawaii is the only state to receive these funds). Each of these initiatives would have an immediate and positive impact on Arkansas’ Marshallese community and on the state as a whole.

Despite the many challenges they face in their own country and in the United States, Marshall Islanders remain a highly resilient, optimistic, and deeply spiritual people who have culturally, socially, and economically enriched all of Northwest Arkansas. This proposed legislation offers a unique opportunity to substantially improve their health and well-being.

Michael R. Duke is on the faculty of the Department of Anthropology at the University of Memphis. He is beginning a multi-year research project focused on the health of Marshall Islanders in Northwest Arkansas.