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Vaccinating one of America’s most vulnerable populations — the Marshallese of northwest Arkansas

The Marshallese people were 96 times more likely to be hospitalized and 65 times more likely to die from COVID-19. Now efforts are underway to vaccinate this community.

By Beth Howard

COVID-19 has swept through immigrant communities around the country, leaving heartbreak and devastating consequences in its wake. But few U.S. communities have taken as hard a hit as the Marshallese of northwest Arkansas — a close-knit population of about 10,000 people from the Marshall Islands who have made this small corner of Arkansas home since the 1980s.

The Marshallese make up just 1.5% to 3% of the total population in the region. Yet they were 71 times more likely to be infected by COVID-19 than Whites, 96 times more likely to be hospitalized, and 65 times more likely to die, according to the CDC. These staggering statistics prompted the agency to deploy a team to investigate the problem in the spring of 2020.

“The CDC’s report validated what we were seeing and forced a broad call to action,” says Pearl McElfish, PhD, director of the Office of Community Health and Research and the Center for Pacific Islander Health at the University of Arkansas for Medical Sciences (UAMS). 

The community is now working together to turn the corner on COVID-19, thanks to the vaccination effort that UAMS spearheaded. It involves coordinating with multiple groups — health care agencies, insurance companies, clinics and hospitals, Marshallese community organizations, government entities, churches, and nonprofits — to offer COVID-19 testing and vaccination. “Our health care partners and social services partners have come together in Northwest Arkansas unlike anything I would have ever imagined,” says McElfish.

Alicia Berkemeyer, executive vice president and chief health management officer at Arkansas Blue Cross Blue Shield (BCBS), a UAMS partner, concurs. “We have recognized that if community groups, businesses, and providers all get on board together, the more we’re able to share information and communicate a consistent message across the different populations.” Arkansas BCBS launched Vaccinate the Natural State, a parallel vaccination effort across the state to address disparities, in addition to providing major funding for the UAMS initiative focused on the Marshallese and other underserved populations. 

A perfect storm

Even before the pandemic, the Marshallese people faced extreme health vulnerabilities and inequities. “Between 1948 and 1956, there was a U.S. nuclear weapons testing program in the islands, where 67 atomic bombs were detonated,” says Sheldon Riklon, MD, who holds the Peter O. Kohler, M.D., Endowed Chair in Health Disparities at UAMS and is one of just two Marshallese physicians in the U.S.

Whole islands were vaporized and the nuclear fallout not only led to cancers and other harmful health conditions among the islands’ population but also destroyed the environment and the means of subsistence for the people who lived there. For decades the Marshallese relied on shipments of processed foods. These factors may help explain islanders’ high rates of diabetes, heart disease, kidney disease, and other chronic conditions — all primary risk factors for COVID-19 infection and its worst outcomes.  

Under an agreement with the Marshall Islands’ government, Marshallese people are allowed to live and work in the U.S. without a visa and many come to Arkansas and a handful of other states. But with limited education, most of those in Arkansas wind up working low-wage jobs in crowded poultry plants, where COVID-19 infection can be spread easily. As uninsured and essential workers, they can’t take time off when they are sick to quarantine.

Outside of work, “our main foundation is the family,” says Riklon. “We revere our elders. We’re very loving, caring people, and very collectivist.” As a result, extended families tend to live together in close quarters.

“That closeness is a challenge,” says Ivy Welch, outreach coordinator in the Office of Community Health and Research. “These communities are so driven to take care of their families. A lot of them broke quarantine not because of a lack of information, or because they didn’t think that they would spread it; it was the need to take care of their families and be able to continue working.”

Although Marshallese living in the U.S. pay taxes, they could not access Medicaid services — even though many are too poor to afford health care — until last January, when Congress finally acted. A 2015 study found that less than half of the population had seen a doctor in the previous year.

A firm foundation

UAMS has run a free clinic for Arkansas Marshallese since 2013 and had diabetes prevention, maternal health, and other health care programs already in place. This infrastructure enabled them to take on the new challenge when COVID-19 hit.  

The organization established several testing sites and also arranged for home tests. Nurses followed up on positive cases to encourage the sick to stay in isolation and arranged for food and prescription drug deliveries, if needed.

The team also offered educational Facebook live sessions, each getting about 25,000 views, and produced YouTube videos about masking and social distancing. And they created toolkits for churches and other faith-based organizations in the Marshallese language.  

When COVID-19 vaccines arrived, the university provided them to community partners and clinics. A team of community health workers was dispatched to canvas neighborhoods and drum up interest.

“Anytime we go to hospitals or clinics, we don’t know who to trust unless you actually have a person who’s Marshallese,” says Riklon. “You’ve got to have somebody who looks like you and talks like you, because you’re already scared, it’s a foreign place, and you don’t speak the language very well.”

Turning out the faithful

The team learned early on that big community vaccination events were not effective when it came to the Marshallese, Welch says. Smaller-scale events, such as those held at Marshallese churches, worked better. “We had to shift our mindset from how many vaccines can we give to every vaccine counts,” Welch says.

One successful strategy is educating faith leaders and having them spread the word at services and other church events. “Seeing leaders getting vaccinated has really helped,” Welch says.   

Eliciting that kind of testimony is Lucy Capelle’s superpower. An outreach specialist and research coordinator for UAMS and a Marshallese pastor herself, she encourages other clergy to get vaccinated and then tell their parishioners about it.   

When she meets with resistance, “I tell them we cannot run away from the reality that we are facing with the pandemic,” Capelle says. “We have to understand that God has given the wisdom to the doctors, to the scientists to discover this medicine for us to receive. If you love your brothers and sisters in the Lord, then this is the right thing to do.”

Such events aren’t easy to pull off. “It takes an army of community health workers who go register people a week beforehand,” says McElfish. “And you need bilingual translators and staff on site.”

But the effort is making a difference. At one recent church event where just 12 people were scheduled for vaccination, 40 ended up getting the shot, Capelle says. 

Vaccination teams are also showing up at other places where Marshallese people gather, such as community festivals and softball tournaments, and they’re even going door to door at apartment complexes. “We keep listening to the needs of the community and evolving,” Welch says. “When we heard that they weren’t likely to come to our drive-through site, we asked, ‘Where do we need to go? Where do we need to meet you to vaccinate you?’ And that’s exactly what we’ve been doing.”

UAMS and its community partners have now vaccinated around 6,000 Marshallese — a little more than half of the population in Arkansas. That’s on a par with vaccination rates among White Arkansans and Latinos in the area.

The secret sauce

“If there is one thing that made us successful,” says McElfish, “it is bringing in a large contingent of Marshallese staff who have deep roots in the community.” Though there are fewer than 10 Marshallese nurses working in the U.S., UAMS employs three of them, along with Riklon.

In fact, perhaps no one has done more for the Marshallese than the Marshallese themselves. “Their compassion and love for the community really showed through and made them champions,” Welch says.

“It’s easy to recruit Marshallese to be involved in these kinds of initiatives, because it’s already part of our culture,” adds Riklon. “We take care of others.”

Caption: Albious Latior receives a COVID-19 vaccine at a Marshallese vaccination clinic at the University of Arkansas for Medical Sciences earlier this year. 

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