Two billion people worldwide are infected with the TB bacillus, but only 9 million people a year actually get the disease. The story of the Marshall Islands can help us understand why.
The lives and health of Marshall Islanders in the equatorial Pacific were disrupted in a unique fashion when the United States occupied their nation and used their outer islands for extensive nuclear testing after World War II. Between 1946 and 1958, 67 atomic devices were detonated -- the estimated yield equivalent to 1.7 Hiroshima blasts every day for 12 years.
After miscalculations on one of the largest explosions caused fallout to land on three inhabited islands, residents were treated, relocated, and tracked to study the effects of radiation exposure on humans. Hundreds of other Marshallese were moved off their home islands to make way for the testing and to build the Ronald Reagan Missile Testing Site on Kwajalein Island.
Their lands, culture, and traditional way of life destroyed, many Marshallese now crowd the island of Ebeye hoping to get a job at the U.S. base on nearby Kwajalein. Here, they face the worst of both the "developing" and industrialized worlds. Tuberculosis and other infectious diseases are fed by poverty and squalid conditions. Lack of economic opportunities and healthy food options, combined with the stress of dislocation and cultural loss, have also led to high rates of chronic illnesses like diabetes, heart disease, hypertension, obesity and cancer.
Three miles away on Kwajalein, American contractors and their families enjoy a pleasant suburban environment. Health outcomes here are comparable to the U.S. Although more than 1,100 Marshallese work on Kwajalein, they’re not allowed to live there and must commute by ferry to and from Ebeye, where power outages and sanitation issues are a continuing problem.
Today, around 10,000 Marshall Islanders, seeking a better future, have ended up in the unlikely place of Springdale, Arkansas. A special treaty allows Marshallese citizens to live and work in the U.S. freely without a visa. Drawn by plentiful jobs in the food processing industry and a low cost of living, most are happy to have better educational opportunities and healthier options.
But even though the Marshallese can leave the impoverished conditions of their homeland behind, they can't escape the effects of having lived in poverty. They must also cope with the stress of an unfamiliar environment. Rates of tuberculosis and other infectious diseases among Marshallese living in the U.S. are far above the national average. Chronic disease rates are also high.
In the U.S. tuberculosis rates fell 70% between 1900 and 1945, even before the drug to treat the disease was invented. Better housing, sanitation and improvements in our standard of living were key.
The health problems that Marshallese people experience today are the price they've paid to help the U.S. maintain a strategic military presence in the Pacific. Our relationship with the Marshall Islands has shaped much of its fate over the past 60 years; it can also help improve their prospects for life and better health in the future.
Unnatural Causes is the acclaimed documentary series broadcast by PBS and now used by thousands of organizations around the country to tackle the root causes of our alarming socio-economic and racial inequities in health.
The four-hour series crisscrosses the nation uncovering startling new findings that suggest there is much more to our health than bad habits, health care, or unlucky genes. The social circumstances in which we are born, live, and work can actually get under our skin and disrupt our physiology as much as germs and viruses.
Extent of continuing physical, emotional, mental, and social ability to cope with one's environment. Good health is harder to define than bad health (which can be equated with presence of disease) because it must convey a more positive concept than mere absence of disease, and there is a variable area between health and disease. A person may be in good physical condition but have a cold or be mentally ill. Someone may appear healthy but have a serious condition (e.g., cancer) that is detectable only by physical examination or diagnostic tests or not even by these.
Science and art of preventing disease, prolonging life, and promoting health through organized community efforts. These include sanitation, control of contagious infections, hygiene education, early diagnosis and preventive treatment, and adequate living standards. It requires understanding not only of epidemiology, nutrition, and antiseptic practices but also of social science. Historical public health measures included quarantine of leprosy victims in the Middle Ages and efforts to improve sanitation following the 14th-century plague epidemics. Population increases in Europe brought with them increased awareness of infant deaths and a proliferation of hospitals. Britain's Public Health Act of 1848 established a special public health ministry. In the U.S., public health is studied and coordinated on a national level by the Centers for Disease Control and Prevention; internationally, the World Health Organization plays an equivalent role.
NARRATOR: In the middle of the Pacific Ocean theres a small country made up of a chain of islands, with white sandbeaches and an aqua green lagoon. The Marshallese people have made their home here for many centuries. But in the last 60years something has gone terribly wrong in the Marshall Islands. Today the tuberculosis rate here is 23 times that of theUnited States. Other infectious diseases also run rampant. There are many reasons why the health of the Marshallesepeople is compromised. Their long relationship with the United States may be one. One of the islands Ebeye is a milelong and an eighth of a mile wide but its home to about 10,000 people, making it more densely populated than Manhattan.This crowded environment is ideal for the spread of infectious diseases like tuberculosis. IRENE PAUL: You cannot buildanything anymore on Ebeye. Its crowded. So if somebody in the family has TB of course its eventually going to spread toeverybody in the house in a short period of time. So if somebody is diagnosed with TB, our staff will go out to theneighbors and even to the same household and start giving them medication right away. RIHNA JAMES (TB ProgramCoordinator, Kwajalein Atoll Health Care Bureau): From this side all the way to the other sidethis is where TB never goesaway. One of the reasons I guess is because the houses are very close together. And so many people in one house, therellbe like 20 or more than 20 individuals in each house. NARRATOR: Like everywhere else in the world, the frontline soldiersin the fight against TB are public health outreach workers like Rihna James and Molly May. Everyday they drive thestreets of Ebeye tracking their patients to make sure theyre taking their TB medications. RIHNA JAMES: They dont havemoney to come to the hospitals but we have to make sure they bring the medicine, so thats why we go to those who cannotcome. NARRATOR: The Marshallese are hardly alone in suffering high rates of TB. Its a disease that shows up whereverpeople are poor. Public health experts estimate that one third of the earths population, about two billion people, carrythe bacterium that causes TB. But most of those people will never become sick. Their immune systems will keep the diseasein check. However, about 9 million people each year do become sick with this potentially deadly lung ailment, oftenbecause they live in conditions of poverty that compromise their immune systems and undermine their bodys ability tofight it off. And because its airborne, TB can spread rapidly among people who live in crowded urban environments. JIMYONG KIM (Harvard University, Brigham and Womens Hospital): What tuberculosis needs to flourish in a persons body is abroken down immune system. So just the stress itself of poverty can contribute to the likelihood of developing activetuberculosis. And malnutrition. We know that people living in poverty are malnourished. And theres nothing likemalnourishment to decrease the immune response enough to let tuberculosis flourish. RIHNA JAMES: We have one patienthere. And door opens to the other door and we just treated the other one on this side and then now were coming to thisside. She was starting to lose weight, and then chest pain, and SOP, shortness of breath. And she doesnt feel well. Shefeels weak all the time. So she was actually admitted in the hospital and they referred her to us. NARRATOR: Tosuccessfully cure tuberculosis requires completing a full course of treatment on schedule - up to four different drugs aday, every day, for six months. If patients fail to complete their drug regimen, the disease can come back in adrug-resistant formfar more dangerous. RIHNA JAMES: She says shes doing good. She got some she has TB of the lymph nodes,swelling of the stomach. NARRATOR: The Marshallese were once known as the master navigators of the Pacific. They createdstick charts, their own unique navigational aids, to plot their way through almost a million square miles of ocean. Forcenturies the Marshallese lived like other indigenous peoples in the Pacific. NEAL PALAFOX (Chair, Dept. of FamilyMedicine, Univ. Hawaii School of Medicine): The traditional diet was breadfruit, and it was taro, a lot of naturallygrown crops. It was a lot of fish; it was bananas, and fruit crop; and just were loaded with natural, you know, vitaminsand minerals, that you know, over thousands of years thats what these people subsisted on. NARRATOR: Today much of thatcultural legacy is lost to centuries of colonization by other countries. But when the United States took the MarshallIslands from the Japanese in 1944, it triggered changes no one could have foreseen. The islands remained under US controluntil the late-1970s, when the Republic of the Marshall Islands became an independent nation. But the US military hasnever left one island: Kwajalein, home of the Ronald Reagan Ballistic Missile base; a facility the US considers vital toits national security. This is where the controversial Star Wars anti-missile program carries out its testing. About 1700mostly American defense contractors and their families live on Kwajalein in a suburban environment - with a golf course,a country club, a small department store, and access to state of the art healthcare. More than 1100 Marshallese peoplework on Kwajalein. The army base is one of the few large employers in the nation. But only a few Marshallese contractorsare allowed to live on Kwajalein. Each day the Marshallese employees take a ferry home to the neighboring island of Ebeyea divide that takes only 30 minutes to cross, but one that separates two worlds of wealth and health. Julie Kroeker isan American anthropologist who lived in the Marshall Islands for three years. JULIE KROEKER: When youre on that ferrygoing from Kwajalein, the base, to Ebeye, the island, I just cant believe it sometimes. This relationship is sopowerfully unequal. NARRATOR: Though Ebeye is just three miles from the US military base on Kwajalein, the contrastbetween the two islands is an everyday reminder of how inequities in wealth affect peoples health. The health ofAmericans living on Kwajelein is similar to what youd expect for a middle class American neighborhood, while on the otherMarshall Islands the indicators are very different. On average, Americans live to 77.5 years old. In the Marshall Islandslongevity is 62 years. Infant mortality in the US is 7 deaths per thousand. In the Marshall Islands its 52 deaths perthousand. In the US, 7 percent of the population has diabetes. In the Marshall Islands its about 30 percent. And the rateof Tuberculosis in the Marshall Islands is 23 times that of the US. NEAL PALAFOX: They have probably the worst of bothworlds. They have a lot of the developing country illnesses you know, all the infectious diseases you find in Africa andplaces in Asia and India. NARRATOR: Dr. Neal Palafox is a family practitioner who researches health issues that affectthe islanders. NEAL PALAFOX: Then they have the illnesses that interface with Westernizing countries. Heart disease, forinstance, is the number one cause of death; a lot of high blood pressure, strokes. And then in between they havemalnutrition. So, they have a spectrum of illness which represents both worlds, which makes it a very difficultsituation. NARRATOR: For most of Ebeyes 10,000 residents, the chores of daily life are made difficult by a neglectedinfrastructure that cant handle the over crowding. Ebeye is plagued by power outages and water shortages. DISE LANGRUS:Two weeks ago, we had a power outage for two weeks straight. And if theres no power, no water. And imagine what we wentthrough. NARRATION: Dise Langrus has lived on Ebeye for over 30 years. The water shortages mean Dise and other residentsoften cant do their laundry on Ebeye. Instead, they take a water taxi or ferry to the American base, Kwajalein, wherethey can do laundry as long as they have a special permit and can pay the price. DISE LANGRUS: If we ride the taxi fromhere to Kwajalein for two people its $8 and then we do laundry for $20. That is why we dont go to Kwajalein and dolaundry all the time. NARRATOR: For the people of the Marshall Islands like Dise theres another fact of life besidespoverty that has profoundly affected their health. Between 1946 and 1958, 67 nuclear devices were detonated on and aroundthe northernmost Marshall Islands. Measured in tons of TNT, it was the most extensive nuclear weapons testing evercarried out by the United States. TONY DEBRUM (Former Minister of Foreign Affairs & Health, Republic of the MarshallIslands): The yield of those tests has been estimated at one point seven Hiroshima shots. Every day. Every day for twelveyears. NARRATOR: The largest explosion took place March 1, 1954. Code-named Bravo, it was a 15-megaton hydrogen bombequivalent to 1000 Hiroshimas. A miscalculation caused radioactive fallout to drift onto two inhabited atolls. More than200 men, women and children were on those atolls. Among them was Dise Langrus, a 4 year old growing up on Rongelap. DISELANGRUS: Young people at the time were saying that they thought the powder that was falling was from heaven. They rubbedtheir faces, hands and legs with it. And thats how they got skin burns from the fall out. NARRATOR: They were treated andthen tracked to study the effects of nuclear fallout on human beings. Among them was Dises father. These are photos ofher father Dise has never seen before. ABBACA: It looks like hes been treated for burns around his ear NARRATION: To makeway for the testing, US military authorities moved hundreds of Marshallese people off their home islands and resettledthem on different islands. These dislocations triggered a chain of events that tore apart Marshallese culture and thatcontinues to undermine their health. NEAL PALAFOX: When you move people off their islands where they live to do thetesting, you break down their entire community structure. What is the impact on health? You know, the stress issues. Youcontaminate their lands; they cant grow things that they used to eat. They get more diabetic, because you know, theyreeating a western diet. They werent urbanized. But when you urbanize, infectious diseases tend to take off, because TB istransmitted person-to-person, very close, very crowded. NARRATOR: The changes on Ebeye began in 1951, when US militaryauthorities re-settled about 600 people from Kwajalein to Ebeye to make way for the military base. In the decades since,thousands more Marshallese have settled herehoping to get a job at the military installation. Now, almost one-fifth ofthe nations population lives on Ebeye. And the small island cant absorb them. In one part of Ebeye residents dont evenhave indoor toilets. Abbaca Anjain Maddison grew up on Ebeye before it became so crowded. Shes now a senator in theMarshall Islands parliament. ABACCA ANJAIN-MADDISON (Senator, Republic of the Marshall Islands): Right here is the publictoilets and these individual units are assigned to individual families. Top of the toilets, theyre open. Even atnighttime they have to use the toilet, they have to use it in the dark. Theres no sink to wash their hands so everyone isresponsible to leave the toilet and go to their houses to wash their hands. NARRATOR: There are many reasons for theslums on Ebeye. Most agree that a leading factor is the lure of jobs at the US base on Kwajalein. TONY DEBRUM: The healthproblems that one would witness on Ebeye in Kwajalein are a result of the military base being there and the politicaldecision to accommodate the military base being there. Because military bases attract people who seek jobs and as long asthe people who are attracted to a military base cannot be accommodated in a better situation youre going to have thesocial problems of Ebeye. Providing more doctors or nurses on Ebeye is not going to solve that problem. There has to be apolitical decision made. NEIL PALAFOX: Theres always been questions of corruption at this level, that level, misspentmonies, and certainly theres even been talk about the US government and the Auditor Generals report that the USgovernment didnt do its homework in monitoring monies. Poverty creates a dynamic in individuals where they feel they dontcontrol their lives or any things that occur in their lives. You dont feel that you have the ability to move where youhave to move. If you feel that the environment controls you, as opposed to you being able to control your destiny. And Ithink thats whats happened a lot in Ebeye and other places in the Pacific where theres been this level of poverty thatsbeen introduced, because of the dynamics that have occurred. NARRATOR: So in a place like Ebeye where poverty is sodeeply entrenched, how do you eradicate tuberculosis? One thing is certain. It will take more than drugs. It will take animprovement in living conditions; alleviating crowding so one infected person doesnt infect others; improving nutritionso peoples immune systems have the strength to fight off the disease. We know this by looking at the history oftuberculosis in the United States. NARRATOR: In the early 1900s tuberculosis was a leading killer in Americas crowdedurban slums. There was no drug treatment available and there wouldnt be for many decades to come. TB victims oftensuffered a painful death, removed from their families to avoid spreading the disease. But then, something unexpectedhappened. TB death rates in American cities began to decline. Between 1900 and 1940 the TB death rate dropped 76 percent,even though drugs to treat the disease had not yet been invented. What made the difference? Aggressive public healthpolicies made sure infected people were removed and isolated so they couldnt spread the disease. Equally important,social reforms brought better housing, better nutrition, the abolition of child labor, and a general improvement in thequality of living. With the advent of antibiotics in 1944 the death rate declined even further. JIM YONG KIM: Both ofthose things are important for tuberculosis. Improve the overall living conditions and nutritional status and as soon assomeone gets sick with tuberculosis, treat them. RIHNA JAMES: Its like a very shameful thing. Once you get TB, they, theydont want people to know, they dont want to come to the hospital. Its gradually going down, but I think its not, its notgoing to go away, like, all of the sudden. NARRATOR: Social and political reforms have been slow to come to the MarshallIslands. For many Marshallese, theres another option: Springdale, Arkansas, near the Oklahoma border. An estimated 10,000Marshall Islanders have migrated here, ever since one Marshallese man arrived in the 1980s and got a job at Tyson Foods.The Marshallese can live and work in the US freely, without a visa, under the terms of our special treaty. Jobs areplentiful in the food processing plants and the cost of living in Springdale is relatively low. MARSHALLESE WOMAN: Lifein Arkansas is much easier, healthier. MOTHER: My kids can get a better education. MARSHALLESE MAN: Looking for the goodlife and the futures NARRATOR: But even though the Marshallese here can leave the impoverished conditions of theirhomeland behind, they cant leave behind the effects of having lived in poverty. Not surprisingly, the rates of TB andother infectious diseases among the Marshallese in the US are far above the national average. So in Springdale, as inEbeye, public health workers drive the streets to make sure their patients maintain the rigorous medication schedulerequired to cure TB. Public Health nurse Sandy Hainline believes the high disease rate results from the pressures ofmaking a new life in an unfamiliar place. SANDY HAINLINE (Nurse Coordinator, Marshallese Outreach Program, AR): Itsstressful living here. Theyre coming from a nice, tropical climate. They get here and they have to deal with workschedules, with traffic. The cold is a serious issue for them, They just are not used to dealing with cold weather at alland most of them work in the poultry plants where its wet and cold at all times. And after about two years of beingconstantly stressed they break down into tuberculosis or other diseases. NARRATOR: For 60 years, the Marshallese havebeen living with the effects of massive dislocation and cultural disruption, largely a result of helping the US maintaina strategic military presence in the Pacific. The Marshallese people have paid a high price for that relationship intheir economic wellbeing and their legacy of illness. Now theres a growing awareness that just as the Marshallese peopledidnt create these problems, they wont be able to solve them without help. JIM YONG KIM: I often tell my students that 50years from now, we will be judged on the basis of what we do for the poorest and the most marginalized people on theplanet today. We have more than enough resources to provide treatment, prevention, and to transform the economic andsocial conditions that give rise to the diseases of poverty like tuberculosis that are so prevalent today.