In the early 2000s, the governments of the Republic of the Marshall Islands (RMI), the United States and Hawaii worked cooperatively to prevent the exploitation of families in the Marshall Islands. Over the preceding few years, rising demand for international adoptions, a lack of adoption oversight within the RMI and abuse of the Compact of Free Association (COFA) led to the RMI becoming the highest per capita source nation of international adoptions into the U.S.

Adoptions of Marshallese children became big business and led to incidents of deceit and coercion involving well- meaning families on both sides. Unfortunately, as subsequent protections were put in place in the RMI in 2002-2003 to protect children and families from exploitation, adoption agencies began out-adopting, bringing pregnant Marshallese mothers to Hawaii, completing the adoptions on U.S. soil to avoid RMI jurisdiction and oversight.

Media reports from 15 years ago were rife with stories of coercion, false promises, Medicaid abuse, crowded apartments full of pregnant women and agencies accused of poaching pregnant women, all under the guise of paternalistic self-righteousness.

Media attention, national and state legal protections stemmed the tide in Hawaii by the mid-2000s. However, out-adoption practices moved to the mainland and have persisted for the last 15 years, most notably in the large Marshallese community in Arkansas. The same stories that plagued Hawaii 15 years ago are prevalent in that community: coercion, false promises, threats, isolation and critical misunderstandings.

The RMI government has reached out to the governments serving their communities in the U.S., detailing the personal and cultural risks and imploring respect for their community and for their efforts to protect the future of their small nation and their people.

From late 2016, there has been concern of incidents that out-adoptions have returned to Hawaii; pregnant women brought here in groups with the intent to give their children over to adoptive families who come here from the mainland and leave with little awareness of the personal and cultural impacts of their good intent.

Medical professionals, hospital and clinic administrators, adoption lawyers, social workers, family court judges, legislators, community agencies, interpreters and leaders in the Marshallese communities should be aware of COFA rules on adoptions, the rights of the families involved and state requirements for adoption oversight and translation of information and must be vigilant for potential exploitation of this vibrant yet vulnerable population.

The Marshall Islands are a sovereign nation and the relationship between our nations is codified through the COFA, which intends to protect and strengthen both the RMI and the U.S. and does not intend to expedite access to human children for convenient and easy adoptions. The U.S. relationship with the RMI has been largely one-sided since 1946 with devastating consequences for the Marshallese people, using COFA for profit and conceit cloaked in self-righteousness continues to do harm.

Those of us in positions to protect must hold unethical adoption agencies and their intermediaries accountable while respecting individual confidentiality and determination without criminalizing well-intentioned families. To that end, many community agencies may be able to provide assistance or information if encountering a suspected situation of exploitation or human trafficking.

Consultation with Child Welfare Services (832-5300 on Oahu/1-800-494-3991) may be appropriate under the new Public Law 114-22, which adds suspected human trafficking of minors to CWS investigations. The Parent Line — 526-1222 (Oahu) or 1-800-816-1222 (neighbor islands) or online at theparentline.org — can connect one with immigrant services, translation and support via community agencies such as The Pacific Gateway Foundation and the Susannah Wesley Community Center. Contact the Marshallese Consulate at 545-7767 for more information.

Michael L .Walter, M.D., M.P.H., is a pediatrician and interim medical director at the Kalihi-Palama Health Center.