Uncovering Chronic Disease Disparities within Compacts of Free Association Migrant Populations in Hawaii

Historical events including US neocolonial administration and thermonuclear weapon testing within their homelands left many Compacts of Free Association (COFA) citizens, including those of Chuukese, Marshallese, Pohnpeian, Yapese, and Kosraean descent with poor health and educational outcomes that led to their migration to Hawaii. A case-control study was conducted to quantify relative prevalence and severity of chronic diseases among COFA-affiliated patients compared with age- and sex-matched controls. Inclusion was based on a Preferred Language labeled as a COFA-affiliated language in the electronic health record. Cases and controls had received primary care at The Queen Emma Clinics, a hospital-embedded, mission-based clinic in Honolulu between January 1, 2018, and August 10, 2023. In comparison with the age- and sex-matched control group ( n =1076), patients with COFA-affiliated Preferred Languages ( n =353) had prevalence rates of diabetes mellitus two-fold higher (54% versus 28%), CKD 1.8-fold greater (24% versus 14%), and history of stroke two-fold greater (13% versus 7%; all P < 0.001). The prevalence of uncontrolled diabetes in the studied population was more than three-fold higher (16% versus 5%) and kidney failure was 3.9-fold higher than that of the control group (10% versus 3%). COFA-affiliated clinic patients had lower engagement with medical services on various indicators. COFA migrants in the United States present to primary care with uniquely prevalent and advanced chronic diseases, especially type 2 diabetes mellitus and CKD.