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The journey to make it into Majuro is quite an interesting one. It starts long before we touch down on a seemingly impossibly skinny runway, a strip of concrete floating amidst the otherwise pristine ocean blue. While I theoretically and conceptually knew that the purpose of my summer in the Marshall Islands was to experience what providing healthcare in a resource-limited environment is like, receiving my boarding pass 24 hours prior to departure solidified a new expectation for what my upcoming month would be like, because there is no scheduled departure time for the world famous island hopper between Honolulu and Guam - only an “estimated” departure time. This lay the foundation for the “island time” that we would experience over the next month (and this island time is on a different scale than what we have in Hawaiʻi), and, probably most importantly, that a lot of things outside of my own control will determine what I’m able to do and when I’m able to do it.
Just moments after I landed in Majuro, the light drizzle outside turned into a torrential downpour, with whipping winds and crashing waves - a sight historically unusual for July in Majuro, which usually boasts calm waters and perfect fishing conditions. I was really looking forward to traveling to the outer islands surrounding Majuro during our stay there (as the culture in the outer islands is known to be more conservative than in Majuro, and therefore I was curious about their attitudes towards healthcare), but the weather was rarely safe enough for us to venture into the lagoon, let alone the Pacific Ocean. What ended up being a missed opportunity for me is what everyday life can be for the people of the Marshall Islands. The only two public hospitals are in Majuro and Ebeye, and residents on outer islands rely on safe weather conditions to travel to and from the city centers to get their necessities. The recent, unexpected changes in weather due to climate change mean that people can get stuck at home or in a place away from home for weeks to months on end, and in the context of non-communicable chronic diseases, it means that barrier of access to medications and other aspects of healthcare can lead to serious and life-altering complications.
My own experience of providing healthcare in Majuro was mostly that of the complications of non-communicable diseases, primarily diabetes, and while we speak regularly about the large burden of diabetes we have in Hawaiʻi, I was wholly unprepared for the severity of the degree of diabetes in Majuro, and the routine plentitude of peripheral neuropathy, regular infections, and amputations. Furthermore, I felt somewhat helpless when counseling patients on how to best take care of themselves with such serious news. We always start the conversation about diabetes treatment with lifestyle modifications, namely improving diet and increasing exercise, but fresh vegetables and clean protein sources are hard to come by in the Marshall Islands. Many Marshallese residents, especially those living on outer islands, rely on heavily processed and pre-packaged foods, like rice and ramen, because those items last well on the shelves and provide them with the energy they need. So when your patients have an A1c of 14+ and little to no access to non-carbohydrate food sources and no access to personal glucometers to monitor their blood sugars, how can I practically advise them, given the resources they [don’t] have access to?
When I told those around me I was spending part of my summer in Majuro, many of them admitted that they had never heard of the place before, and when they Google Maps’ed it, they were surprised by how tiny the numerous islands that make up this country are, and how tiny the landing strip is, and the biggest kicker of them all: how short the flight is from Honolulu to Majuro (the Marshall Islands are closer than one would expect to Hawaiʻi, only a four-and-a-half hour plane ride barely south and mostly west of Honolulu). I guess this relative proximity makes sense, because we have a significant Marshallese (and other Micronesian) population in Hawaiʻi, which underscores the importance of the experience I had and the knowledge I gained during this month in hopes of trying to better understand Marshallese values when it comes to culture, which then translates into their values and expectations for healthcare. This is especially apparent in what individuals see as adequate quality of life, which may differ significantly from what we expect in the United States and what we are taught to strive for in Western medical education.
While I learned so much over my time in Majuro, what I hope I can bring most with me into my care for patients in Hawaiʻi is cultural humility. By living for a short period of time in a culture that is so different from my own, each interaction made me feel a little more comfortable in this new environment, a little more comfortable in being open to experiencing something new, a little more aware of what differences exist between my opinions and that of my patients’. While I will never be able to truly understand any culture that is not my own, what my time in Majuro gave me was assurance that my relationship with these cultures and my patients is dynamic, and that I am hopefully getting more and more competent in caring for my patients in a culturally concordant manner with each encounter. I look back on my time in Majuro with gratitude and fondness, and I hope I can apply all that I’ve learned over this summer in bettering the lives of all my future patients.
Kalpana Balaraman is a second-year medical student at the John A. Burns School of Medicine. She, alongside fellow MS2s Kaela Akina-Magnussen and Trini Leung, spent one month of her MD5 on Majuro Atoll, in the Republic of the Marshall Islands.