A Special Handbook

For working with the

Sensitivity Issues in Bridging the Gap

Of the

Cultural Health Barriers

With our

Marshallese Clients and Patients

In Hawai`i
 Marshallese Cultural Health Barriers
Finding ways to improve Communications with Marshallese Clients

Marshallese History:
1. The Ancient Migration of the people of the Republic of the Marshall Islands
2. World War II and the Marshall Islands
3. The Trust Territory of the Pacific Islands (TT) & the Republic of the Marshall Islands
4. The Compact of Free Association with the United States of America COFA

Marshallese Culture:
1. Head of Kingdom, Atoll, Clan, & Household
2. Traditional Practices: Financial Responsibility, Healing arts, Sharing, & the Work Ethic
3. Cultural Taboos: Relationships, Gender, Body Parts, & Language
4. Modern Political Expectations & Realities

A “New World” Outlook:

America is the “New World” for Marshallese Immigrants

1. The United States of America is a “ Land of Plenty & Luxury”

2. Marshallese Time Orientation is very different
3. American Needs & Expectations for Legal Papers & Documentation
4. Learning Responsibility for: Public expenses, Appointments, Self Help, & Supporting
Others

Health Care Provider Challenges:

1. Who to talk to: Family, Friends, Clergy, & Interpreters
2. Understanding the differences between Marshallese and other Micronesian People
3. Helping Clients realize their Responsibilities
4. Finding ways to Motivate Marshallese People toward a Successful “Life in America”
 Marshallese History: Where are modern Marshallese People Coming From?

I. Ancient Migration
The Ancient Marshallese people migrated by sea going canoes from Japan, China, India,
and all of ancient Asia in a way that carves a great hook from Southeast Asia to the South
Pacific, and finally to the lands of Micronesia.
II. The Marshall Islands and World War II
First through international whaling ships, then by Sail and Steam Trade Ships, and finally
by way of Japan & United States military occupations much of the ancient culture of the
Marshall Islands was modified or entirely lost.
III. The Marshall Islands and the Trust Territory of the Pacific Islands (TT)
After World War II, the United Nations - Trust Territory of the Pacific Islands led to many
damaging bad habits including Navy & Surplus foods, loss of traditional agriculture and
fishing, and an unhealthy dependence on White Rice, White Flour, Sugar, and Canned
Meats.
IV. The Compact of Free Association (COFA I)
1. Under the Compact of Free Association I with the U.S., the Republic of the Marshall
Islands failed to encourage self reliance, self sustaining agriculture, support for traditional
cultural practices, and the use and preservation of the Marshallese Language.
2. The Compact of Free Association (COFA) II blamed the Marshallese for all their failures,
and mandated that corrections had to be made for the Marshallese by their own efforts
independent of any American support other than the monies included in COFA II. The
epidemic occurrence of Diabetes, Hepatitis, and other serious health problems were not
given priority in the COFA II negotiations. Zero Kidney Dialysis machines, limited
educational support, and refusal to address the “Changed Circumstances” clause are
important examples of COFA II inadequate responses to significant problems.
3. Worst of all, the “177 section” of COFA I & II indemnified the United States Federal
Government from paying it's share of Health, Education, Welfare, & Housing costs. This
leaves the State of Hawai`i, and the County Governments here in Hawai`i holding the ball
for these expenses, which should be paid by ALL the people of America.
4. The Congress of the United States passed special “Compact Impact” funding to off set the
expenses for Hawai`i, Guam & CNMI, and other locations in the Mainland. The funding
for Hawai`i was far to little and did not amount to enough funding to even cover a single
hospital in Hawai`i. Further legislation helped somewhat, but was still far to little to cover
the cost here in Hawai`i. We are still waiting for a real re-negotiation to remove the
indemnification of the federal government's share of the cost from COFA entrants in
Hawaii.
 Marshallese Culture: What Differences affect our relationships?
I. Social Rank
1. In the Ratak Chain of the Marshall Islands, the Queen is the Paramount Leader. In the
Railik Chain, the King is the Paramount Leader.
2. For each Atoll there is a Queen or a King who is the head of state (Leroij or Iroij),
followed by lesser Kings (Iroij Idrik), greater Lords (Alap), lesser Lords (Alap Idrik),
Workers (Dri-Jerbal), and finally Kajur (the strength of the people). Almost all
Marshallese people who come to Hawai`i are of the last category. Only a few higher
ranking people immigrate outside of the Marshall Islands.
II. Traditional Practices
1. Financial Responsibilities are left to the Queens, Kings, and Lords by tradition and the
lower rank of people only earn a small amount of money which they use for their own
needs while sending their shared responsibility portion of their income to the royalty and
the lords above them.
2. Healing and health matters are left to the traditional healers, although each family often
has at least one (often only one) person who knows a single kind of healing practice.
3. Sharing of food, household goods, belongings, and often even children is common among
the family, and greater extended family. Often the first born child is taken by
grandparents to insure that someone will look after them in their senior years.
4. The work ethic is to provide food and shelter for the immediate family, as well as an
extended support (sharing of preserved food & salted fish, sleeping mats, coconut massage
oils, and other items) for the Queens, Kings, and Lords.
III. Cultural Taboos
1. The relationships between a person's mother (including in this category your mother's
sisters and her daughters) as well as your own sister, require a special respect which does
not allow discussion of any sexual topic, as well as any discussion of other family members
sexual subjects. Visual contact of any sexual body parts is also taboo, for any male
children over the age of puberty, and any visual contact of any sexual body parts of any
female of any age. Even healing massage can involve this kind of limitation between the
sexes.
2. Generally speaking boy children are given far more freedom than young girls. Young men
are allowed to have appropriate sexual partnerships (under the limitations above) with
women of almost any age past puberty. Women on the other hand, are often required to
satisfy their “non-mother line” cousins if asked to do so. In other words a woman's cousin
may ask you to sleep with someone of their choice. They require permission for most other
relationships with men of any age who are not cousins. although the limitations as listed
above are still taboo.
This leads to many restrictions for clothing, sitting postures, rank of being fed, and many
other hidden restrictions which are the purview of women only.
3. Taboos as per body parts include all of the above restrictions plus any male relationships
which involve members of your “mother relationships” direct brothers. In other words as
a man, your Uncles are not allowed to see your private parts (sexual organs and behind)
 and visa versa. One has to observe careful restrictions with your Uncles.
4. Spoken references to any thing sexual hold the same kind of taboo relationships as the
visual restrictions already mentioned. No “dirty” talk in front of your Uncles or your
mother relationships, although if there are no other male family members present women
can say anything to you, or in your presence. Because of the many Uncle relationship's
this is usually limited to when a man or boy is alone in the presence of many women. For
that reason, men and boys avoid this situation completely.
IV. Modern Political Expectations and Realities
1. Most Marshallese people today believe that all Americans live a very good life, filled with
money and luxury not available to them in their homeland. They believe all Americans
are quite rich and that all Americans are employed automatically if they are adults.
2. Many or most of the Marshallese immigrants believe that health care, education, and
many if not most services are free and paid for by the government automatically.
3. Many or most of the Marshallese community believe that Health Care, and Education is
done without their involvement in any way. They often do not understand the need for
child supervision concerning health care, education (like studying and homework), and
even their own “self help” practice of good nutrition and health care.
4. Adult education is not available for the most part in their homeland, and they are usually
not aware of educational opportunities for adult or “life long” educational opportunities
here in Hawai`i, or elsewhere in the United States. They are also not aware of the costs for
those programs that are indeed available.
5. Most Marshallese do not know or understand the requirements and responsibilities for
paying taxes on their income if they do work. Other taxes (other than sales tax) are also a
new concept for them to understand.
6. Life in Hawai`i is often void of the social structure that they experienced for their whole
lifetime at home in the Marshall Islands. Here in Hawai`i, it is very important to make
contact with the Marshallese Churches.
Pastors, Deacons, and other clergy elders and supporters are one of the only ways we can
know about, and help those who are in need of assistance. If the socially high ranking
members of the Marshallese community are not available, then we must look to the
support that is often only available through the elders of the Churches and their various
organizations. Asking clients who is their Pastor may be the only way to find someone
who can help a person who is displaced from their extended family members, their
royalty, or their higher ranking community members. These are the people that they must
rely on here in Hawai`i when the other sources of help are missing.
 A “New World” Outlook
I. The United States is a “Land of Plenty and Luxury”
1. Marshallese people are often bewildered by the need to pay for virtually everything,
because they come from an experience where most of their life is supported by hunting
and gathering from the lagoon, the trees over head, and by simple labor to get the job
done.
2. Except for: White Rice, White Flour, White Sugar, Coffee, Tea, Condensed Milk,
Cigarettes, and Clothing items; most of the daily needs for the Marshallese family are
found on their island or from the sea. They can live a very good life of joy and peace
without ever having very much money at all. This causes a lot of stress when they arrive
here in the United States (particularly here in Hawai`i where so many things are
expensive) and they often find themselves helplessly dependent on family members with
more experience to support their daily needs.
3. Most of the luxury and abundance they expected are not available to them.
Transportation, movies, dinning out, and many other small but significant luxuries that
they hoped for are simply out of reach for the “new arrivals” to Hawai`i. Many times only
the radio or television (if family members already have one) is the only form of
entertainment they know or can experience.
4. Often it takes a long time to find out about free events, parks and beach parks, or
educational opportunities at the Universities and Community Colleges. Seniors most
often are not aware of any programs for the elderly which they could enjoy.
II. “Marshallese Time”
1. Marshallese people live by the sunrise and sunset, the seasonal changes in the weather,
and special days of celebration. The idea of looking at a watch to see what time it is has
very little meaning for them. Yet for many Marshallese people, wherever they are, they
can tell you when the high tide or low tide will happen. They can tell you what phase of the
moon we are under. Living in Hawai`i, much farther away from the ocean than their
homes back in the Marshall Islands were, they feel a disconnect with the whole world of
time. They do not pay attention to the “time of day”, and therefore often do not realize
that they are not ready on time or at a location when they said that they would be.
2. Getting to an appointed time event in the Marshall Islands is often limited to being there
on the day that they said they would be. Getting there on time by the hour is not a
concern and very often will be not happen. A watch is far more often considered an item
of jewelry rather than a “time piece”. This can cause lots of problems which Americans
just don't understand. They mean well, and will say that they can meet you at a given
hour, but any time in the morning, afternoon, or evening is considered, pretty much “on
time” for “Marshallese Time”!
III. Legal Papers and Documentation

1. Paper in the Marshall Islands (especially for people living in the outer islands) is most
often used to start fires, to wrap around small items, or as toilet tissue when using the
bathroom (on the outer islands this can often be the ocean side tide pools, a small hole dug
in the jungle, or under a rock or bush along a vacant area of the shore line).
2. The only exceptions to this general rule is the Bible or the Hymnal song book. All the
other books will end up missing pages that were used for convenience. School books are
beginning to be an exception, and some folks will keep records of money spent or expenses
paid, but this is the exception, not the rule.
3. Personal Identification is not necessary, because most people living on an island not much
larger than a shopping center parking lot, know every single person on that island. Most
of those people they know by name and they also know their relationship to their own
family as well, so that they are prepared to follow the taboo restrictions.
4. Passports, and I-90 forms have started to become important objects that are kept in the
same place as their Bible and Song book. In some cases Social Security Cards are also
kept with the other important papers and books, but very few people know their Marshall
Islands Social Security number by heart. Knowing such information is never required
back home in their homeland, and they frequently forget to bring them to medical
appointments. Their insurance ID and their Driver's license are also a new way of life
that takes time to get used to.
5. Wills, the “Right to Life” and “Right to Death”, Power of Attorney for Finance and
Health Care are unheard of and not available in the Marshall Islands. They have never
needed them and do not understand the function of their use. These are barriers to
certain rights that Marshallese people don't even know that they can obtain.
6. Immigrant's rights to an Interpreter under Hawai`i law (ACT 290) & other Limited
English Proficiency (LEP) legislation are not know to almost all Marshallese people.
Their ability to obtain these rights are often displayed at offices in Marshallese printed
materials that are so poorly translated that they have no idea what they mean or are
about!
7. Most debts that are not paid back within a calendar year are forgiven! The whole idea of
interest on loans, late fees and penalties, and almost all documentation for car, health, and
homeowners, insurance are not even a part of the Marshallese mind set. Many of these
concepts are not understood at all by Marshallese, and are considered not worthy of
worrying about. Even attendance at Welfare or Housing hearings are not things that are
understood as a responsibility.
There is little or no documentation of these responsibilities in their own language, and the
question of their LEP rights and their need for documentation in Marshallese is actually a
neglect and mitigating failure on the part of agencies receiving federal dollars. Recent
court action on the Mainland U.S. serves to educate us that this can cost agencies a lot of
money in lost subsidies, penalties, and often financial awards to those who were never
given written documentation of the client responsibilities in their own language. It is a
problem that is being dealt with slowly, but no one wants to be the first to pay for their
legitimate failure to provide this information in the client's language.
IV. Responsibility for: Public Expenses, Appointments, Help for Self & Others
1. Many Marshallese people are not aware how much Public Expenses (dollars spent on their
behalf for housing programs, health care, education, and welfare) are used up by the State
of Hawai`i for helping Marshallese people. They do not want to be a burden on the people
of Hawai`i, but the programs that they are put into often cause the State of Hawai`i to use
a disproportional amount of funding to support the new arrivals from the Marshall
Islands who end up needing help.
2. Many if not most Marshallese are not aware that Doctor's offices will charge for any
appointment that is missed, or often appointments where the client arrives more than 10
or 15 minutes late for said appointment and have to re-schedule! This causes many times
as much funding costs, as well as the clerical and staff efforts required to re-schedule
appointments that are often needed in a timely manner.
3. Many if not most Marshallese people are not aware that the quality of their responses to
Doctor questions is paramount for the success of their treatment regime. This is
particularly an important matter for Diabetes, Heart Disorder, Kidney or Liver ailments
and many other patients as well as young mothers who are experiencing their first
pregnancy without the presence of family members who have “home birth” skills.
4. Because so many people from the Marshall Islands arrive without the full extended family
structure, they do not realize the need to help each other out when the new people arrive.
Paying the bills, making and keeping appointments, applications for Welfare, Health
Care, and Educational opportunities are all matters that those with some experience can
help those who are new arrivals here in Hawai`i. Without the help of extended family
relations, the State of Hawai`i and the County agencies may not even know about those
who are in desperate need of help.
 Health Care Provider Challenges:
How can we Bridge the Gap in Providing Services that are needed?

I. Who to talk to: Family, Friends, Clergy, and Interpreters

1. For Marshallese people, the family structure is based on the general rule that the head of
each family is the “Family Father”. If the father of the extended family is present, he will
often have as much or more authority than the father of your client. That means that in
some cases decisions will be made by a grandfather, or possibly even a grandmother. It
will all depend on who and how many people from the Marshall Islands are here on the
Big Island.
In a few cases, there may be a Queen, King, or Lord who also has an important role in all
of the dealings of a particular family. You will need to ask these kind of questions, so that
you actually know who you are supposed to deal with when it comes to decision making.
Remember, that in some cases (including but not limited to pregnancy) only the female
elders or parents will have final authority over certain health issues. Please remember to
treat female clients with very careful scrutiny as to “who exactly is in charge and will be
making decisions”. It would be a mistake to think any young woman can just make a
decision for herself. Someone else will almost always be involved in that decision making
process.
2. Some times people are here with distant relatives or even family friends. It is not
uncommon for Marshallese families living here to have adopted mothers or grandmothers
who are actually “in charge” of particular children. This could mean that a family who is
in charge of a child or young person on paper, will defer to the adopted mother or father's
decision making when it comes to the time to say yes or no to a particular procedure.
If you are not aware of this fact, special kinds of problems can develop that can cause a
failure of communication, and your client will simply disappear. (there are cases where
pregnant young women are sent home to have a baby at home rather than to possibly get
far better care here) Knowing who is in charge of decision making will help this kind of
problem. If approaching the proper authority figure is accomplished, different solutions
may be possible that would not even be considered if a person of less social rank made a
wrong or inappropriate decision without consulting the proper authority individual.
3. When students or individuals who have no close relations living here in Hawai`i are met
with health challenges, the Pastor of the individual or even the Pastor of a friend of the
individual may also help to insure that proper decisions are made. This is often a
responsibility that people will ask of a Pastor, so we should honor that choice even if
special permission has to be obtained to allow the Pastor to serve this function.
4. If all else fails, some interpreters are aware of the cultural rules, and they can also find out
who will be needed to make the client/agency relationship positive and successful.
II. Understanding differences between Marshallese & other Micronesian Cultures

1. Marshallese people are one of the most passive groups of the seven or more cultural
identities who make up the cultural mix of Micronesia.
2. Most American people do not understand that the island groups that make up Micronesia
do not speak the same language, or even have exactly the same kind of culture.
3. Micronesian people include the following basic Island Groups:
In the Republic of the Marshall Islands = Marshallese
In the Federated States of Micronesia (FSM)
Kosrae = Kosraean
Pohnpei = Pohnpeian
Chuuk = Chuukese
Yap = Yapese
In the Republic of Palau = Palauan
Plus often also considered Micronesians:
In the Commonwealth of the Northern Mariana Islands there are people who are
Chamorro
Carolinian
4. Marshallese people are some of the most isolated people in Micronesia living on 29 coral
atolls and 5 isolated islands. The islands and atolls are lined up into two distinctive chains,
the Ratak Chain and the Railik Chain.

5. Of all the areas in Micronesia, the Marshall Islands was most directly affected by the 67
Atomic Test Blasts that have caused so much illness and displacement of people from their
homeland.

6. One out of 5 Marshallese has Diabetes and the country has zero Kidney Dialysis machines.
The outer island health dispensaries do not have refrigeration, and may cases of Diabetes
go untreated or treated with unrefrigerated insulin. This is many times the cause of
Marshallese people immigrating to the United States. Their greatest fear is the loss of
limbs due to extended problems with Diabetes management.

7. Marshallese people are very generous and often give much of their money away at family
gatherings for 1st birthdays, funerals, and weddings. Most of the people living here have
distant “extended” family members living with them who are not actually adopted “on
paper” and often have no legal association with the rest of the family.

8. Unlike most of the other locations in Micronesia, Marshallese people do not like to
aggressively stand up for their rights. They are easily tricked or badgered into giving up
their rights, their money, and their jobs. They are likely as not to never mention these
infractions against them to any authority or often even to their family or community
elders or leaders.
9. The Marshall Islands has very few lawyers and very little understanding of what their
rights and responsibilities are when they arrive here in the United States of America.

10. All COFA II entrants are allowed to enter and move about, as well as to work, purchase
property or homes anywhere within the United States of America under the guidelines of
the Compact of Free Association II.

11. Marshallese people cannot apply for citizenship unless sponsored by a blood nuclear
family (father/mother by son/daughter) relative who was born in the United States of
America or has obtained citizenship by other means like service in the United States
Armed Forces.

12. Many if not most of the people of the Republic of the Marshall Islands live on coral atolls
which are less than 10 feet above sea level and are already experiencing the damages due
to global sea rise. Their homeland is not expected to remain above sea level for more than
possibly 20 years. They will almost surely become the first refugees from Global Sea Rise
and the destruction and disappearance of their homeland. Of course the people from
Enewetok and Bikini are already nuclear refugees. The people from Enewetok are the
first people of our planet to have their homeland vaporized by an atomic bomb!
III. Helping Clients realize their Responsibilities

1. First of all, it is important for you to explain to Marshallese people that you respect their
culture very much, but they must learn how to operate correctly to succeed here in
Hawai`i because we have certain ways or cultural requirements here in America too.
The best approach is to say that you are sorry, but we have to share Marshallese culture
(Mantin Majol) along with American culture (Mantin Belle). If you can actually use these
words it will help a great deal. (Man Tin - Ma Jul) & (Man -Tin Bell – Lay)
All the 'a' letters in these two word are like the 'a' in manipulate – a short 'a' sound. Tin
is like the metal Tin, Jul is like the 'u' sound in bull, and Belle is like the noun Bell and the
verb Lay. (Man Tin - Ma Jul) & (Man -Tin Bell – Lay) Give it a try.
2. When arranging appointments, be sure to give your client a card with the date and the
hour that they need to be at the clinic or location for their appointment. Make sure that
you give them the time which is early enough for them to fill out forms and adding a little
bit of waiting room “extra time” is advisable. Giving them a calendar is needed if the
appointment is for the following month.
3. Please insure that you call on the day before the appointment, and that you also call as
early as possible on the day of the appointment if it is on a Monday. If you have not been
able to reach them call again on the day of the appointment as above. When calling please
only inform them of the time they need to be there ahead of the appointment so that they
do not arrive too late to fill out paperwork. This is extra effort, but it is better than to
have to reschedule the appointment all over again.
4. If there is an interpreter being used for the appointment, please give that interpreter a call
as well, so they don't forget to be there and ask them to insure that the client understands
the hour to be at the appointment ahead of time for filling out forms.
5. Please explain or have the interpreter explain that missing an appointment more than
once without informing the office at least 24 hours ahead of time will result in their not
being able to obtain a new appointment. This is most critical when scheduling
appointments with specialists or appointments that have to be booked long in advance.
IV. Finding ways to Motivate Marshallese People toward a Successful “Life in America”

1. There is only one word for pain in each of the Micronesian languages. They may have
many names for the kind of waves or the kind of rain, but pain is almost always only one
word. Therefore it is best to use the “Happy to Sad to Horrified” faces on a sheet to point
to, so that you can understand the level of pain involved. It is always easier with an
interpreter, but especially with family members interpreting, it is best to use images.
2. Avoid male nurses with young women or even with older women whenever possible. Avoid
female nurses with young men or even older men whenever possible. Most people are
willing to break down cultural barriers with the actual doctor, but schedule same sex
doctors and nurses whenever possible for the best chance of getting valid responses.
3. Do not have close family members do interpretations with any breast or urogenital
questions if they are part of the taboo group of relationships listed above.
4. Explain medications very carefully and write on their prescriptions bottles if possible
what time and dose they take at each time of day that they should take the medications.
5. Explain the process for calling in or pointing to their refill numbers for prescription refills.
With many patients, they think that they are out of pills when the bottle is empty, and will
go without medications until they next see their doctor if the pills in the prescription bottle
are empty. If they know to always take their empty bottles with them to the drug store,
they will stand a much better chance of getting them refilled.
6. Help those patients who do not have a ride to find some kind of transportation, and if they
are coming by city bus, have them arrive one hour early just in case. Check the bus
schedule that they know about or contact a family member to bring them. If a family
member is to bring them to the appointment, be sure to make contact with that person at
their number (often different than the patient's number) so that their ride is ready to
bring them to your office. Avoid appointments that will make arriving on time very
difficult. (Work hours for family members who need to bring them to the office, or very
early appointments for those who use public transportation)
7. Do not leave any female patient with her skirt or dress removed or lifted up without a
sheet to provide a solution to dress taboos. The result will be very difficult for a patient
who does not know who will see them next if they are not sufficiently “covered up”.
8. If visiting a patient at their home try to find someone who can interpret for you and don't
forget to take off your shoes when you enter the home.
9. Explain to workers who are required to have a physical examination that they are
required to take the examination even if they have nothing wrong with their health.
Otherwise, they will assume that you have made a mistake or that they did not succeed in
explaining to you that they don't have any medical problem.
10. Finally remember to remind Marshallese people that they might have made the whole
journey to America so that they could enjoy better health care for themselves and their
families. If they do not work hard to succeed in adapting to the American way (Mantin
Belle) they might loose the opportunities that they made such a difficult effort to achieve.
With every patient or client there are differences and exceptional situations, so be as
understanding as possible. Think of how difficult it would be for you to understand them
if you were in their homeland. Be supportive and kind. Take extra time to explain things
 without talking down to them as though they were children. This is only fair because it is
what they would do for you if the tables were turned. Realize that they come from a more
simple lifestyle but not a more simple culture! Their culture is not at all less worthy of
your kindness and your interest.
When problems occur, think first of what you might not have understood, or what they
might not have understood. Most of the time people don't miss appointments or make
mistakes on purpose, and your own understanding of their culture may well be a part of
the problem. Try to enjoy the challenge of understanding a people whose culture is based
on kindness and accommodation.
The very highest compliment in the Marshall Islands is to be told that you are a very kind
and forgiving person. We could all seek that way of thinking and it would not hurt us at
all.

Thank you for your kind attention, I know that you will succeed in
building a better relationship with all Marshallese clients and patients

if you take the time to try.

Kommol tata non kom im kejbarok ami mour mai juan “Iia Ien”.

Thank you all very much and take care of yourselves until some
“Rainbow Day”