In Washington, a small band of lawmakers is trying to restore the islanders’ Medicaid coverage, a fight that one Democrat already has fought and lost for a decade. Here in Iowa, meanwhile, these islanders are finding that Dubuque offers them something they desperately need: The promise of free health care, delivered at a local clinic. And for residents of the Marshall Islands, where some radiation levels are still higher than Chernobyl, that’s more than enough to travel across the globe, to move to this chilly city nestled near the border of Illinois and Wisconsin.

“I came because I wanted to see the doctors,” says 60-year-old Mary Lenja, a former schoolteacher who arrived in Dubuque last spring from the Marshall Islands. Lenja has needed to use a wheelchair for more than two years, and she still isn’t sure what’s going wrong inside her, as we talk in October, sitting in the small Iowa apartment she shares with six other family members. She is physically unable to leave without being carried down the stairs. “I want to get out of this chair,” she says.

To the Marshallese, like Lenja and their advocates, their migration story is a stain on the United States that keeps spreading: A failure to take responsibility for Cold War-era nuclear testing that endangered a native population; for promising and then denying that population health care; for neglecting to correct for a quarter-century old mistake that deprived them of services; and for leaving them struggling against an alien system and knocking on the doors of elected officials who won’t represent their interests.

“People are getting sick from what they’ve done to us,” said Maitha Jolet, a 61-year-old Marshallese who was one of the first to move to Dubuque. “They think we are not human. The U.S. government think we are from some … ” he trailed off, disgusted. “They did not realize we are human beings.”

The Marshall Islands, which stretch across 70 square miles in the middle of the Pacific, have a cinematic feel when viewed from above: Two chains of atolls, tiny slivers of land scattered across an endless sea. They were long coveted for their strategic importance as a waypoint in a vast ocean, roughly equidistant between San Francisco and Singapore.

In the 1800s, traders arrived with boatloads of goods and Christian missionaries, who quickly set to work converting the population. In the 1900s, the Japanese brought schools as well as suffering, with thousands of Marshallese affected by widespread starvation and hard labor on the islands as World War II turned against Japan.

When U.S. soldiers first arrived in 1944, they were greeted as liberators—a status they swiftly capitalized on, appealing to the islanders’ Christian faith when seeking permission to test nuclear weapons two years later. In one exchange, captured by military cameras, Commodore Ben Wyatt told an island leader named Juda that the Marshallese would be like the children of Israel who wandered in the desert and sacrificed to bring peace to the world. Would the islanders be willing to make their own sacrifice, to help the United States end wars forever?

“Men otemjej rej ped ilo pein Anij,” replied Juda—a response that roughly translates, “everything is in God’s hands.”

Testings on Bikini Atoll commenced within days and U.S. officials ordered families out of their homes to a more distant island. It was the start of a series of tests that would end up spreading nuclear fallout across the region. Within several years, islanders were suffering from thyroid cancers and a slew of other illnesses that researchers quickly determined were linked to nuclear testing. While the U.S. finally ended its nuclear tests in 1958—after detonating 67 bombs that vaporized entire islands and left deep craters in others—horrifying birth defects cropped up for decades.

“I saw the head. It was like [a] grape,” one Marshallese woman recounted, telling the story of how her family rushed to the hospital as news spread about one particularly misshapen, stillborn baby. The memory remains seared into her mind 40 years later, along with seeing another stillborn baby that had one twisted, fingerless arm—and another arm with at least six fingers, splayed in all directions.

Some Marshallese allege that the U.S. government, even after learning about the risks of radiation, willfully experimented on the islanders, pointing to a set of declassified documents that appear to reveal that residents were deliberately put in harm’s way. The United States has said contaminating the islanders with nuclear fallout was not intentional.

Around the globe, the public became fascinated with the islands while largely ignoring the human cost. Within days of the first public bomb test, the Bikini Atoll had given its name to a risqué new style of swimsuit; the idea of nuclear mutations helped inspire the Godzilla story. More recently, the islands even served as the striking opening footage for a Godzilla movie reboot.

More serious reckoning with that legacy took decades. Under a deal hammered out in the 1980s, the U.S. allowed residents of the Marshall Islands, as well as those of Micronesia and Palau, to relocate to the United States under what’s called the Compact of Free Association. The agreement also promised them access to health coverage through the American safety-net health program Medicaid—a pledge that collapsed a decade later, an incidental casualty of Newt Gingrich and Bill Clinton’s sweeping welfare reform package in 1996, which excluded the islanders from a list of Medicaid-eligible groups.

“I’m not sure whether we’ll ever know whether it was intentional to remove the [island] communities from Medicaid or just something folks missed,” said Holly Barker, an anthropologist who spent more than a decade working for the Marshall Islands government to receive compensation from the United States for the military’s nuclear testing. “Few people know about the unique political arrangement between the United States and the [COFA] states.”

A handful of lawmakers from Hawaii, drawn to the plight of the Marshallese as fellow Pacific islanders and, in some cases, residents of their state, have fought to reverse the change, but the effort has fizzled in every session of Congress.

Meanwhile, the Marshallese who lived through the nuclear tests, which ended in 1958, have largely passed away, with the average life expectancy on the islands reaching only 63 for men and 67 for women. Their children and grandchildren, inheritors of the toxic legacy, have looked for new homes as the islands face old problems like radiation and emerging crises like climate change.

Pockets of islanders have since cropped up in the continental United States, with large populations in Hawaii and Arkansas and smaller circles in places like Oklahoma, Oregon and Dubuque, Iowa. And they bring their illnesses with them.

“It’s cases like this when I wish our patients had surgical services that were offered to them,” says Cynthia Woods, staring down at a three-inch abscess, contemplating how to delicately remove blood-soaked gauze from inside her patient’s chest. “I’m definitely internal medicine, not a surgeon,” laments Woods.

Four years ago, the young osteopath graduated from medical school in Philadelphia. Now Woods is in Dubuque, standing over a Marshallese man in the city’s Crescent Community Health Center, armed with a pair of forceps. She’s accompanied by Irene Maun, a Marshall islander who was hired as Crescent’s ambassador to the community and plays the clinic’s crucial role of translator, case manager and recruiter.

The two work briskly—Woods gingerly examining the wound and changing the dressing, Maun translating instructions and updates—and within seven minutes, the patient visit is complete.

“Inside, it looked like it’s healing—there’s not any pus or anything,” Woods tells the patient. “So I’m just going to pack right here.”

Maun painstakingly translates Woods’ words into Marshallese, wary of creating any misapprehensions.

Some Marshallese have been in Iowa for years, but many came simply because they heard about Crescent Community Health Center, with more Marshallese relocating all the time. It’s a population marked by chronic disease. Like many Pacific Islanders, the Marshallese suffer from rampant diabetes and heart disease—in their case, exacerbated by a diet that became heavier on imported canned foods after the local fruits and vegetables were tainted by radiation. Other illnesses are more mysterious: Birth defects, rashes, the never-ending questions over cancer rates.

Crescent is more like a MASH unit than the Mayo Clinic. Every space is reused, repurposed—even the building itself, which advertises DUBUQUE CASKET COMPANY in three-foot-high letters near the roof, the ghost of a long-failed business. A corner hallway became a conference room. The kitchenette? It was actually an old vault. Crescent’s staff, like Woods and Maun, play multiple roles too—a receptionist doubles as a translator, a social worker is training to be a certified health insurance counselor—when they’re not stepping on each other’s toes in the narrow corridors.

Some of the Marshallese patients’ issues would be familiar to U.S. medical workers in any city. One woman hasn’t been taking the medicine that Crescent prescribed for her. Another patient is 30 minutes late. A third patient had worked with Crescent to sign up for private health insurance, but couldn’t afford to keep paying his premiums and dropped out.

Other health issues are unique to the islanders, whose difficulties navigating the health system are accelerated by culture: Lots of simple English words, like “stress,” don’t have translations in Marshallese, Maun says. More pressing, Crescent estimates that nearly 80 percent of their islander patients have severe kidney disease, largely linked to the poor diet the Marshallese adopted after the U.S. irradiated their crops.

One of those patients is Jemty Aititi, a 40-year-old whose kidneys had nearly failed when he first came to Crescent. Working with Crescent case managers, he’s now stabilized and his diabetes is under control.

But Aititi has a new, serious complication: He recently had a heart attack, severe enough that he lost consciousness while driving, with his children riding in the car. His 10-year-old son tried to take the wheel, a frantic effort that came too late to stop them from crashing, he tells Woods and Maun in broken English interrupted by Marshallese.

Aititi is now facing a $38,000-plus medical bill from a local hospital—and a $5,000-plus car-repair bill. Working as a part-time cook, and his family’s primary breadwinner, there’s no chance he can pay either.

The first Marshallese arrived in Dubuque to attend Christian seminary, nearly 30 years ago. But the biggest draw now, aside from the clinic, is the service industry, with staffing agencies working to place the islanders in part-time jobs that don’t include health benefits. More than a dozen work at the local Spam plant, making a canned food beloved in their homeland, and also likely a contributor to their diabetes. Other islanders have jobs as maids and cooks, hiding in plain sight in this city that’s overwhelmingly white, with language and customs that are wildly different.

At this point, the Marshallese population in Iowa is effectively serving as a recruiting poster for islanders back home or scattered across the country, said Maun, the translator at the health clinic. “They hear that life is good here,” she added, saying that new Marshallese are resettling in the city every month.

One reason that life is so good: the islanders, some of whom have struggled with chronic illness for decades, finally have a place to seek care.

For years, Dubuque officials routinely encountered islanders who refused to get treatment for their diabetes and lost fingers, toes or their eyesight as a result. Health workers also found other older islanders sleeping on the floor, incontinent, or dealing with other severe medical crises that left them bedridden and incoherent. One survey of local Marshallese found that 73 percent had no health coverage, while 60 percent hadn’t seen a doctor in a year. Nearly one in four had diabetes; about 10 percent had heart disease.

“Staff at the hospital had no idea of who the Marshallese were,” said Neil MacNaughton, a nursing professor at the University of Dubuque who spent part of 2016 educating other health workers about the islanders who lived in their midst. That lack of understanding went both ways, he added, even as the islanders were regularly arriving to local emergency wards in various states of medical crisis.

MacNaughton was among a group of two dozen local leaders—a mix of public health workers, civic officials and members of the religious community—who saw the emerging crisis five years ago and formed an initiative in response. Their effort, now known as the Dubuque Pacific Islander Health Project, was aimed at providing free or subsidized care to the islanders who had come to settle in their city. It’s centered at the Crescent clinic, which treats what it can while referring patients elsewhere for specialty procedures.

The coalition’s argument: That Americans—even their fellow Iowans, who scarcely knew that the islanders even existed—owed the Marshallese after years of nuclear testing had rendered their islands unlivable, before promising and then taking away their access to Medicaid.

“Specialty care, which many Marshallese individuals need due to serious and chronic health conditions, is almost impossible to obtain because of being uninsured,” the coalition wrote in one 2016 grant application, seeking about $50,000 in funding to hire a community worker who would specialize in serving the Marshallese community. Today, those islanders receive incentives for regularly attending Crescent’s health education classes, which subsidize the patients’ care and can also get help for immigration-related issues like renewing passports.

The problems go far deeper than diabetes and other chronic diseases, say the coalition’s members; they link the islanders’ illnesses to the nuclear testing in the islands in the 1940s and 1950s. The evidence on the connection between radiation decades ago and illness today is mixed—one federal study estimated that about 1.6 percent of islanders’ cancers between 1948 and 1970 were attributed to the testing, a significant figure, but one that wouldn’t explain the severe differences between health outcomes in the United States and on the island.

Barker, the anthropologist who worked for the Marshall Islands government, argues that the full extent of the radiation damage to the population is unknown, given the complications with tracing individual cancers and even the initial lack of transparency by the U.S. military about its operations.

“It is so hard to come up with exact numbers, as there is no baseline data, and so many factors that are hard to account for,” Barker said. It’s a problem that animates her, prompting her to point out that the Marshallese don’t just lack access to a safety-net health program like Medicaid, they lack access to advanced medical services, too.

“It is appalling that there is no oncologist or cancer-care facility in the islands today despite the large amount of radiation released by the U.S. in the islands,” she said.

Beyond Iowa, the plight of the Marshallese has won sympathy in other communities across the United States—like Springdale, Arkansas, where health workers have found a similar pocket of chronically ill islanders—and attracted a small but growing number of champions in Congress.

The leader of that effort: Mazie Hirono, the Hawaii senator who first introduced a bill to restore the islanders’ Medicaid coverage when she was a House member about a decade ago and has reintroduced similar legislation in every subsequent session of Congress.

Hirono argues that the United States is effectively discriminating against the Marshallese and other islanders in the compact, which she finds particularly cruel given the history of the U.S. military’s nuclear tests—and given that some younger Marshallese even serve in the U.S. military now. “Don’t you think it’s important ... that when they do come to our country, they are able to live, work and access health care, like anyone else who is legally present in our country?” she said.

Hirono and other members of Hawaii’s delegation have been so focused on the problems facing the Marshallese and fellow islanders covered by the compact because so many islanders—nearly 20,000, by some estimates—have resettled in Hawaii and, like the population in Dubuque, need health care and other social services. Hirono has recruited other allies, like Rep. Tony Cárdenas (D-Calif.), who sits on the House’s powerful Energy and Commerce committee, which helps oversee Medicaid.

But they’ve struggled to win over colleagues and party leaders because of a simple legislative calculus: the islanders aren’t voters, and lack the key advocacy groups willing to go to war with Congress on their behalf. Under the COFA agreement, the Marshallese can live, work and study in the United States without needing visas—and while here, they pay taxes and even volunteer to serve in the military at higher per capita rates than many U.S. states. But they remain citizens of the Republic of the Marshall Islands.

After Democrats reclaimed the House in 2018, Hirono, Cárdenas and other supporters of the islanders planned out a new strategy as Congress hashed out a sweeping, year-end budget package in the fall of 2019. Cárdenas was tapped to lead the way, and his office developed a bill to restore Medicaid coverage. Meanwhile, the Asian & Pacific Islander American Health Forum and other advocates for the Marshallese took to the Hill, meeting with members of both parties.

The plan was partially successful. For the first time in more than a decade, the Democrats pushing the package won over a key Republican: Steve Womack, a House member who represents the Arkansas district where many Marshallese have relocated. A second Republican, Del. Aumua Amata Radewagen of American Samoa, also joined the package as a nonvoting member of Congress.

But the effort sputtered when they failed to win over Republicans on the relevant House committees, and Democrats also expressed concern about the cost to fund the provision, estimated at about $350 million over a decade, amid dozens of other health care budget battles.

Hirono and Cárdenas are aiming again for a budget bill currently slated for May. House Democrats also are eyeing a plan to raise the issue of the islanders’ lost Medicaid at an upcoming congressional hearing and further lay the groundwork for a legislative fix.

The fate of the Marshallese also will be shaped by multiyear, multination diplomatic talks that are now underway. The Trump administration has begun to renegotiate terms of its decades-old Compact of Free Association with the Marshall Islands and fellow nations ahead of the deals’ expiration in 2023 and 2024. Health care advocates are pressing the U.S. government to commit to covering the islanders’ health conditions as part of any final deal.

The Marshallese do have a card to play: Their islands and the two nearby nations covered by the compact, Micronesia and Palau, hold significant strategic value for the U.S. military, which currently enjoys exclusive access to the islands’ airspace and waters. That makes the Marshall Islands, which are about twice as close to Beijing as they are to Washington, D.C., a useful staging ground to project force when dealing with China and other Pacific rivals.

The Trump administration previously signaled some openness to boosting financial subsidies for the islands, especially as the Marshall Islands have made diplomatic overtures to China, and a bigger financial package could help subsidize residents’ health costs. But any resolution remains years away.

Back in Dubuque, residents say they’re committed to caring for the Marshallese—even if their project leads to a flood of islanders continuing to relocate to their small city, seeking subsidized health care, and the cost of the project mounts.

“If we have an influx … we can’t take it all on,” acknowledged Mary Rose Corrigan, the city’s top health official and a member of the board overseeing the island health project, saying that a surge of uninsured Marshallese would force tough decisions about whether to ration care and services.

But Corrigan added that Crescent wouldn’t turn away any new Marshallese arrivals, even if a surge of patients forced clinic leaders to seek out new financial support. “We have people in Dubuque who will help,” Corrigan predicted. “That’s the kind of community we are.”

One reason for Corrigan’s optimism: City officials annually identify the Marshallese plight as a top priority. “We look at the COFA agreement and say, the Marshallese should be granted Medicaid [and] entitlement program rights like everybody else,” she added. “They’re here in our community, they’re part of our economic engine.”

Meanwhile, the clinic has moved operations to a newer building across the street, where the patient rooms are bigger and the hallways are wide enough that staff aren’t stepping on each other, or on the hundreds of islander patients who flock to Crescent for their care.

“People keep coming. They keep coming here,” said Maun, the clinic’s representative to the Marshallese community. “Because they heard about this program.”