Marshall Islanders: Migration Patterns and Health-Care Challenges

Approximately one-third of the population of the Republic of the Marshall Islands, a series of islands and atolls in the Pacific, has relocated to the United States, with Hawaii and Guam key destinations as well as—perhaps more surprisingly—Arkansas. Lack of economic and employment opportunities are among the leading factors that have prompted this dramatic outmigration, enabled by the Compact of Free Association (COFA).

Access to education and health care—critically important for a population that has reduced life expectancy and significant negative health indicators—also represent key factors that propel a sizeable share of the Marshall Island’s population of 68,000 to the United States. Yet, as this article explores, this economically vulnerable population confronts significant health-care coverage and access barriers in the United States.

Migration Seeded by the Compact of Free Association

The Republic of the Marshall Islands (RMI) consists of a series of widely dispersed, low-lying coral islands and atolls located about 2,400 miles southwest of Honolulu. Although its territory encompasses more than 750,000 square miles of ocean, the country’s total land mass is just 113 square miles, which is approximately the size of Washington, DC.

Signed in 1985 by the United States and three Pacific microstates—the Federated States of Micronesia, Palau, and the RMI—the COFA treaty grants the United States exclusive military rights over the more than 2 million square miles of ocean encompassing these three countries. In exchange, these nations receive much-needed financial aid and their citizens are permitted to live and work in the United States without a visa or green card (and thus technically are not immigrants).

Although many COFA migrants have relocated to Hawaii and Guam, a sizeable number of Marshall Islanders (or ri-Majol, as they refer to themselves) reside on the U.S. mainland. This migration is recent, with the Marshallese population in the United States increasing from 6,700 in 2000 to 22,400 as of the 2010 census.

Causes for ri-Majol Migration

A number of factors have contributed to the significant out-migration of the Marshallese from their homeland.

First, globalization associated with the U.S. military’s outsize presence in the region has been significantly responsible for the deterioration of the subsistence economy of the outlying islands. Given the country’s geographic isolation, relatively poor soil, and lack of a consistent fresh water source, agricultural production is also very limited, and the government has had marginal success in attracting industry or business investments. Moreover, the RMI’s ecosystem of coral atolls is extremely fragile, thus limiting the potential for large-scale tourism or other forms of economic development. The rising sea levels caused by climate change pose a grave threat to the country’s future, and the RMI has been a forceful advocate in the United Nations for international efforts to reduce greenhouse gases.

The country’s largest industry consists of the processing of copra (dried coconut flesh from which coconut oil is extracted), but local production is dwarfed by that of other nations, particularly the Philippines. The leading employer in the RMI is the U.S. military, which operates the Ronald Reagan Ballistic Missile Defense Site on Kwajalein, the country’s largest atoll. These positions are low-skilled and poorly compensated, with workers receiving the RMI minimum wage of US$5.00 per hour. However, given the country’s high rates of unemployment, these jobs are considered highly desirable.

The high level of unemployment overall has prompted many in the Marshall Islands to leave. Although most Marshallese in the United States reside in Hawaii, more than 6,000 live in northwest Arkansas, with many working in the region’s vast poultry processing industry.  The continued migration of Marshallese to Arkansas is due to several factors. First, the ri-Majol population is large and generally well-established. Second, the cost of living is low relative to other locales where Marshall Islanders have settled, including Honolulu, Sacramento, CA, and Salem, OR.  Most important, low-skilled jobs are relatively plentiful—albeit hazardous and poorly compensated—in Northwest Arkansas’ vast poultry processing industry.

A second factor contributing to out-migration is the relative absence of educational opportunities in the RMI. Although a community college and a branch of the University of the South Pacific operate in Majuro, the nation’s capital, their programs are relatively limited, and there remains a widely held perception among Marshall Islanders that educational institutions in the United States are of better quality and more prestigious. Thus, small but growing populations of Marshallese have relocated to communities such as Pittsburg, KS, and Enid, OK, in order for their children to attend the local community college.

Lastly, Marshallese migration patterns are tied to health care. The Marshallese enjoy low-cost health care in their country, generally $5 per consultation. For those living outside the population centers of Majuro and Eyebe, however, health-care access is very limited. Regardless of where one resides in the RMI, the country’s health sector lacks the capacity to provide technologically advanced medical interventions. Health care not only influences migration from the RMI, but internal migration within the United States as well. For example, because Arkansas’ health insurance for low-income residents is limited and difficult to access, Marshallese families will sometimes send their elderly parents or other relatives to states such as California or Oregon, whose benefits are considered more generous.

Improved Access to Health Care: An Elusive Goal

Access to high-quality, affordable health care is critically important to Marshall Islanders, given the wide range of health problems suffered by this population, including tuberculosis, diabetes, hypertension, thyroid tumors, alcoholism, depression, and Hansen’s Disease/leprosy, as well as higher rates of suicide. Life expectancy in the RMI is 60 years, compared with 69 years and 72 years for residents in the Federated Republic of Micronesia and Palau, respectively. (Life expectancy in the United States is 79 years).

A variety of factors contribute to these negative health conditions, including poverty, overcrowding, and poor sanitary conditions in the country’s population centers, as well as the loss of traditional forms of subsistence. The ecological, genetic, and psychosocial impact of sustained nuclear weapons testing in the Marshall Islands by the United States during the 1940s and 1950s undoubtedly also contributes to these ongoing health problems. For example, the social dislocation and radiation contamination caused by these tests, coupled with the U.S. military’s outsize presence in the region, has led to the loss of the traditional diet of fresh fish, breadfruit, coconut, and pandanus in favor of white rice and highly processed packaged foods. As a result, Marshall Islanders in both the RMI and the United States have among the highest rates of Type 2 diabetes in the world. For the ri-Majol, access to dialysis is difficult to obtain in the islands and cost-prohibitive for those living in the United States. Among Marshall Islanders in Arkansas and elsewhere, untreated diabetes has frequently resulted in blindness, amputation, and other impairments. Moreover, despite the fact that atomic testing ended more than 60 years ago, the Marshallese continue to suffer from unusually high rates of thyroid disorders, birth defects and cancer.

Marshallese migrants who work full-time in the United States are typically eligible for health insurance, but the cost for ensuring their family members can be prohibitive. Moreover, due to their distinctive matrilineal kinship structure, adult Marshall Islanders typically have substantial obligations toward family members (e.g., parents, nieces, and nephews) not typically covered by health insurance. Sisters, for example, typically raise their children collectively across multiple households (the word for “mother” and “aunt” [jinõ] are the same in the Marshallese language), and males take an active role in raising their sisters’ children. However, few insurance policies cover policyholders’ nieces and nephews.

Lastly, although ri-Majol and other COFA migrants pay U.S. income taxes, they are barred from receiving most forms of federal assistance, including Medicaid, Medicare, and Social Security. The original COFA treaty permitted migrants to apply for these programs; welfare reform legislation signed by President Clinton in 1996, however, explicitly barred the Marshallese and other Pacific microstate migrants from receiving these benefits. While COFA migrants are eligible to participate in the Affordable Care Act, their exclusion from safety-net programs such as Medicare and Medicaid has had a negative impact on the health and well-being of these economically vulnerable families. Most Marshallese-serving health-care providers in Arkansas report the belief that their patients’ inability to access these programs has contributed to poor health, since they tend not to seek health services until symptoms become significantly acute, and therefore difficult and expensive to treat. To address this disparity, Senator Mazie Hirono (D-HI) introduced an amendment to the Border Security, Economic Opportunity, and Immigration Modernization Act adopted by the Senate in June 2013 that would restore Medicaid coverage for U.S.-based Marshall Islanders and other COFA migrants. Concurrently, her House colleague, Rep. Colleen Hanabusa (D-HI) filed the Compact Impact Aid Act (HR 1222) in 2013, which would provide mainland U.S. states with special grant funding to reimburse public spending—including on health care—for COFA migrants. (Currently, Hawaii is the only state to receive these funds).

Challenges Beyond Health Care

In addition to health-related problems and coverage issues, Marshall Islanders face a variety of additional challenges in the United States, particularly the fact that many arrive with limited English proficiency. Even in cities with sizable concentrations of ri-Majol, such as Honolulu and Springdale, AR, few service providers, health workers, or public safety personnel are proficient in the Marshallese language.

Highly distinctive cultural values and social organization can leave the Marshallese vulnerable to misunderstandings with their U.S.-born neighbors. For example, Marshallese society’s emphasis on collectivism, extended families across multiple households, and adherence to a traditional hierarchy based on hereditary chiefs run counter to U.S. cultural norms of individualism, status equality, and the nuclear family. As a result, ri-Majol in the United States have been frequent targets of discrimination and prejudicial beliefs. The Marshallese report that they commonly wait far longer to be seen than other patients at some hospital emergency rooms, and that they are treated in a condescending manner by hospital staff.  Likewise, local police have issued citations to Marshallese parents when they see their children walking through the neighborhood unattended, not realizing that many children reside in more than one household and are in transit from one home to another.

Still a Major Draw

Despite these substantial obstacles, the United States remains a powerful draw for the Marshall Islanders. Although neither the RMI nor the United States keep track of these migration patterns, U.S. Census data and qualitative interviews with key informants suggest that migrant flows continue more or less unabated. Furthermore, the pattern of migration tends to be unidirectional, as it is fairly uncommon for U.S.-based Marshallese to resettle in their home country once they have established themselves in the United States.

Marshall Islanders continue to economically and culturally enrich the communities in which they reside. In U.S. localities where the population is well established, Marshallese-owned businesses have begun to take root, and the country’s rich cultural heritage is increasingly perceived by local residents as a benefit to the community.

Sources

Central Intelligence Agency. 2014. The World Factbook: The Marshall Islands. Last modified February 1, 2014. Available online. 

Duke, Michael R. 2013. “Health for the Marshallese.” Arkansas Democrat-Gazette, June 23, 2013.  Available online. 

Government Accountability Office (GAO). 2011. Compacts of Free Association: Improvements Needed to Address and Assess Growing Migration (GAO-12-64). Washington, DC: GAO.  Available online.

Johnston, Barbara R., and Holly M. Barker. 2008. Consequential Damages of Nuclear War: The Rongelap Report. Walnut Creek, CA: Left Coast Press.

Marshall Islands Ministry of Health. 2004. Ministry of Health Annual Report. Majuro, Republic of the Marshall Islands: Republic of the Marshall Islands Ministry of Health. Available online.

McMurray, Christine and Roy Smith. 2001. Diseases of Globalization: Socioeconomic Transition and Health. New York: Routledge, 2001.

Perez Williams, Deanna and Ann Hampton. 2005. “Barriers to health services perceived by Marshallese immigrants.” Journal of Immigrant Health, 7, no. 4 (2005): 317-26.

World Health Organization. 2014. Health Profile: Marshall Islands. Last modified February 1, 2014.  Available online.