Medical refugees find themselves shut out from the care they need

By Peter Sessum
For Northwest Asian Weekly

Miochi Kabua waits for his wife to get out of physical therapy at Valley Medical Center. As with their medical situations, he is left out while she is able to receive care. (Photo by Peter Sessum)

Serah Alexander lives under the crushing weight of medical bills. The mother of three was diagnosed with metastatic breast cancer that has spread to her bones. Lifesaving medications, treatments, and tests will cost up to $300,000. She will have to pay this amount out of her own pocket.

Like some of her fellow natives of Micronesia, Alexander is caught in a medical catch-22.

Thanks to a special compact, residents of several South Pacific Islands are considered permanent residents. They can travel and work freely in the United States. However, the terms of the compact also prohibit them from getting any federal or state aid, including some health care programs that are open to other immigrants.

“She is like a medical refugee,” said Heidi Winston, a social worker at Health Point, which runs community health clinics in King County.

Winston, who works to find assistance for more than a dozen low-income women with breast cancer, has been trying for more than two years to find financial support for Alexander and two other Pacific Islanders.

Miochi Kabua, from the Marshall Islands, is the husband of another Health Point patient. He recently went to the emergency room with severe lower abdominal pain. Even though he may have stomach cancer, which is more common on his home island, Kabua won’t seek treatment.

He can’t afford to pay for the services.

Kabua came to Washington with his wife, Nenar, a cancer patient, in 2008 to visit their son.

For Winston, the lack of options for some Pacific Islanders like Alexander and Kabua is a source of frustration, in part because many experts trace the high cancer rates among islanders to American nuclear bomb testing in the South Pacific in the decades following World War II.

“We caused this,” she said.

The United States detonated the Bravo Bomb on Bikini Atoll in the Marshall Islands; the bomb was nearly 1,000 times more powerful than what was dropped on Hiroshima. It was the most powerful of the 67 atmospheric nuclear tests conducted between 1946 and 1958.

Currently, the United States recognizes only four of the 33 islands — Bikini Atoll, Ronfelap Atoll, Alinginae Atoll, and Rogerick Atoll — as being contaminated from the testing.

“They say only four Atolls are contaminated, but I don’t think so,” said Kabua. His wife, Nenar, has had thyroid and breast cancer.

Dr. Neal Palafox, chair of the family medicine and community health program at the University of Hawaii medical school, lived in the Marshall Islands for 12 years, where he met the Kabuas.

He continues to work with Marshallese patients.

“There is no doubt that there is a direct correlation between the Bravo testing and cancer,” Palafox said.

In 2004, the National Cancer Institute (NCI), at the request of Congress, conducted an independent study of cancer rates in the Marshall Islands.

Of the 13,940 people living in the Marshall Islands in 1954, the NCI estimates that 6,130 have or will develop some form of cancer. The NCI also confirmed that all 33 of the Marshall Islands were impacted by the atomic tests. There is documented evidence that radiation went all the way to Guam.

The cleanup efforts were incomplete, said Palafox. “The U.S. government has spent a lot of money, but didn’t clean it all up,” he said.

The Marshallese and Micronesians from Free Compact nations were once allowed to receive medical benefits in the United States. However, in 1996, Congress passed a law prohibiting them from receiving Medicaid benefits.

In California, MediCal still gives unrestricted health insurance to low-income families, regardless of status.

But in Washington, some Micronesians and Marshallese fall through the cracks due to their permanent migrant status.

There is a state program that provides free treatment for low-income women — citizens, as well as legal and illegal immigrants — diagnosed with cancer. But those from Free Compact nations, like Alexander, aren’t eligible.

This leaves Pacific Islanders with limited options for health care, including early cancer detection back in their home islands, said Winston.

Micronesia doesn’t have mammogram machines, and there is only one in the Marshall Islands.

Purchased in 1997, it wasn’t set up until 2002, Palafax said. In 2008, there was no one to operate the machine, so the Kabuas had to come to the United States for Nenar to be examined. “Early detection saves lives,” Winston said. “If you diagnose in stage four, there is nothing you can do.”

By the time a woman feels a palpable lump, she is out of the early stages of breast cancer.

Without the medical tools or people with the medical knowledge, citizens of Micronesia and the Marshall Islands typically have to travel to the Philippines or Hawaii for diagnosis or treatment.

Palafax said that care is cheaper in the Philippines but that the quality is inferior.

Alexander migrated to the United States with her family when she was 18. Because of a lack of opportunities, she hasn’t gone back. Under the Compact of Free Association Nations, she could work here without a green card.

Alexander, now 31, never considered becoming a naturalized citizen, even though she had no intention of going back to live in Micronesia. She returned only to bury her husband, who died of cancer. Alexander is receiving collection notices for the $3,000 MRI bill and other medical expenses.

Alexander said that even if she were back in Micronesia, she wouldn’t want to go to the Philippines. She knows of too many people who have gone there and didn’t survive the treatments.

Winston was able to get short-term treatment for Alexander at Multicare in Covington and the University of Washington for specialty care. Winston is trying to schedule surgery for Alexander at the UW before the short-term care expires on Dec. 31, 2010.

Alexander is concerned with what will happen when she can’t get treatment here. Her children are American citizens. The oldest is only 12.

Nenar Kabua is more fortunate. Being from Ronfelap, one of the four atolls considered contaminated by atomic testing by the U.S. government, her treatments are covered. When Bikini and Ronfelap were given compensation from the U.S. government, the island council purchased health insurance for its residents. The council verifies people who are eligible, then provides them with an insurance card for care in the United States.

That makes her fortunate, Winston said. Without insurance, Winston said Nenar Kabua would have had to wait upward of five years to become a citizen and qualify for Medicaid. “The way cancer works, that is too late,” Winston said.

Nenar continues to see her medical oncologist every three months. She is on anti-hormone treatment. She has completed all surgery, chemo, and radiation treatments. But her husband, Miochi, doesn’t have coverage since he is not from one of the recognized islands.

He is currently trying to get the Department of Social and Health Services (DSHS) to assist him.

Until he can get health care, he won’t see a doctor. He can’t afford to pay the bills. “I don’t think I will win,” Miochi said. “You cannot win when you are the only one.” ♦

Peter Sessum can be reached at

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