After decades without insurance, many Marshallese regain Medicaid coverage
Natives of the Marshall Islands in the Pacific Ocean have reason to feel victimized by the U.S. government. Now, a coalition in Dubuque, Iowa, including MercyOne Dubuque Medical Center, part of Trinity Health, is building trust and trying to help make things right.
A diabetes education class hosted by the Pacific Islander Health Project in Dubuque, Iowa, is part of a community coalition's health outreach efforts to a population that has higher than average rates of diabetes, cancer, hypertension and other chronic illness. MercyOne Dubuque Medical Center was instrumental in bringing the coalition together.
After the United States gained control of the Marshall Islands from Japan in World War II, the U.S. tested biological weapons and detonated 67 nuclear bombs there between 1946 and 1958. According to the Los Angeles Times, bombs exploded "on, in and above" the islands leaving behind an "environmental catastrophe."
The nuclear contamination and the adverse health effects it caused remain a problem to this day for those living on the archipelago and those who moved to the U.S. Although the Compact of Free Association gives the Marshallese and other Pacific Islanders the right to live and work in the U.S. without a green card, legislation enacted 25 years ago ended the islanders' Medicare and Medicaid eligibility.
Malissa Sprenger, vice president of mission integration for MercyOne Eastern Iowa Region, said most of the Marshallese don't earn enough to afford health care for themselves or their families. Additionally, they contend with language barriers, cultural differences and low health care literacy when they seek medical attention.
Sprenger said Marshallese people have higher than average risks for cancer, hypertension, tuberculosis, diabetes and leprosy. Many of the estimated 800 Marshallese living in Dubuque were born in the islands and brought to the U.S. as young children. Experts say some of their serious health conditions result directly from radiation exposure or indirectly from a change in dietary preferences when, having poisoned the fishing atolls and farmland, the U.S. provided high-fat, high-calorie foods that supplanted a plant- and fish-based diet.
MacNaughton
The U.S. government sent surplus cheese and butter, Spam and canned corned beef, foods that are high in fat, said Neil MacNaughton, a professor of nursing at the University of Dubuque. "They became reliant on those foods, instead of their traditional diet, which was pretty darn healthy." The convenience of processed foods won out, and that led to higher rates of obesity, diabetes and heart disease.
Right neighborly
Kay Takes is president of the Eastern Iowa Region of MercyOne, including MercyOne in Dubuque. She said that because the islanders have regularly used services such as obstetrics and the emergency room, the hospital's diversity, equity and inclusion committee focused on how to do a better job of reaching out to them on a variety of health and wellness issues.
Takes
Working with the University of Dubuque in 2014, the hospital invited MacNaughton, who had experience caring for Marshallese and other Pacific Island nationals, to conduct nursing grand rounds to increase the cultural knowledge of caregivers. It was an eye-opening session and one that spurred MercyOne Dubuque to bring stakeholders including Marshallese community leaders into the conversation about their needs, Takes said.
"That was really the trigger for all the work that's been done through the years, culminating today in a wonderful communitywide coalition," Takes said. "The Marshallese folks are at the table, very actively engaged in how we can improve not just their health care situation but the life of the Marshallese people overall. We knew from the beginning that in order to be successful, they had to be active members of the team. We couldn't impose on them. It came down to engaging them in the process, and that wasn't as easy as you might think. It took the better part of a year to understand how to connect, share our vision and lay the foundation for a trusting relationship."
MercyOne Dubuque Medical Center took delivery of a mobile medical unit last month that will provide outreach care to Marshallese and other community members. Prior to a blessing ceremony, Kay Takes, president of the MercyOne Eastern Iowa Region, talks about the Winnebego's customized exam rooms and furnishings with Pastor Stan Samson, a pillar of the Marshallese community.
The coalition expanded to include community health center representatives, women religious, school system leaders, public health and city officials, local legislators and others. Takes said the coalition has influenced state and national legislation.
The community coalition gave rise to the Pacific Islander Health Project. Centered at Crescent Community Health Center, it employs a community health worker, nurse and social worker to bridge the gap between health and human services access for Pacific Islanders. Staff salaries are funded in part by community benefit dollars from MercyOne Dubuque.
The team coaches clients in lowering their body mass index, and, for clients living with diabetes, their A1c scores. A survey conducted at a community event helped identify other unmet needs, not only in terms of health but navigating across cultures and dealing with government red tape.
Why they came
MacNaughton said several Marshallese nationals originally came to the city's theological seminary and found the community to be welcoming and friendly. Others followed.
Maitha Jolet immigrated in 1997, after visiting a sister who had arrived a few years earlier to attend a Bible study college in Dubuque. Jolet, now 62, said the attraction to live in the United States was clear: "a better living for my family."
"It was really hard for the Marshallese people to access medical help," Jolet said. "Right now, I think we are doing much better. At least we have something," she said of the Pacific Islander Health Project.
Late last year as part of a COVID-19 relief bill, Congress restored Medicaid eligibility for Marshallese and other Pacific Islanders living in the U.S. "It's a wonderful new development," Sprenger said, adding that a large percentage of the Pacific Islanders in Dubuque have gotten their Medicaid benefit restored.
Adapting to cultural differences
In dealing with the islanders' legacy of health problems, leaders of the Pacific Islander Health Project had to learn to communicate in a culturally aware way, and they had to build trust.
"Micronesians are very communal in what they do," MacNaughton said. "Everything is done together. They like to be together, to learn together, to participate in things together. And they have a different response to authority. Anyone who is seen as in position of authority, they will acquiesce to. For many of them, that would be health care workers, teachers, and so on — those folks they would just agree with.
"They may say yes when they really mean no, when it comes to scheduling appointments, for example," MacNaughton said. "You ask, is it OK, can you come to this appointment at 3 o'clock on the 25th, and they say yes" but they may not be available at that time, or they may not have transportation to get to the appointment.
"You have to help them understand they don't have to say yes right away. That got better because they now understand they have the ability to let us know when they can't make those meetings, and that kind of thing," MacNaughton said.
Rough waters
Early on, the community health center began providing public health information translated into Marshallese, including educational videos and regular announcements on how to cope with the pandemic. But the Marshallese were nevertheless disproportionately affected by COVID-19, Takes said. "The way they live together in large households and in community with one another obviously played a role in the spread of COVID-19, especially in the very early days of the pandemic, when we had less knowledge and fewer tools to care for people with the virus."
The Pacific Islander Health Project has found traction. Takes and MacNaughton point to a 38% decline in ER visits since 2016, and a 60% drop in missed medical appointments.
Now, MacNaughton said, the project is beginning to transition to a new phase, concentrating more on social determinants of health, including addressing food and housing insecurity.
Jolet thinks American help is owed to the islanders. He puts it this way:
"We want the United States to recognize what they have done to us, back in 1967. We suffered from the bomb, and a lot of people are dying. They should do whatever is necessary to pay the people of the Marshall Islands."
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