Micronesian migrants struggle to access health care in Oklahoma and Arkansas.


Ernest and Lenwa Joab outside their rental home in Enid, Oklahoma. Lenwa, as well as many other Marshallese living in the United States, is in poor health but cannot afford medical care. KRISTA LANGLOIS


Lenwa Joab has a soft, creased face and hands that rest motionless in her lap. She is 65 but looks older. Her husband, Ernest, is 66 but looks younger, his hair still thick and black except just at the temples, where it fades to gray. He sweeps a leaf blower across the yard of a tidy brick home on the east side of Enid, Oklahoma, while Lenwa sits in a wheelchair in the driveway, watching silently. One of their grandsons — Frederick, Tony or Peculiar, it’s hard to tell which — darts around the wheelchair and the Ford F-150 next to it, playing a game only he knows.

Lenwa doesn’t speak much. She had a stroke a few years ago, and has high blood pressure, diabetes and poor vision. She isn’t receiving any medical care.

Soon, snow will shiver through the bare branches of the trees in the yard. 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.

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 he and Lenwa 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. 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 and 1958, the United States dropped the equivalent nuclear power of nearly 7,000 Hiroshimas on the Marshallese atolls of Bikini and Enewetak. 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.

These Marshallese families now found themselves fighting terrible disease. 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, tuberculosis and typhoid spread. And Marshallese exposed to nuclear fallout experienced increased rates of birth defects and thyroid cancers.

When the Marshall Islands gained independence in 1986, the nation signed a Compact of Free Association with the United States. 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. This is how Marshallese health problems have arrived in places like Enid, Oklahoma.

When the compact was signed, few Marshallese had emigrated to “Amedika.” But as the government of the Marshall Islands struggled to provide jobs and health care for its citizens, many 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 health care 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 they can find plentiful jobs in meat processing plants and a lower cost of living.

Although actual numbers are difficult to find, it’s widely acknowledged that northwest Arkansas has the largest Marshallese population outside of the Marshall Islands. 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.”

When I visited in November, Lenwa needed insulin for her diabetes, medicine for her high blood pressure and perhaps other medical care. But like other Marshallese elders, she is ineligible for Medicare and Medicaid and is thus uninsured. The family wasn’t seeing a doctor because of the cost.

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’s 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 problems 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 2000 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 treatment for two months or more, possibly aiding the spread of the disease. Marshallese also have higher rates of communicable diseases like syphilis. Last summer, a mumps outbreak among fully 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 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 Compact of Free Association (COFA) migrants access to state-funded health benefits equivalent to Medicaid. But though several bills aimed at providing similar benefits have been introduced in Arkansas and 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: “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, some 21 bills seeking to expand health care access to Micronesian migrants have been introduced to the United States Congress, including the Restoring Medicaid for Compact of Free Association Migrants Act of 2015, written by several Hawaiian delegates.

If Marshallese and other COFA migrants were to receive access to Medicaid, it would increase federal spending by an estimated $200 million over a 10-year-period, according to the Congres-sional Budget Office. That’s $20 million a year — roughly a tenth of the $180 million that the U.S. Department of Defense spends annually to maintain its military base in the Marshall Islands.

Marshallese families in Enid and elsewhere aren’t without options. Pregnant women in Oklahoma are covered by a state program, and a volunteer-run clinic in Enid offers uninsured Marshallese some primary care and help with prescriptions. Terry Mote translates for Marshallese migrants and helps them navigate the health care system, while a nonprofit called Rural Health Project teaches classes on how to cook healthy meals instead of relying on the white rice and canned meat that have become staples of the Marshallese diet.

These may seems like small steps, but for Janet Cordell, who directs the Enid Community Clinic for low-income residents, they’re a sign of something bigger: Oklahomans are finally reaching out to the 4,000 or so Marshallese weaving themselves into the fabric of the Sooner State, and Marshallese are no longer falling through the gaps of that fabric. Things are getting better.

“The early days were a big struggle because here you are in farm country, redneck country,” Cordell says. “I’m from farm country, and we don’t take kindly to outsiders. But my front desk girls learned early on that you don’t schedule an appointment for a Marshallese person at 9:30 in the morning and expect them to show up.” (Marshallese notoriously run on “island time.”) “It’s not that we’re catering to them,” she adds. “We’re just trying to fit with each others’ culture.”

In early November, when I visited Cordell at her clinic, she was still hopeful that either state or federal lawmakers would pass legislation making it legal for COFA migrants to receive Medicaid or similar benefits. But as the leaves blew off the trees and temperatures dropped, hope faded. Neither a local Oklahoma effort nor the federal legislation were voted on. They expired and will have to be reintroduced in a future session.

A month after our interview, Lenwa Joab was again hospitalized, this time for complications related to her diabetes. Her hospital bills multiplied. But as of press time, she was receiving help with prescriptions and diabetes care from the clinic, and was back home with her family in the small brick house on the east side of Enid, quietly waiting for something to change.



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