Many least-wealthy, rural, remote and resource-poor small island communities are unlikely to benefit from high-profile global water improvement initiatives. Their small landmasses, geologic composition, geography, social and technological isolation, colonial history, and weak educational and financial resources constitute significant barriers to improving access to safe drinking water. This paper discusses the relatively unique position of such island societies in the international community, providing a case study of the Federated States of Micronesia that integrates data and information pertaining to water resources management and governance, spanning from the island village to national scale. A vision is offered regarding the interaction between small island human and biophysical water systems, manifesting ways to pursue water resource development to improve public health which are constructed to be economically, physically and culturally sustainable.