Health Concerns of Micronesian Peoples

Abstract

Several states in the United States have been experiencing an influx of migrants from an area of the world that most people have only heard of when learning about the atomic bomb and World War II. This area is the former U.S. Trust Territory of Pacific Islands now called the Freely Associated States. At the end of World War II, the United States took possession of many of these islands and in 1948, the United States formally took over administration of the Marshalls, the Carolines, Palau, and the Northern Marianas islands. Collectively this area is known as Micronesia. Micronesians come from areas that have high prevalence of several communicable diseases and there is growing concern that Micronesian immigrants may enable the spread of infectious disease to the United States from Asia. Data concerning Hansen's disease and tuberculosis support this claim. According to data from the Hawai'i State Department of Health, a 5-year trend examining new cases of tuberculosis in Hawai'i identified that 65 out of 77 new cases came from the Freely Associated States of Micronesia. Presented is an overview of the health concerns and health status of the people from the Federated States of Micronesia.

Full text

Journal of Transcultural Nursing
24(3) 305 –312
© The Author(s) 2013
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1043659613481675
tcn.sagepub.com
Clinical Practice Department
Introduction
The State of Hawai’i has been experiencing an influx of
migrants from an area of the world that most people have
only heard about when learning about the atomic bomb and
World War II. This area is the former trust territory of pacific
islands now called the Freely Associated States (FAS). At the
end of World War II, the United States took possession of
many of these islands and in 1948, the United States formally
took over administration of the Marshalls, the Carolines,
Palau, and the Northern Marianas islands. The administra-
tion was initially called the United Nations Mandated
Strategic Trust and known as the United Nations Trust
Territory of the Pacific Islands or more simply as the TTPI
(Fairlamb, 2002; Yamada & Pobutsky, 2009). Collectively
this area is known as Micronesia (Figure 1).
Starting in 1985, the United States entered into agree-
ment with the Republic of the Marshall Islands (RMI) and
the Federated States of Micronesia (FSM); joint resolutions
were developed to dissolve the U.S. trusteeship over the for-
mer TTPI. In 1986, the Compacts of Free Association
between the United States, RMI, and the FSM went into
effect. These Compacts were further amended in 2004.
Special considerations were granted to the people of the
FSM and RMI, who are not considered citizens or nationals
of the United States; these include the ability to enter the
United States as nonimmigrants without visas (however,
their admission is not guaranteed), if admitted they may
live, study, and work in the United States with the United
States reserving the right to set terms and conditions.
Currently, they are granted unlimited length of stay, and
according to the U.S. Customs and Border Patrol, the I-94
form they are required to have noted them as Compact of
Free Association/Republic of Marshall Islands of Federated
States of Micronesia or more simply known as “CFA/RMI”
or “CFA/FSM” (Office of Communications, U.S. Citizen
and Immigration Services, 2008).
As a new group migrating not only to the United States
but also to other parts of the world, such as Australia and
Japan, health care systems and nurses need to recognize the
issues and struggles Micronesians encounter both at home
and as immigrants. As a group, this population faces an
increased relative risk or susceptibility to adverse health out-
comes as defined by Flaskerud and Winslow (1998). This
increase in susceptibility may be evidenced by a lower social
481675TCNXXX10.1177/1043659613481675Journal of Transcultural NursingMacNaughton and Jones
research-article2013
1University of Dubuque, Dubuque, Iowa
2St Olaf College, Northfield, MN, USA
Corresponding Author:
Neil S. MacNaughton, Department of Nursing, University of Dubuque,
309E Goladthorpe Science center, 2000 University Avenue, Dubuque,
Iowa 52001-5099.
Email: nmacnaughton@dbq.edu
Health Concerns of Micronesian Peoples
Neil S. MacNaughton, PhD, RN1 and Melissa L. Jones, BAN, RN2
Abstract
Several states in the United States have been experiencing an influx of migrants from an area of the world that most people
have only heard of when learning about the atomic bomb and World War II. This area is the former U.S. Trust Territory
of Pacific Islands now called the Freely Associated States. At the end of World War II, the United States took possession of
many of these islands and in 1948, the United States formally took over administration of the Marshalls, the Carolines, Palau,
and the Northern Marianas islands. Collectively this area is known as Micronesia. Micronesians come from areas that have
high prevalence of several communicable diseases and there is growing concern that Micronesian immigrants may enable the
spread of infectious disease to the United States from Asia. Data concerning Hansen’s disease and tuberculosis support this
claim. According to data from the Hawai’i State Department of Health, a 5-year trend examining new cases of tuberculosis
in Hawai’i identified that 65 out of 77 new cases came from the Freely Associated States of Micronesia. Presented is an
overview of the health concerns and health status of the people from the Federated States of Micronesia.
Keywords
community health, transcultural health, Micronesians, Marshallese, Kosraean, Pohnpeian, Chuukese, Yapese, Palauan

306 Journal of Transcultural Nursing 24(3)
economic status, a lack of environmental resources where
they may be subject to intolerance, or politically marginal-
ization (Evans, Barer, & Marmor, 1994).
Formal nursing care has been delivered in the FSM since
the arrival of physicians (B. Hedson, personal communica-
tion, January 18, 2012). They have affected the care the peo-
ple of the FSM receive, providing needed first aid, screening
for health conditions, providing midwifery care, and aiding
in public health battles for sanitation and nutrition. However,
for nursing to fully affect the health and care of Micronesians
we must first understand who Micronesians are, their current
health status as a population, and the social issues that they
face. The purpose of this article is to describe the current
health care system, the current health status of Micronesians,
and the implications for nursing in understanding the broad
health concerns Micronesians encounter.
Micronesians
Micronesia encompasses more than 3 million square miles,
and 2,000 islands excluding Guam, which has been a U.S.
territory since 1898 (Fairlamb, 2002). It is approximately
3,100 miles wide or roughly the same distance between the
east and west coasts of the United States and lies between 5°
to 10° north of the equator (Petersen, 2009). The area typi-
cally described as Micronesia includes the Territory of
Guam, and the Commonwealth of the Northern Mariana
Islands (which became a Commonwealth in 1975), the FSM,
which includes the states of Chuuk, Kosrae, Pohnpei, and
Yap, the RMI, the Republic of Palau, the Republic of Nauru,
and the Republic of Kiribati (Pobutsky, Buenconsejo-Lum,
Chow, Palafox, & Maskarinec, 2005). This article will only
include those people from the FSM (Micronesians).
Figure 1. The Federated States of Micronesia.
Source. University of Texas Libraries—public domain: http://www.lib.utexas.edu/maps/islands_oceans_poles/micronesia_pol99.jpg

MacNaughton and Jones 307
The name Micronesian is not a name these people tradi-
tionally have called themselves—they had no collective
name (Petersen, 2009). Within academic circles, there is a
debate over the actual existence of Micronesia as a unique
global area. Hanlon (1989, 1999, 2009) believes Micronesia
has
existed only in the minds of people from the outside who have
sought to create an administrative entity for purposes of control
and rule . . . as a figment of ethnographers imaginations–a
colonial construct . . . the term “Micronesia” actually reveals far
more about Euro-American society’s concern for a neat,
manageable, efficient and logical ordering of the world.
On the other hand, Petersen argues that all the island soci-
eties of Micronesia have much more in common with one
another than they do with societies in adjacent areas of the
Philippines, Indonesia, Melanesia, and Polynesia (Petersen,
2009). He bases his argument on the premise that the funda-
mental patterns of social organization, especially with the
use of matrilineal clans with landholding power along with
cultural and linguistic similarities contributes to the defini-
tion of Micronesia as a unique area of the Pacific (Petersen,
2009). Although there are many similarities among
Micronesians, one of the issues confronting them is having
eight distinct languages. As a result of the language difficul-
ties, English is now the official language. This writer sup-
ports the premise of Petersen that Micronesia is a unique
entity made up of several different cultural groups.
Within Micronesia there are several different types of
islands, and the differences are important to note as they do
affect health and access to health care. The islands range
from being large (high islands which are volcanic uplift
islands some more than 100 square miles) to very small low
islands or atolls less than 1 square mile in area, and others
that are simply uninhabited shoals and reefs. The low islands
or atolls while having little land mass often have vast areas of
lagoon that are full of life and thus are able to adequately
support atoll populations (Petersen, 2009). There are numer-
ous similarities between the high and low islanders and yet,
there are important distinctions between how these people
live their lives. High islanders are typically less dependent
on the ocean and are more dependent on their gardens and
cultivation of foodstuffs; low islanders are more dependent
on subsistence from the lagoon and the deep ocean in which
voyaging skills and esoteric navigational knowledge are
highly desired (Petersen, 2009). The size of the island does
affect the economic and environmental conditions of the
people of these islands with larger islands having larger pop-
ulations and more resources, which include more health
resources such as hospitals and medical practitioners.
The FSM capital is located in Palikir, Pohnpei. According
to the World Health Organization (WHO) in 2009, the esti-
mated population of the FSM was 107,973; 37% of whom
were younger than 15 years, 4% were 65 years and older, and
59% were between 15 and 65 years with an average age of
18.9 years. There are slightly more men than women: 101 to
100. Even when taking into account migration (mostly to the
United States, specifically Hawai’i) the population has
increased by 0.9% since 2000; however, the U.S. Central
Intelligence Agency Factbook (2011) currently shows a
−.313% growth rate. Approximately 49% of the population
lives in Chuuk state, 32% in Pohnpei, 11% in Yap, and 8% in
Kosrae, with almost 23% living in urban areas (see Table 1).
The largest areas of employment are the public sector (gov-
ernment positions) at approximately 43%; 19.8% are
involved in trade with subsistence farming and fishing
accounting for a large portion of this sector. Farming consists
of raising black pepper (for export), tropical fruits and veg-
etables—mostly locally consumed with some interisland
exchange, coconuts, cassava, betel nut, sweet potato, along
with pigs and chickens for local consumption. Approximately
7% of the working population is involved in education.
Unemployment is currently at approximately 22%. Average
wages are approximately $6,037a year (WHO for Western
Pacific, 2010). According to President Mori of the FSM, the
primary source of revenue in the economy is the U.S. gov-
ernment with approximately $92 million a year until 2023
coming to the country from the United States (personal com-
munication, January 18, 2012).
Health of Micronesians in Country
Obtaining accurate mortality and morbidity information is
difficult in the FSM because of the isolated nature of the area
which leads to late reporting along with a lack of a standard-
ized reporting system (Kohler, Alik, Kaplan, & Anderson,
2010). The WHO states that the overall health situation for
the entire FSM has remained unchanged from 2000 and
2009, with the population showing continuing susceptibility
to both communicable and noncommunicable diseases. Data
from 2009 show that the leading causes of death in the four
states were cardiovascular disease, diabetes mellitus, chronic
obstructive pulmonary disease, and cerebral–vascular dis-
ease. Leading health problems are often chronic illnesses
such as primary hypertension and diabetes mellitus (WHO
for Western Pacific, 2010). For instance, in Pohnpei state, a
Table 1. Vital Statistics for All States of the Federated States of
Micronesia.
Current vital statistics
Birth rate 22.22/1,000
Death rate 4.35/1,000
Infant mortality 24.34/1,000
Population growth rate −.313%
Net migration rate −20.99%
Literacy rate 89%
Source. Central Intelligence Agency (2011) Factbook.

308 Journal of Transcultural Nursing 24(3)
survey completed in 2008 demonstrated that 32.8% of the
adult populations between the ages of 25 and 64 years were
type II diabetics. This alarmingly high proportion of adults
with diabetes has been attributed to the change in local diet
from a traditional diet based on local foods (breadfruit, taro,
banana, local fish, and other seafood) to one of that is more
westernized with reliance on wheat flour, white rice, sugar,
and fatty canned meats such as canned corn beef (WHO for
Western Pacific, 2010). Other contributing factors are
believed to be lack of exercise, gender, and age.
The FSM is afflicted by disease patterns of both a devel-
oping country and a developed country as it is in the unfortu-
nate position of having both increasing rates of
noncommunicable diseases while at the same time it is com-
bating communicable diseases such as Group A streptococ-
cal infection (GAS) which may lead to rheumatic fever and
rheumatic heart disease. The FSM has the highest rate of
Hansen’s disease (leprosy) in the Western Pacific region
along with a high rate of tuberculosis (TB) similar to other
developing countries (see Table 2).
According to WHO data, the number of vaccine-prevent-
able diseases has declined considerably. However, water-
borne and food-borne diseases are major causes of hospital
admission. Other infectious diseases that have been seen in
the FSM are periodic outbreaks of zika virus (in Yap State),
dengue fever, and hepatitis A in recent years. TB in the FSM
is a major concern as it is found throughout the islands of the
Pacific and multidrug-resistant (MDR) TB has been detected
in Chuuk. In 2008, Chuuk reported a case of MDR TB and
through increased screening they found 21 active MDR TB
cases and 100 cases of latent TB; the cases of MDR were
attributed to a breakdown of the direct observation therapy
and a lack of staff. This was brought under control with con-
siderable international assistance and the cases have since
been resolved (Fred et al., 2010).
The FSM has been fortunate in that the number of
instances of HIV infection remains very small and it has not
strained the health care system. However, there is growing
concern that the FSM may be ripe for an increase in the num-
ber of cases. The rationale for this concern according to the
WHO is related to cultural norms where the discussion of sex
is refrained, yet it is acknowledged that there are behaviors
within the population that could lead to acquiring the infec-
tion. For instance, in the States of Yap and Pohnpei the rates
of sexually active teenagers is considered high and there is a
very low-level use of condoms along with numerous partners
putting these teens at risk for pregnancies and sexually trans-
mitted infections (Noble, Pereira, & Saune, 2011).
There are high rates of rheumatic fever and with resulting
rheumatic heart disease throughout the FSM particularly in
Kosrae. The rates of rheumatic fever have ranged from 50 to
134/100,000 in Kosrae. Treatment of GAS is often difficult
when patients only experience mild discomfort or do not
have clinically apparent symptoms. Treatment of GAS prior
to the development of rheumatic fever and rheumatic heart
disease is relatively simple and very cost-effective. However,
if GAS proceeds to rheumatic heart disease the cost of treat-
ing patients becomes very expensive, as patients who develop
heart problems must go out of country for treatment such as
valve replacement, at a total cost of well more than $30,000/
episode (Kohler et al., 2010).
As previously mentioned, most health care facilities in the
FSM are government owned and controlled (see Table 3). It
is believed that the current system is adequate and effective
in delivering health care to the people of the FSM. Although
there is an adequate system for providing care there are prob-
lems related to the geographical remoteness of the islands.
The isolation makes it difficult to obtain needed supplies
along with having adequate storage of supplies once they are
obtained. For example, laboratories in the FSM have diffi-
culty buying premade agar culture plates as often they are
damaged in transit or become outdated before they can be
used. Preparing a supply locally is difficult as sheep blood is
needed to make the agar plates and sheep blood is unavail-
able in the FSM. Laboratories will use outdated, banked
human blood; however, hemolytic patterns of streptococci
are more difficult to differentiate on agar plates made with
human blood versus those with sheep blood and these types
of cultures are not recommended (Kohler et al., 2010).
One of the tragic issues facing the FSM is the lack of
mental health services. Unfortunately, there are no psychia-
trists or psychologists in the country and few, if any; health
care providers have comprehensive training in providing
mental health services. There are no beds available for
patients to be hospitalized in a therapeutic milieu; although
there are beds assigned for mental health they are often sim-
ply rooms attached to the regular wards. In the event that a
person requires a locked unit environment there are no beds
available and the island’s jail cells are used for these indi-
viduals (R. Williams, personal communication, January 15,
2012). Health care providers in the FSM are not happy with
these facilities but because of limited resources and the lack
of providers they believe that they are doing the best they are
able to do. The lack of resources and personnel trained in
mental health is especially stressful to local health care pro-
viders, who recognize WHO data, which state that the FSM
has one of the highest suicide rates in the world for young
Table 2. Disease Rates for the Federated States of Micronesia.
Communicable disease rates
Hansen’s disease (leprosy) 40/10,000
Tuberculosis 157/100,000
Noncommunicable disease rates
Malignant neoplasms 48.01/100,000
Cardiovascular disease 195.41/100,000
Hypertension 27.6/100,000
Diabetes 23.6/100,000
Cerebral–vascular disease 62.42/100,000
Source. World Health Organization for Western Pacific. (2010).

MacNaughton and Jones 309
adult males (Noble et al., 2011). It is believed that this is
because of the cultural and economic dislocation; however,
alcohol is also believed to be a major contributor to this situ-
ation and it plays a definite part in the high rates of violent
injury in some of the island groups (Noble et al., 2011).
In all states of the FSM, hospitals are in the major urban
areas. This is convenient for the urban populations and the
close surrounding areas; however, this becomes an issue for
those in more rural areas. For instance, on the island of
Kosrae, the hospital is located on the major road and is easily
accessible to most islanders. However, one village is inac-
cessible by road and the only way to reach this village is by
boat through the channel in the mangrove swamp or outside
the reef in open ocean. If the channel is blocked (a frequent
occurrence) or the tide is out, it is impassable, and if the
ocean is too rough then access by boat outside the reef is
impossible. Consequently, people must wait until conditions
are just right. In other states, if you live on an outer island
and become ill or injured, you must have boat access under
the right conditions to travel to the urban area. Although
there may be an aid station or health center they are often
underequipped or the personnel do not have the expertise
needed to treat the patient (B. Hedson, personal communica-
tion, January 18, 2012).
Individuals in the FSM seeking education for positions in
health care currently must leave the country for their educa-
tion. Many of the physicians of the past were contract
workers from the United States, working off education loans
through the U.S. Public Health Service assigned to the FSM.
Local physicians are beginning to replace these contract
employees, many having attended medical school in Fuji,
Hawai’i, or the Philippines. Nursing education in the FSM is
very scant with only a very small program in Yap for local
Yapese. The rest of the country’s nurses must be educated
outside the country. However, the College of Micronesia
main campus in Pohnpei started a nursing program in the fall
of 2011. These students at the end of their first semester were
prepared at the level of a certified nursing assistant in the
United States. They have the option and are actively encour-
aged to continue their education, but most have dropped out
to work (K. Benjamin, personal communication, January 19,
2012). Most nurses in the FSM have attended the University
of Guam, University of Hawai’i, or the College of the
Marshall Islands in Majuro.
Micronesians in the United States
Pobutsky et al. (2005) reported that 8,725 non-Chamorro
Micronesians were living in Hawai’i, with the bulk residing in
the city and county of Honolulu. At that time nearly one half of
the population was aged 18 years and younger and the vast
majority (80.1%) were Marshallese, 16.6% were Chuukese, and
the remainder report being from the different ethnic groups of
the FSM. Approximately 65% of the population migrated to
Table 3. Health Care Facilities in the Federated States of Micronesia (FSM).
Facility type FSM total Kosrae Pohnpei Chuuk Yap
I. Total health facilities 122 6 19 71 26
Hospitals 5 1 2 1 1
Community health
centers
5 0 1 0 4
Dispensaries 92 0 9 64 19
Aid posts 6 5 0 0 1
Health clinics 6 0 3 3 0
Pharmacies 6 0 2 3 1
Dental clinics 2 0 2 0 0
II. Government-owned
health care facilities
107 6 11 65 25
Hospitals 4 1 1 1 1
Licensed beds 326 35 116 125 50
Operating beds 312 45 92 125 42
Occupancy rates 65.5 83 62 58 59
III. Privately owned
facilities
15 0 8 6 1
Hospitals 1 0 1 0 0
Licensed beds 36 0 36 0 0
Operating beds 36 0 36 0 0
Private health clinics 6 0 3 0 0
Private pharmacies 6 0 2 3 1
Private dental care 2 0 2 3 0
Source. Data compiled from personal communications and World Health Organization for Western Pacific (2010).

310 Journal of Transcultural Nursing 24(3)
Hawai’i between 1986 and 1999 and 35% have migrated since
2000. Pobutsky et al. (2005) further report that Micronesian
migrants are in low-paying, low-skill positions, not highly edu-
cated, and are concentrated in service, sales, production, and
laborer jobs. Since these initial numbers were reported by
Pobutsky, Krupitsky, and Yamada (2009), they have revised
their estimate that the population has grown and is between
12,000-15,000 based on crude estimates from census data and
the U.S. Customs and Border Patrol Office in Honolulu.
Micronesians are coming to the United States for a variety
of reasons, which in many ways are similar to previous
groups immigrating to the United States. Often they come
for health reasons and then decide to stay, or a single male
may come to earn more money and to support their families
back in the FSM through remittances. Additionally, many
come to provide better education for their children. As with
many immigrant groups once one person comes and brings
their family more immigrants follow in their footsteps.
Health of Micronesians in the United
States
The impact of Micronesian migration has been most evident
in Hawai’i and its impact on the state is striking. A large body
of the antidotal evidence suggests that a significant number
of Micronesian migrants do not have private pay insurance
and as a result depend on publicly funded providers for their
health care needs. This combined with the cost of providing
education in the school system and to a much lesser extent
public safety and welfare has cost the state of Hawai’i
approximately $140 million dollars from 1997 to 2002
(Hawai’i Institute for Public Affairs, 2004).
In the United States, the Native Hawai’ian and Other
Pacific Islander (NHOPI) population has grown 14.2% since
2000 (Association of Asian Pacific Community Health
Organizations [AAPCHO], 2006). The per capita income for
this group is $15,054 and the median income for NHOPI is
$42,717, this income has not maintained the same growth
pattern and is considerably lower than that of non-Hispanic
Whites. Among the NHOPI ethnic groups Micronesians
have an even lower income of $8,373 (AAPCHO, 2006).
According to the AAPCHO in 1999, 17.7% of NHOPI were
at or below the poverty level compared with 9.1% for non-
Hispanic Whites and 12.6% for Asians. The poverty rates
among the different ethnic groups vary vastly but
Micronesians and Tongans have the highest rates at 43% and
36%, respectively. According to Vorsino (2007), a single par-
ent with two children on Oahu needs approximately $54,161
to be self-sufficient which is defined as needing no assis-
tance from outside sources such as the state, private groups,
or family. Consequently, due to the high cost of living in
Hawai’i, many people live in crowded conditions in order to
afford housing. Still others are unable to afford housing and
are homeless. Honolulu reports that number of homeless
population in 2010 is at 4,171 with approximately 20% of the
homeless population being Micronesians largely from Chuuk
in the FSM and the RMI (Vorsino, 2007).
In terms of communicable disease there is growing con-
cern that Micronesians may enable the spread of infectious
disease to Hawai’i from Asia. Data concerning Hansen’s dis-
ease, TB, and sexually transmitted disease support this claim
(Pobutsky et al., 2005). For instance, in a 5-year trend exam-
ining new cases of TB in Hawai’i, 45 out of 58 new cases
have come from the FAS of Micronesia (Hawai’i State
Department of Health, 2005). The state of Hawai’i reported
that between 1994 and 2003 there were 187 cases of Hansen’s
disease and 97 (52%) occurred in people from the FSM and
the RMI; most current data available (Hawai’i Department of
Health Communicable Disease Division, 2004). The Hawai’i
Department of Health Easy Access Program provides ser-
vices and referrals for immigrant and migrants along with
translation services. Of the total population using the ser-
vices, Micronesians use 12.8% of the services provided yet
they make up less than 1% of the total Hawai’i population
(Pobutsky et al., 2005). This is an especially sensitive topic
to Micronesians in Hawai’i as it thought that these statistics
negatively reflect on the entire Micronesian population (B.
Tom, personal communication January 28, 2010).
It is know that chronic disease conditions such as diabetes
and cancer are affecting the Micronesian population who seek
treatment in Hawai’i. However, there is a lack of tangible data
concerning chronic diseases among Micronesians living in
Hawai’i. Of issue, is the lack of data concerning the popula-
tion of Micronesians in the FSM, RMI, Hawai’i, and the con-
tinental United States. Although both the FSM and RMI do
track health statistics and rates of diseases it is difficult to
locate and ensure their reliability. Within Hawai’i and the rest
of the United States there is simply too small of a population
to have strong reliable data concerning the population.
Implications
The impact of infectious diseases for Micronesians is not a
new issue. Problems with diseases in the islands occurred
prior to the arrival of Westerners but it greatly increased with
their arrival. Statistics for the islands demonstrate that in the
19th century after increasing contact with the West, the popu-
lation dropped by 30% to 40% overall and in some areas it was
as high as 50% to 90% of the population (Hezel, 2010). What
is now occurring is a shift from communicable diseases to
noncommunicable diseases. Micronesia has been able to
rebound from communicable diseases through the years; the
new challenge for Micronesians is to understand this new shift
in combating noncommunicable diseases. We in the West and
specifically the United States have a responsibility to the peo-
ple of the FSM. We have a strong relationship that goes back
to the end of World War II. As a result of the negotiations, the
FSM relies on the United States fully for their defense; in
exchange the United States has full authority over access and
use of the strategic waters surrounding the FSM. In the past,

MacNaughton and Jones 311
this included the nuclear testing sites just outside the FSM in
the RMI. Micronesians especially those of the Marshall
Islands and to a much lesser extent in the FSM were exposed
to nuclear fallout with its associated health risks: from 1946 to
1958 when the equivalent of 152 megatons of explosion
occurred releasing more than 150 times more contamination
than that from Chernobyl in 1986 (Hezel, 2010). During the
1950s, the U.S. Navy and the Department of Interior provided
leadership in the islands and local islanders had little say in the
governance of their islands. In 1961, the United Nations
accused the United States of neglect and prompted Washington
to send in aid and Peace Corps Volunteers including nurses
and health educators (Hezel, 2010). Additionally, since World
War II, the United States has been responsible largely for the
escalation of imported goods to the islands. The increase in
importation brought with it many of the commodities, such as
refined sugar and canned meats, and a reliance on white rice,
which are partly responsible for increasing the risks of non-
communicable diseases, replacing the communicable diseases
of the past (Hezel, 2010).
The Governments of the FSM and the United States maintain
deep ties and a cooperative relationship. Reflecting a strong leg-
acy of Trusteeship cooperation, more than 25 U.S. federal agen-
cies continue to maintain programs in the FSM including health
programs. Also under the Compact, Micronesians may live,
work, and study in the United States without a visa. Micronesians
volunteer to serve in the U.S. Armed Forces at approximately
double the per capita rate as Americans (P. Prahar, personal com-
munication, January 19, 2012); they are also eligible for admis-
sion to U.S. Service Academies. Americans can and do live and
work freely in the FSM without the need for a visa.
Nursing has an important role in helping to decrease the bur-
den of illness and disease in the Micronesian population.
Because of the important roles they hold in the FSM, nurses are
able to influence the health of Micronesians. Although the num-
bers of nurses in the FSM are relatively small at 22.6/10,000,
below the standard 23/10,000 that is required to meet the WHO
millennium goals, the nursing personnel in the FSM are making
a difference and aiding in improving the health of the people in
the FSM. Nurses in the West need to be aware of the historical
and current responsibilities we have to assist the people of the
FSM to be as vibrant as they choose to be.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
References
Association of Asian Pacific Community Health Organizations.
(2006). U.S. and State fact sheet on AAPIs. Oakland, CA: Author.
Central Intelligence Agency. (2011). World Factbook: Federated
States of Micronesia. Retrieved from https://www.cia.gov/
library/publications/the-world-factbook/geos/fm.html
Evans, R. G., Barer, M. L., & Marmor, T. R. (1994). Why are some
people healthy and others not? The determinants of health of
populations. Hawthorne, NY: Aldine De Gruyter.
Fairlamb, J. (2002, July 12). Compact of free association nego-
tiations: Fulfilling the promise. Honolulu, HI: Island State
Security Conference, Asia-Pacific Center for Security Studies.
Flaskerud, J. H., & Winslow, B. J. (1998). Conceptualizing vul-
nerable populations health-related research. Nursing Research,
47, 69-78.
Fred, D., Desai, M., Song, R., Brostrom, R., Bamrah, S., Pavlin, B.
I., & . . . Ekiek, M. J. (2010). Multi-drug resistant tuberculo-
sis in Chuuk State, FSM, 2008-2009. Pacific Health Dialog,
16(1), 123-127.
Hanlon, D. (1989). Micronesia: Writing and rewriting the history of
a non-entity. Pacific Studies, 12(2), 1-21.
Hanlon, D. (1999). Magellan’s chroniclers? American anthropol-
ogy’s history of Micronesia. In R. Kriste & M. Marshall (Eds.),
American anthropology in Micronesia (pp. 53-79). Honolulu:
University of Hawai’i Press.
Hanlon, D. (2009). The “Sea of Little Lands”: Examining
Micronesia’s place in “Our Sea of Islands”. Contemporary
Pacific, 21, 91-110.
Hawai’i Department of Health Communicable Disease Division.
(2004, November/December). Hansen’s disease in Hawai’i’s
Pacific Islander population, a ten year review: 1994-2003.
Communicable Disease Report, pp. 10-12.
Hawai’i Institute for Public Affairs. (2004). Policy brief: Impacts
of the Compact of Free Association on Hawaii’s Health Care
System. Honolulu: Hawai’i Uninsured Project.
Hawai’i State Department of Health. (2005). TB cases from Pacific
jurisdictions Hawai’i, 2000-2004. Honolulu: Author.
Hezel, S. (2010). Disease in Micronesia: A historical survey.
Pacific Health Dialogue, 16(1), 11-26.
Kohler, L. A., Alik, T., Kaplan, E. L., & Anderson, F. L. (2010).
A pilot study for the primary prevention of rheumatic fever in
Kosrae, Federated States of Micronesia. Pacific Health Dialog,
16(1), 99-108.
Noble, C., Pereira, N., & Saune, N. (2011). Urban Youth in the
Pacific: Increasing resilience and reducing risk for involve-
ment in crime and violence. Suva, Fiji: United Nations
Development Programme Pacific Centre.
Office of Communications, U.S. Citizenship and Immigration
Services. (2008, February 13). Fact sheet: Status of the citi-
zens of the freely associated states of the Federated States
of Micronesia and the Republic of the Marshall Islands.
Washington, DC: Department of Homeland Security.
Petersen, G. (2009). Traditional Micronesian societies: Adaptation,
integration and political organization. Honolulu: University of
Hawai’i Press.
Pobutsky, A. M., Buenconsejo-Lum, L., Chow, C., Palafox, N., &
Maskarinec, G. G. (2005). Micronesian migrants in Hawaii:
Health issues and culturally appropriate, community-based
solutions. Californian Journal of Health Promotion, 3(4),
59-72.
Pobutsky, A. M., Krupitsky, D., & Yamada, S. (2009). Micronesian
migrant health issues: Part 2: An assessment of health, language

312 Journal of Transcultural Nursing 24(3)
and key social determinates of health. Californian Journal of
Health Promotion, 7(2), 32-55.
Vorsino, M. (2007, November 12). Nonprofit fighting rental bias.
Honolulu Advertiser. Retrieved from http://the.honoluluadver-
tiser.com/article/2007/Nov/12/ln/hawaii711120352.html
World Health Organization for Western Pacific. (2010). Federated
States of Micronesia country profile. In Western Pacific
country health information profiles. Manila, Philippines:
Author. Retrieved from http://www.wpro.who.int/countries/
fsm/17MICpro2011_finaldraft.pdf
Yamada, S., & Pobutsky, A. (2009). Micronesian migrant health
issues in Hawaii: Part I: Background, home island data, and
clinical evidence. Californian Journal of Health Promotion,
7(2), 16-31.