Caught Between “The Rock” and a Hard Place: The Native Hawaiian and Pacific Islander Struggle for Identity in Public Health

DURING THE CONGRESSIONAL debate over health care reform in the fall of 2009, Saturday Night Live opened a show with a parody of President Barack Obama trying to persuade reluctant senators to endorse an overhaul of the nation's health care system. His best sales pitch was that each of the senators would have a voice in the process, but his overtures fail to win their support.¹ The president becomes so frustrated by the politicians’ steadfast opposition to reform that he transforms into “The Rock Obama,” a Hulk-like character played by Dwayne “The Rock” Johnson.

FAR LEFT: Murina Sony and her baby, Ketsen. Printed with permission.

The skit evoked a mixed response from Dorothy E. Schmidt-Vaivao of the Samoa National Nurses Association (SNNA). “It made me laugh but it also made me think,” she says. “There is profound irony in The Rock Obama—with his commanding voice—being played by a Samoan American at a time when Pacific Islanders are among the faintest voices in our country's health care dialogue.” SNNA and a growing number of other health advocacy groups believe that giving Native Hawaiians and Pacific Islanders parity in health research and services should be a priority for health care reform but is not because most people assume that they are in large part a healthy group. As Schmidt-Vaivao put it,

There is a false perception out there that the highly conditioned Pacific Islander athletes who thrill sports fans on Monday Night Football or Saturday night wrestling are the norm. We are very proud of people like Dwayne Johnson and Troy Polamalu but unfortunately they do not represent the health status of most Pacific Islanders.

Taunuu Ve'e-Remmers, Native Hawaiian and Pacific Islanders Affairs Manager of the Asian & Pacific Islander American Health Forum (APIAHF) agrees that Native Hawaiians and Pacific Islanders are at risk for negative health outcomes because of these assumptions. “The scant public health data collected about Native Hawaiians and Pacific Islanders have traditionally been overshadowed because they were combined with much larger data sets about Asian Americans,” she points out, “but the socio-cultural context of Pacific Islanders is different from Asian Americans and as a result their health issues are different.”

Historically, there are pros and cons regarding why Asian American, Native Hawaiian, and Pacific Islander census and health data were aggregated. Now, however, most progressive health researchers recognize that aggregating such data distorts the true picture of Native Hawaiian and Pacific Islander health and have begun collecting separate data sets on these distinctly different groups. “Because of their relatively small population sizes, Pacific Islanders have tragically been almost invisible to public health, and as a result resources have not been made available to assess and respond to their particular health needs,” says Ve'e-Remmers. APIAHF and other Native Hawaiian and Pacific Islander advocacy groups have been pushing hard for more disaggregated health data to quantify the health issues facing these groups in an effort to teach others about the disparities and needs that are in plain view within their communities. Armed with data, these groups hope to marshal the support and resources needed to improve Native Hawaiian and Pacific Islander health.

INTO THE MELTING POT

Whether by choice or by coercion, many islands have historically provided much larger and more powerful nations with strategic commercial and military advantages in remote areas of the world. In the early nineteenth century, American merchants had already begun to amass fortunes through trade with China; by the start of the twentieth century, the United States had established significant commercial and military interests in different areas of the Pacific Ocean.² As trade routes and military ambitions expanded, the United States selectively brokered relationships with several Pacific islands that could help advance its interests in the region. Eventually these relationships strengthened to such an extent that formal arrangements were made to incorporate some islands into the United States. The first of these was Hawaii, followed by the Samoan islands of Tutuila, Manu'a, Rose Atoll, and Swains Island.

As the United States grew into a world power, its economic and military interests in the Pacific intensified. Most relationships between the governments of the United States and select Pacific islands centered on US military interests—notably, the operation of naval and air force bases during World War II and testing grounds for military arsenal and nuclear weapons during the Cold War. By the end of World War II, the United States also controlled Guam and the islands now known as the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.

TOP: Chuukese mothers participate in a Talk Story Session at Kakua Kalihi Valley Comprehensive Family Services clinic. Printed with permission.

ABOVE: Santiryna Sonis participates in a Talk Story Session at Kakua Kalihi Valley Comprehensive Family Services clinic. Printed with permission.

The relationships these islands now have with the United States are varied. Hawaii is the only island of the group that was incorporated into the country as a state. Guam (and nearby Wake Island) were made US territories in 1950. The Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau were administered by the US government for more than 40 years, but in the 1980s and 1990s, each became sovereign states in an arrangement whereby the United States is allowed to maintain military bases on the islands in exchange for financial assistance.

Today, the Pacific Islander American population is relatively small yet incredibly diverse with myriad cultures, languages, and health issues. In the 2000 US Census, which was the first to report Native Hawaiians and Pacific Islanders separately from Asian Americans, Native Hawaiians and Pacific Islanders were the smallest subgroup reported, with a total of 861 000 persons, or 0.3% of the total US population. Native Hawaiians, Samoans, and Guamanians/Chamorros account for 74% of the Native Hawaiian and Pacific Islander population in the US and Tongans, Fijians, Marshallese, and other Pacific Islanders comprise the remaining 26%.³ Most Native Hawaiians and Pacific Islanders in the United States trace their heritage back to one or more islands in the Polynesia, Melanesia, or Micronesia regions of the Pacific, but today they live mainly in six states: Hawaii, California, Washington, Arizona, Utah, and Nevada. In recent years, local health agencies, advocates, and researchers in these states have been warning those in control of research and care dollars of the critical need to take stock of and act upon the declining health conditions of their Native Hawaiian and Pacific Islander residents.

SIGNS OF TROUBLE

Just fifty years ago, residents of the Pacific Islands had an enviable health status, a benefit of lifestyles that often included vigorous daily activity and abundant fresh produce, seafood, and starches. However, influences from the West have negatively impacted the health of many Native Hawaiians and Pacific Islanders. Among these harmful influences are sedentary daily routines, processed foods, and as an extreme example, the effects of thermonuclear weapons testing. Once considered a model of good health, some groups of Native Hawaiians and Pacific Islanders now represent some of the highest instances of general health disparate rates in the nation.^4,5

Changes in diet and exercise are among the obvious causes for declines in Native Hawaiian and Pacific Islander health but there are other less recognized factors that have been acquired during the process of acculturation. The majority of Native Hawaiians and Pacific Islanders in the United States have not had the educational opportunities or training to make the transition from a communal, agricultural, noncompetitive, and nontechnological way of life to an independent, urban, competitive, and highly industrialized society.⁶ As a result, Native Hawaiians and Pacific Islanders face significant socioeconomic disparities that have a direct impact on their health. For example, almost 18% of Native Hawaiians and Pacific Islanders live below the poverty threshold compared with about 12% in the general population, which could explain why Native Hawaiian and Pacific Islanders are more likely to be uninsured and more likely to be on Medicaid than are Asians and non-Hispanic Whites. ^7,8

In recent years, a number of health surveys and research studies have begun to profile the troubling health status of various Native Hawaiian and Pacific Islander groups. Although most of these studies have been small in scale, they highlight the disproportionate effects of serious illnesses on different segments of this population. For example, a report published by the Hawaii Department of Health found that Native Hawaiians have the highest mortality rate from diabetes than does any other group in the state. Furthermore, Hawaii has a higher incidence and prevalence rate of patients with end-stage renal disease on kidney dialysis when compared with the national average, and almost 60% of patients receiving kidney dialysis for end-stage renal disease have a primary diagnosis of diabetes.⁹ Other researchers have discovered segments of the Native Hawaiian and Pacific Islander population that are disproportionately affected by other conditions and illnesses including cancer, heart disease, substance abuse, infant mortality, and tuberculosis. Additionally, the Centers for Disease Control and Prevention reports that Native Hawaiians and other Pacific Islanders have the second highest rate of diagnoses of HIV infection and the second shortest AIDS survival rate of all Americans.¹⁰

Large minority groups in the United States have benefited from comprehensive community health surveys but there has never been such a survey of Native Hawaiian and Pacific Islander health. Baseline health data for these groups are extremely limited, and as a result, public health programs fall short of addressing the health needs of persons living under the Native Hawaiian and Pacific Islander umbrella. As mentioned earlier, federal agencies and other researchers have been collecting and reporting data on Asian Americans, Native Hawaiians, and Pacific Islanders as a heterogeneous group, which has mischaracterized the health status of the latter two groups.

Many Native Hawaiian and Pacific Islanders have distinct health problems that are dangerously masked when they are aggregated with other larger groups. For instance, Asian American adults are 50% less likely to die from heart disease than are non-Hispanic White adults (6.8% versus 11.7%, respectively), but Native Hawaiian and Pacific Islanders are 40% more likely to be diagnosed with heart disease than are Non-Hispanic Whites (16.6% versus 11.7%).¹¹ In Hawaii, numerous disparities have been discovered between Native Hawaiian and other Hawaiian residents, including that Native Hawaiians are 2.5 times more likely to be diagnosed with diabetes than non-Hispanic White Hawaiians, and that infant mortality among Native Hawaiians was almost 60% higher than among White Hawaiians.¹² In addition to Native Hawaiians and Pacific Islanders suffering inaccurate portrayals of their health status, researchers have found that official cause of death estimates for Native Hawaiians and Pacific Islanders are probably inaccurate because the race listed on death certificates for Asian American, Native Hawaiian, and Pacific Islander populations is often misclassified.¹³

The picture that has emerged of Native Hawaiian and Pacific Islander health is like a puzzle with only a few of its pieces in place. To adequately assess and respond to the full spectrum of Native Hawaiian and Pacific Islander health needs, researchers and advocates are calling for a number of changes—most importantly, the universal implementation of a key federal requirement to disaggregate the collection and reporting of Asian American, Native Hawaiian, and Pacific Islander data.

The Plan for Parity: Key Strategies for Eliminating Native Hawaiian and Pacific Islander Health Disparities

In recent years, local community-based organizations working with Native Hawaiian and Pacific Islander populations have conducted community outreaches, town hall meetings, and conferences throughout the United States to determine the needs of Native Hawaiians and Pacific Islanders as voiced by its members, chiefs, churches, business owners, and professionals. The following strategies have been summarized to address these needs:

• Facilitate Native Hawaiian and Pacific Islander baseline data and data reporting by local, state, and federal agencies, and epidemiological profiles on the health of Native Hawaiians and Pacific Islanders disaggregated in accordance with OMB Directive 15 requirements. The use of the “Asian and Pacific Islander” ethnic identifier is no longer acceptable.

• Strengthen and ensure inclusion of the voice of Native Hawaiians and Pacific Islanders in social development policies and programs that affect their lives at the federal, state, and local levels.

• Empower urban Native Hawaiian and Pacific Islander communities to develop their organizational and management capacity to operate community-based and faith-based program delivery systems and services in the high-need areas of health, education, economic development, and language and cultural preservation.

• Train and promote additional Native Hawaiian and Pacific Islander professionals in the areas of health, education, economic development, policy implementation, law, business, and other areas lacking Native Hawaiian and Pacific Islander representation.

• Strengthen advocacy and awareness of Native Hawaiians and Pacific Islanders among the Department of Health and Human Services, Department of the Interior, Department of Education, Department of Housing and Urban Development, Department of Commerce, and other federal agencies, including the hiring of Native Hawaiians and Pacific Islanders and the development of internships within those respective departments.

• Increase awareness and support for the unmet health care needs of Pacific Islanders on the following issues: (1) immigration status, as accessing health care is problematic as immigration status is not clear for individuals from the US Territories, Freely Associated States, and various Pacific Island countries; (2) language barriers, including needed translation services and translation of health materials into Native Hawaiian and Pacific Islander languages, such as Chuukese, Marshallese, Samoan, and Tongan; and (3) cultural barriers, as mainstream health care does not include or incorporate Native Hawaiian and Pacific Islander culture or cultural norms.⁶

EVERYONE COUNTS

Among the many gains made from the civil rights movement of the mid-twentieth century was an improved approach to collecting and reporting federal data so that the government could more accurately quantify America's diversity. By the mid-1970s, the Office of Management and Budget (OMB) instituted an important system for documenting racial data with Statistical Policy Directive Number 15 (hereafter referred to as Directive 15). This directive set for the first time a benchmark measure for race and ethnicity data collection that all federal agencies were required to follow. Five categories of race and ethnicity reporting were created: American Indian or Alaska Native, Asian or Pacific Islander, Black, Hispanic, and White. Following the directive's issuance, the 1980 Census was the first to count populations based on these categories.

During the planning process for Directive 15, Asian American advocates lobbied for their own category and most felt that it was mutually beneficial to be as inclusive as possible since in many communities Native Hawaiians, Pacific Islanders, and Asian Americans had lived and worked together for many years in solidarity. However, from the start there were concerns from some Native Hawaiian and Pacific Islander groups and others that such a broad category would fail to give adequate voice to subgroups within it.

Beginning in 1994, a formal review process of the original OMB directive highlighted the fact that multiple-race/ethnicity categories were not reflected in the data. During this time strong arguments were also made to recognize the special situation of Native Hawaiians as indigenous persons. In 1997, the OMB issued a revision that did not resolve the issue of counting those with multirace identities but did recognize the dangers of aggregating large data sets on Asian Americans with much smaller data sets on different segments of the Pacific Islander population. As a result, the OMB revised its previous Asian and Pacific Islander category by creating two new categories: “Asian” and “Native Hawaiian and Other Pacific Islander.” The revision also included a requirement that all federal agencies implement these revised standards in their collection, analysis, and reporting of data by January 1, 2003.

Compliance with the OMB's 2003 implementation deadline was mixed. After years of successful advocacy for an equitable revision in the directive, Native Hawaiian and Pacific Islander groups found the need to also become public health watchdogs. Advocates worked behind the scenes and at public meetings to ensure that agencies followed the OMB's new directive. In September 2003, the chair of the National Committee on Vital Health Statistics, John Lumpkin, MD, wrote to then Secretary of Health and Human Services Tommy Thompson, saying:

The single most compelling and recurrent request…is for the collection and analysis of health data on subgroups of specific racial and ethnic minorities, especially those concentrated in geographically distinct areas. These data are urgently needed to adequately monitor the health status and health care quality of the diverse US population. Those who provided testimony…Native Hawaiians and Pacific Islanders indicated that the lack of quantitative data both hampered their planning and delivery of health care in their communities, and put them at serious disadvantage in their attempts to compete for state and federal funding.¹⁴

More than seven years after the OMB's deadline, many agencies have made the switch to collecting separate data sets for Asian American, Native Hawaiian, and Pacific Islander populations, but the OMB's directive has not been universally implemented across federal agencies. That could soon change, however. Never before has there been a larger or more vocal coalition of Native Hawaiian and Pacific Islander advocacy groups working to ensure that the OMB's directive is honored. On national, state, and local levels, these groups have begun mounting pressure on the remaining researchers and government agencies that have failed to implement Directive 15 so that everyone does, indeed, count.

In addition to the campaign to ensure compliance with Directive 15, Native Hawaiian and Pacific Islander advocates, public policymakers, and researchers are employing other strategies to improve what is known about the health of their constituents and what can be done to address and end disparities. A number of national conferences and summits focusing on the health of Native Hawaiians and Pacific Islanders have convened in recent years and with each successive one, a more focused approach to defining Native Hawaiian and Pacific Islander health emerges.

Likewise, there have been notable efforts among legislators to end Native Hawaiian and Pacific Islander health disparities. The Congressional Pacific Islands Delegation has mobilized policymakers, researchers, and advocates to support federal legislation that would ensure comprehensive baseline data on Native Hawaiian and Pacific Islander health,¹⁵ achieve equity in Medicaid funding for the Pacific Island jurisdictions,¹⁶ and provide the means for a strengthened Native Hawaiian and Pacific Islander workforce.¹⁷ A movement has evolved that aims to end Native Hawaiian and Pacific Islander health disparities and it is gaining traction.

Looking back on that Saturday Night Live skit featuring “The Rock” last year, Ivoni Nash of the National Tongan American Society was also struck by the power “The Rock Obama” gave those reluctant senators when he assured them that they all had a voice in health care reform. According to Nash,

We still have a long way to go but in my years of working on this issue, I finally hear Pacific Islanders’ voices at the table in more and more influential health care debates. Raising our voices has raised awareness of the health disparities that went unnoticed for too long. Now it's time to raise the health status of our many communities through better research, better funding and better health care that meets the needs of Native Hawaiians and Pacific Islanders. Like “The Rock Obama,” we won't take no for an answer.