Centering FAS Mental Health: From Home Islands to Diaspora
By Caroline Adams, for Micronesian Stick Chart Institute (MSCI) - World Mental Health Day
For families from the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI), and Palau - together, the Freely Associated States (FAS) - mental health is both deeply personal and structurally complex. At home, small health systems struggle to staff specialized services; abroad, our diaspora often feels unseen in United States (U.S.) health data and uncomfortable seeking support. The result is predictable yet preventable: elevated risks for suicide, trauma, and justice involvement that are not matched by the culturally grounded care our communities deserve (World Health Organization [WHO], 2022a, 2022b, 2022c; Subica et al., 2019).
What the numbers show at home
Recent WHO Mental Health Atlas country profiles underscore thin specialist capacity and incomplete surveillance in all three FAS countries - a structural reality that constrains prevention and treatment (WHO, 2022a, 2022b, 2022c). In FSM, the age-standardized suicide mortality rate was 28.99 per 100,000 in 2019 - among the world’s highest - while mental-health workforce counts remain very low (WHO, 2022a). In RMI and Palau, Atlas profiles likewise document limited services and patchy data systems, reinforcing what providers know on the ground: need outstrips capacity (WHO, 2022b, 2022c). At the same time, national Family Health and Safety Studies (FHSS) led with United Nations (UN) partners have documented high levels of violence against women - an upstream driver of mental-health burden - across FSM, RMI, and Palau (Federated States of Micronesia Department of Health & Social Affairs [FSM DHSA], 2014; UN Women, 2023; Pacific Women, 2014).
The diaspora reality - in the U.S. and territories
In the U.S. territories, we finally see disaggregated numbers: Guam recorded 31 suicide deaths in 2023 (age-adjusted 23.9 per 100,000), and Chuukese residents had the highest suicide rate per 100,000 among ethnic groups counted that year. Hanging accounted for 83 percent of suicides (David, 2024). These are FAS people on U.S. soil, yet the systems around them are still not tailored to their needs.
On the U.S. mainland, community reports and research in Hawaiʻi, the Pacific Northwest, and Arkansas consistently describe barriers that depress help-seeking: stigma around mental illness, experiences of discrimination in health settings, language access gaps, and fears tied to cost or eligibility (Subica et al., 2019; Inada et al., 2019; McElfish et al., 2016; Pobutsky, 2009). Local press in Clark County, Washington (Vancouver area) has covered the Chuukese community’s efforts to navigate school, health, and social services - illustrating both resilience and the friction families face when systems are not culturally responsive (Harsh, 2018; Harsh, 2023). Together, this helps explain why many FAS community members in diaspora do not feel comfortable seeking care even when services exist.
Why our data - and our people - go missing
A core problem is data invisibility. Although federal standards split “Asian” and “Native Hawaiian or Other Pacific Islander (NHPI)” in 1997, small sample sizes still lead to suppression or lumping many groups into “Pacific Islander - other” in surveys and dashboards, masking FAS-specific patterns (Office of Management and Budget [OMB], 1997; Kamaka et al., 2021; Wu & Tran, 2017). Kaiser Family Foundation (KFF) synthesis work notes that NHPI communities are often excluded from data and analysis because of small numbers; several studies show that reliable estimates often require special sampling or combining many years of data (Centers for Disease Control and Prevention, National Center for Health Statistics [CDC/NCHS], 2014; KFF, 2024; Lim et al., 2023). When we disappear in the data, we also disappear in planning - and in funding for care tailored to our needs.
Youth risk, incarceration, and violence
For young people, unaddressed mental-health needs meet punitive systems. National reviews show youth incarceration harms mental health and life chances and is plagued by racial or ethnic disparities (Mendel, 2023). In Hawaiʻi, administrative data show NHPI youth were referred to the juvenile system at rates 89 percent higher than other races (2018 to 2020) (Hawaiʻi Office of Youth Services [OYS], 2022). Add to this high rates of family and sexual violence documented at home and increased risks of sexual and dating violence among NHPI youth in U.S. schools, and the case for culturally grounded prevention is urgent (FSM DHSA, 2014; UN Women, 2023; Swaminath et al., 2023).
What we can do now
1) Invest in FAS-led, culturally grounded care: Expand community health worker (CHW) and navigator programs staffed by FAS speakers (Chuukese, Marshallese, Palauan), normalize help-seeking, and embed traditional supports (elders, faith leaders) alongside licensed care. Evidence from NHPI communities shows stigma reduction plus literacy boosts help-seeking (Subica et al., 2019).
2) Require data disaggregation: When funding surveys or programs, mandate NHPI sub-group fields and avoid “PI - other.” Use NHPI-specific instruments or oversampling when feasible; the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey (NHPI-NHIS) shows it can be done (CDC/NCHS, 2014; KFF, 2024).
3) Build trusted access points: Partner with schools, diaspora associations, and Pacific Islander-serving community-based organizations (CBOs) in places like Clark County, Washington; Springdale, Arkansas; and Hawaiʻi to host multilingual screening days and low-barrier tele-therapy slots. Local reporting shows these are where families already go (Harsh, 2018; Harsh, 2023).
4) Territories first: In Guam and the Commonwealth of the Northern Mariana Islands (CNMI), expand crisis response and youth prevention tailored for FAS communities; Guam’s 2023 data show acute need and clear ethnic disparities (David, 2024).
5) Violence prevention as mental-health policy: Resource FAS women’s protection services at home (FHSS follow-ups) and in diaspora. Violence reduction is mental-health promotion (FSM DHSA, 2014; UN Women, 2023).
What’s working (and adaptable) - low-cost, culturally grounded actions
Across Small Island Developing States (SIDS) in the Pacific, several approaches have shown promise because they meet people where they are, build on culture, and do not require large specialist teams.
1) Train non-specialists with the Mental Health Gap Action Programme (mhGAP) and embed care in primary clinics. Kiribati, Vanuatu and Fiji have expanded mental health support by training nurses and front-line providers with WHO’s mhGAP, using brief, practical protocols plus periodic supervision. This approach is low-cost, scalable, and feasible on outer islands - exactly the kind of “good enough” care that prevents crises and supports safe referrals (World Health Organization, 2019, 2022d, 2025; United Nations Sustainable Development Group [UNSDG], 2022; Charlson et al., 2019).
2) Build gatekeeper networks among pastors, teachers, and village leaders. Training trusted adults to recognize warning signs and connect people to help - often called “gatekeeper” training - has been used with Pacific communities and faith groups and can be delivered in short, low-cost sessions. Evaluations show these trainings improve confidence and referral behavior; Pacific programmes stress family- and church-centered adaptations (New Zealand Ministry of Health, 2016; Faleafa et al., 2021; Le Va, 2025).
3) Run 24 hours a day, 7 days a week helplines and tele-counselling with local nongovernmental organizations (NGOs). Fiji’s Empower Pacific operates free, round-the-clock counselling lines staffed by trained counsellors and para-professionals - a proven, low-cost lifeline that communities actually use. Similar models can be stood up with basic telecoms, on-call rosters, and partnerships with churches and schools (Empower Pacific, n.d.; European Commission - International Partnerships, 2020).
4) Use cultural dialogue formats to reduce stigma (Talanoa or fa‘afaletui). Community talanoa - guided, relational dialogue - has been used with Pacific peoples to talk about distress, grief, and help-seeking in ways that feel safe and familiar, and can be facilitated by trained community workers with clinician backup. Toolkits and research from Pacific scholars outline how to do this ethically and effectively (Ravulo, Winterstein, & Said, 2021; Yamada et al., 2019).
5) Make schools and youth groups true “safe spaces.” Several countries have piloted teacher training, peer-support circles, and youth-led awareness projects through churches and village groups - small, regular gatherings that normalize talking about stress, conflict, and violence, and that connect young people to help early (Hope, 2009; Tonga Community-Based Action Research [CBAR], 2009).
6) Integrate Mental Health and Psychosocial Support (MHPSS) in disaster response. Vanuatu’s post-disaster work shows how rapid psychosocial training for primary-care teams, community workers, and volunteers can be woven into emergency response - skills that keep helping long after the crisis (WHO, 2019, 2025).
Naming the challenge - and each other
We must keep two truths in view: (1) back home, specialized services remain scarce and reliant on external support; (2) in the U.S., many FAS community members do not feel welcome or safe seeking care. Both are solvable when we center FAS voices, invest in culturally grounded care, and insist on data that actually counts us. World Mental Health Day is a reminder that our stories - and our lives - are worth the accuracy, dignity, and care we have been asking for.
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