Health disparities in Marshall Islands

Microwaves By Jack Niedenthal

Majuro—For decades, Marshallese migrants in the United States have lived with a paradox: though they enter the country legally under the Compact of Free Association and contribute to the U.S. workforce, they were denied access to Medicaid for almost 25 years. This exclusion left thousands without affordable healthcare, despite having some of the highest rates of chronic disease in the Pacific.

In December 2020, Congress restored Medicaid eligibility for COFA migrants — a landmark victory for health equity. Yet, nearly five years later, the promise of that policy change remains uneven, as many Marshallese families continue to face structural barriers and persistent disparities. Their experience reveals the deep connections between history, health and policy — and how justice requires more than legislation.

The story of Marshallese health disparities cannot be separated from the history of U.S.–Marshall Islands relations. Between 1946 and 1958, the United States conducted 67 nuclear and thermonuclear weapons tests in the Marshall Islands, leaving a legacy of displacement, radiation exposure, and long-term environmental contamination. From this history emerged the COFA, an agreement granting Marshallese the right to live and work in the United States without visas, in exchange for U.S. military access and strategic partnerships in the Pacific.

Despite this special status, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) stripped COFA migrants of Medicaid eligibility. Marshallese migrants, many of whom worked low-wage jobs without employer-provided insurance, were left unable to access life-saving care. It was not until December 2020—amid the Covid-19 pandemic, which disproportionately affected Pacific Islanders—that Congress finally restored Medicaid eligibility. The decision was widely celebrated as a long-overdue correction of a historical injustice.

Marshallese diabetes rates are among the highest of any ethnic group in America, and related conditions such as kidney failure, hypertension, and obesity are disproportionately common. Many of these illnesses are linked to the disruption of traditional diets following nuclear testing, when subsistence foods were replaced by imported processed staples like white rice, flour and sugar.

These disparities appear across key Marshallese communities in the United States. In Arkansas, home to the largest Marshallese population in the continental U.S., hospitals report high rates of late-stage kidney disease and diabetic complications. In Hawaii, Pacific Islanders face some of the highest rates of premature death. Across Oregon and Washington, providers report similar challenges in managing preventable chronic illnesses.

The Covid-19 pandemic brought these vulnerabilities into stark relief, exposing inequities such as limited insurance coverage, crowded housing, language barriers and frontline employment in poultry plants.

In Arkansas, Marshallese residents made up a disproportionately high share of infections and deaths. At one point in the summer of 2020, at least one Marshallese person was reported to have died every day for 37 consecutive days.

When I was the secretary of health for the Marshall Islands during the pandemic, I once saw a haunting photo of a Springdale graveyard filled with Marshallese flags on freshly dug graves. It remains one of the most painful reminders of how structural inequities can become matters of life and death.

Medicaid restoration was an essential first step, but access remains inconsistent.

Many Marshallese still struggle to navigate an enrollment system that requires complex paperwork and online documentation in English. Limited health literacy and language barriers compound the challenge, especially for elders who may not read or write English fluently.

Even for those successfully enrolled, systemic gaps persist. There are few Marshallese interpreters in hospitals or clinics, leading to miscommunication about diagnoses, medications, or treatment plans.

As Michelle Langmos of the Arkansas Coalition of Marshallese explains: “Access to quality healthcare has improved, but it can still be better. Interpreting and translation have also improved, yet challenges remain—especially when medical terminology is not uniform.

For example, in the RMI doctors may use Marshallese terms like utamwe or mojno ilo enbwinum, but when patients seek care in the U.S., different terms are used, creating confusion. A greater issue is the lack of understanding around health insurance, hospital bills, and available financial assistance. Many clinics and healthcare professionals could also benefit from deeper cultural training.”

Langmos’s comments highlight how linguistic and cultural misunderstandings continue to erode trust between providers and patients. Some state Medicaid officials and even healthcare workers remain unfamiliar with COFA rights, mistakenly assuming Marshallese migrants are undocumented and ineligible.

This misinformation discourages families from seeking care. Economic realities make access harder still: many Marshallese work long hours in poultry plants, warehouses, or service jobs with limited flexibility, making it difficult to schedule medical appointments or prioritize preventive care.

In Arkansas, as mentioned above, the Arkansas Coalition of Marshallese has played a pivotal role in educating families about Medicaid eligibility, assisting with enrollment, and providing culturally tailored health education.

Community health workers and church leaders have become trusted intermediaries, bridging the gap between healthcare systems and Marshallese patients.

Similar efforts have emerged elsewhere. In Hawaii, bilingual health navigators assist families with coverage and care. In Oregon and Washington, nonprofits have launched diabetes prevention programs rooted in Marshallese cultural values, emphasizing family support, faith and collective responsibility. These grassroots initiatives show that progress depends not only on policy but also on cultural competence and community partnership.

The Marshallese experience offers lessons far beyond one community. It highlights how structural inequities—rooted in colonial history, nuclear testing and immigration policy—can shape health outcomes across generations. While Medicaid restoration was a historic victory, achieving true equity requires dismantling barriers within health systems, closing cultural gaps, and investing in trust-building.

Globally, the Marshallese case is a reminder that health disparities travel with migration. Communities displaced or marginalized by global powers often carry disproportionate disease burdens, which are then compounded in host countries. In this sense, the Marshallese story is both unique and universal: unique in its nuclear legacy, yet universal in its lessons about justice, access, and inclusion.

If the United States is to truly honor its commitments under COFA and its responsibility for the Marshall Islands’ nuclear legacy, it must go further. That means investing in culturally competent care, expanding interpreter services, supporting community health workers, and ensuring full implementation of the law across states.

For the Marshallese, the path to health equity is not just about access to insurance; it is about dignity, justice, and the recognition of a history that continues to shape their present.

Jack Niedenthal is the former secretary of Health Services for the Marshall Islands, where he has lived and worked for 43 years. He is the author of “For the Good of Mankind, An Oral History of the People of Bikini,” and president of Microwave Films, which has produced six award-winning feature films in the Marshallese language. Send feedback to jackniedenthal@gmail.com

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