Island Nation, US Territory and Contested Space: Territorial Status As a Social Determinant of Indigenous Health in Guam

Abstract

The United Nations and International Federation of Social Work affirm the right of all people to determine their political status, preserve their environments and pursue endeavours for well-being. This article focuses on CHamoru, Guam’s Indigenous people, and examines distal social determinants of health (SDOH) in the contested spaces of US territorial status and non-self-determining Indigenous nationhood. Published multi-disciplinary literature identified ways in which territorial status functions as an SDOH unique to non-self-determining Pacific Island nations. Indicated is the use of structural approaches that address mechanisms of US power and control, including economic policies that ‘defacto’ promote coca-colonisation and non-communicable diseases risk. Critical race theory centres race, colonisation and subversive narratives. In line with fourth-generation SDOH action-oriented research, we posit a CHamoru critical race theory model that weaves Indigenous, social work and public health perspectives. Lack of community input is a limitation of the current research. To assure relevance, the model will be vetted through community discussions. Our discussion guide may be tailored for other Indigenous communities. Social workers may play a meaningful role in promoting health equity through participatory action-oriented, cultural–political social work that upholds Indigenous self-determination and survivance in contested spaces.

I fuetsan i nanan nanahu

In acknowledgement of Indigenous ways of knowing, this article begins in the way many CHamoru pedagogies begin—with a story that speaks to past and present lessons. In this opening story, the first author remembers the strength of her grandmother (I fuetsan i nanan nanahu) at a critical time.

My Nana (grandmother) worked hard in the family home and raised 12 children with my Tata (grandfather). She outlived Tata, but like many CHamoru, she battled diabetes. Nana was seen at the nearby military hospital and was prescribed insulin. But throughout her life she also sought care from yo’åmte (traditional healers) who treated her with herbs and roots. As diabetes advanced, doctors recommended partial amputation of her foot as a life-saving measure. She had several hospitalizations but eventually opted to remain home where family members took turns caring for her. The decision about her foot was a difficult one. In the process of decision-making—we shared our deepest feelings about Nana, about family. Nana opted against amputation and explained that she wanted her body to be whole when she died, which according to her faith, allowed her to go to a better place. Family members respected Nana’s decision. She died peacefully in her home. In this deeply personal space, I was compelled to reflect on CHamoru people’s strengths, how we live, how we die, and ultimately, who determines the choice.

This article is developmental and aims to: (i) increase understanding of upstream or distal determinants of non-communicable disease (NCD) disparities in Guahan (Guam) and (ii) lay a foundation for articulating a CHamoru critical race theory (CRT) to address social determinants of health (SDOH).

Indigenous culture

Languaging is a vital step in de-colonisation and survivance or cultural expression of active presence in the lived experience of contested spaces (Vizenor, 2008). Thus, Indigenous terms like ‘Guahan’ are used in lieu of ‘Guam’, except when referring to its political status as the US Territory of Guam. The Indigenous people are named as ‘CHamoru’ in lieu of ‘Chamorro’ with the former more closely reflecting native language and pronunciation.

CHamoru are the Indigenous people of Guahan whose ancestors settled the Mariana Islands some 3,500 years ago (Vilar et al., 2013). In the native language, CHamoru are referred to as ‘taotao tano’ (‘people of the land’), indicating a deep and spiritual connection to the land and ocean that sustains all life. Prior to Spanish colonisation in the sixteenth century, CHamoru were a sovereign people residing in permanent dwellings with an established subsistence economy and a social system organised through matrilineal kinship and clans (Cunningham, 1992). CHamoru culture and ways of living were communal and rooted in cooperation. Daily life was mediated via a key collectivist ethic known as inafa’maolek (interdependence, to restore harmony and order, a responsibility to others and to the land) with values that included chenchule’ (reciprocity in all relations), inagofli’e’ (the act of caring, seeing the good in others), mamåhlao (a sense of shame and humility that guides proper behaviour) and inarespeta (mutual respect) for all that lives, with an emphases on honouring ancestral wisdoms and caring for manaina (elders) (Underwood, 1978; Cunningham, 1992). Despite Western colonisation, these values remain core to CHamoru culture in contemporary times.

Traditionally, CHamoru believe that illness is not merely the absence of disease but is further determined by taotaomo’na (ancestral spirits, the people who have become before). Well-being is maintained through use of suruhånas and suruhånus (female and male traditional healers), now more commonly referred to as yo’åmte. These traditional healers have skills that are carefully transmitted across generations. In contemporary times, yo’åmte utilise medicinal plants, herbal preparations, ointments and massage to heal illness and promote good health (Lizama, 2011).

Colonialism then and now

Guahan lies in the western Pacific Basin and is the southernmost island of the Mariana Islands chain. It was ruled by Spain for approximately 300 years and ceded to the USA in 1898 under the Treaty of Paris (Hattori, 1998). US Congress has held plenary power, that is, complete administrative power without limitations, since the nineteenth century with interruption only during the Japanese Occupation in World War II. Passage of the 1950 Guam Organic Act solidified Guahan as an unincorporated US territory. As with its other possessions, the USA maintains plenary power and designates administrative oversight to its Department of Interior, Office of Insular Affairs. Under the Organic Act, US citizens living in the territories are accorded selected constitutional rights. For example, persons born on Guahan are granted US birthright citizenship but are not able to vote for president. They may elect a representative to the US Congress, but their delegate lacks voting privileges. The US Census Bureau (2010) estimates a population of about 160,000 persons, with CHamoru comprising the largest segment of the population at 37 per cent.

US territory of Guam as borderland

Guahan is a significant US borderland. Its proximity to the Philippines, Japan, Korean Peninsula and China renders it of essential value to the US military. Because of its designated strategic location, the territory functions as a launching pad for US military action and a buffering zone for protection of the 50 states. Military officials commonly refer to Guahan as ‘the tip of the spear’ or the ‘unsinkable aircraft carrier’ (Natividad and Kirk, 2010; Evans, 2017). Designation as a US military stronghold is not without consequence to CHamoru. In World War II, CHamoru endured atrocities of internment, rape and execution by the Japanese. More recently, Guahan lives under the spectre of nuclear attack from North Korea.

Non-self-governance, CHamoru self-determination and contested space

Guahan’s territorial status and positioning as a primary US military outpost is a contested space. It is one of the 17 remaining countries on the United Nations (UN) list of non-self-governing nations (United Nations, 2009). This is predicated on the UN Declaration on the Granting of Independence to Colonial Countries and Peoples that recognise the right of colonised peoples to self-determine their political status and freely pursue economic, social and cultural development (United Nations, 1960). In recognition of this right, Guam Public Law 23–147 (1997) mandates the appointment of a Commission on Decolonisation to implement and exercise CHamoru self-determination. At present, the commission has created three task forces—Statehood, Free Association and Independence—to provide public education on each self-determination status. Ultimately, the Commission will hold a plebiscite on Guahan’s political status.

Historic colonisation and US territorial status have significantly impacted CHamoru health. Notably, the Indigenous subsistence economy has shifted to that of a cash economy. Global enterprise and modernisation have resulted in more sedentary lifestyles, diets high in sugar and salt and reliance on imported foods—all of which have resulted in increased NCDs (Mummert et al., 2013).

Non-communicable health disparities

In 2010, severe disparities in NCDs across the US Affiliated Pacific Islands prompted regional health leaders to declare a state of emergency (Durand, 2013). In response, Guahan convened a Non-Communicable Disease Consortium comprised of government organisations and non-profit representatives from the fields of cardiovascular disease, diabetes and cancer.

NCDs are the leading cause of death on Guahan and contribute to long-term disability and decreased quality of life. Heart disease, cancer, stroke and diabetes are among the most common of these to impact morbidity and mortality. Combined they account for 58.9 per cent of deaths on Guahan and represent significant health disparities among residents (Mummert et al., 2013). Epidemiological data indicate in 2010 that Guahan’s age-adjusted heart disease mortality (254.9) was higher than the USA (179.1) by 42.3 per cent and cerebrovascular death rate (71.6) was higher than the USA (39.1) by 83 per cent. The diabetes death rate (37.1) was almost 80 per cent higher than the US rate (20.8) (Mummert et al., 2013).

Overall cancer mortality (133.6) is lower than the US rate (172.8) by approximately 20 per cent, but there are two factors crucial to consider: (i) cancer incidence and mortality for primary cancers (breast, prostate and colorectal) continue to rise in Guahan while trends in the USA reveal a decline in these cancers, and (ii) when compared with United States, CHamoru in Guahan have higher mortality rates due to lung, prostate, colorectal, liver, stomach, mouth and nasopharyngeal cancers (David et al., 2015).

Healthcare challenges

Federal regulations exert significant influence on Guahan’s health system and infrastructure. Approximately 26 per cent of the population is enrolled in Medicaid (Centers for Medicare and Medicaid Services, 2016). Medicare and Medicaid payments account for approximately 51 per cent of patient revenues at Guam Memorial Hospital Authority (GMHA), the sole public hospital on the island (Guam Office of Public Accountability, 2017). Up until the opening of a new private hospital three years ago, GMHA was the only hospital available to local, non-military residents and is mandated to serve all who seek care regardless of their ability to pay. Due to high demand for services and accrued debt, GMHA has struggled to maintain operations and retain US accreditation. Extensive shortfalls include physician shortages due to low salaries, repairs to medical equipment and insufficient bed capacity at 0.9 beds per 1,000 population (Office of the Governor of Guam, 2012). Technology for medical care on island is available albeit limited. Diagnostic laboratories perform at minimum capacity, necessitating specimens to be sent off-island for analysis, risking loss of specimens and delayed diagnosis. Due to lack of specialists and comprehensive treatment, residents may seek off-island medical and surgical care if they are able to afford out-of-pocket costs and have family caregiver support (Guam Comprehensive Cancer Control Coalition, 2007).

Social determinants of health, NCD and social work perspectives

Structural barriers contribute to the perpetuation of inequalities, discrimination, exploitation and oppression (International Federation of Social Work, 2014).

In a seminal publication on the role of social work in addressing health disparities, Gehlert et al. (2008) call attention to the impact of upstream socioeconomic and political factors on the ‘not so gentle’ disparate health outcomes affecting marginalised persons, families and communities. Multi-systemic interventions that address both down- and upstream factors are recommended. The Guam Non-Communicable Disease Strategic Plan 2014–2018 (Mummert et al., 2013) similarly identifies down- and upstream determinants to NCD disparities.

Downstream interventions are well-detailed and focus on provision of accessible, culturally appropriate health promotion, early detection screening and other preventative services. Globalisation and other systemic factors are identified as upstream determinants, but these require additional detail if they are to be used in systems-oriented interventions.

Other published social work scholarship makes a case for colonialism/neo-colonialism (e.g. territorial status) as an upstream social determinant of health, with relevance to Indigenous health (Dames, 1992; Czyzewski, 2011; Dames et al., 2013). Czyzewski (2011) argues that colonialism at its nexus with Indigeneity operates as an SDOH through the mechanisms of inter-generational trauma, on-going marginalisation and the failure of colonising or settler entities to address the guiding ideologies that impact the disproportionate burden of disease on Indigenous people. Notably, Dames et al. (1992, 2013) extend a similar perspective to the Guahan context. Dames (1992) states the ‘need for the US government to reconsider its characteristic denial that it has colonies’ and ‘to recognise the inherent right to self-determine freely their political status, support and encourage the political status process’ (p. 342). Strongly recommended is the need to address colonial status as an upstream SDOH, with concomitant foci on policies and practices that advance elimination of colonial relations of inequality. Processes that accelerate transfer of power demonstrate sustained commitment by the settler status quo, and meaningfully involve participation with diverse sectors of the Indigenous community are endorsed (Czyzewski, 2011). Such perspectives align with that of structural social work (Mullaly and Dupré, 2018; Weinberg, 2008).

Structural social work

The uniqueness of social work research and theories is that they are applied and emancipatory (International Federation of Social Work, 2014).

Structural social work enunciates a critical perspective concerned with the broad socio-economic and political dimensions of society, especially the effects of capitalism and its impact on fostering racism, ethno- and geo-centrism and other unequal social patterns that maintain power and privilege. Social work ethics of social justice and self-determination compel practitioners to inhabit a progressive stance within social work agencies and resource-constrained communities, with attention to reflection of personal experiences embedded within larger social and political structures. Such a perspective is valuable in understanding issues of contested space. However, navigating through such issues in practice may be considerably more difficult (Mullaly and Dupré, 2018). Recent publications suggest that use of methods grounded in CRT may be a promising means for addressing structural determinants that perpetuate health and other disparities (Ford and Airhihenbuwa, 2010a,b; Wright and Balutski, 2016; Nakaoka and Ortiz, 2018; Salis Reyes, 2018). Public Health CRT was specifically developed to address SDOH (Ford and Airhihenbuwa, 2010a,b) and emphasises action-oriented health research with marginalised groups.

CRT across Indigeneity, social work and public health

CRT, originally situated in legal theory, encourages anti-racist praxis by centring race, oppression and power in applied disciplines such as education, social work and public health. A CRT approach assists analysis on the impact of structural racism on health and well-being. Thus, a CHamoru CRT model could facilitate links between SDOH and territorial status. The centrality of race as social construction, the importance of intersectionality, use of narrative, critique of neo-liberalism and commitment to social justice are key tenets of CRT. CRT is action-oriented and focuses on identifying structural interventions to produce more equitable outcomes. Delgado and Stefancic (2012) explain ‘It [CRT] not only tries to understand our social situation, but to … transform it for the better’ (p. 3). In analysing political systems, the importance of history ‘from the bottom’, is highlighted as a valid and crucial methodology that stress narrative and storytelling. The fundamental importance of narrative and storytelling are a key feature aligning CRT with Indigenous perspectives and methodologies.

As Indigenous Pacific Islanders, CHamoru benefit most from CRT models developed by/with Native Hawaiians hereafter known as Kanaka Maoli (Salis Reyes, 2018) or Kanaka Ōiwi (Wright and Balutski, 2016) CRT. Salis Reyes (2018) calls for a recognition of the endemic nature of colonialism, as well as acknowledgement of the multiple, intersectional identities of Kanaka Maoli, their values and their strengths. Through mo’olelo (stories, oral history), Kanaka Maoli carry on the storytelling and counter-storytelling tradition of CRT to re-centre history and reclaim power through narrative. Of special note is the concept of survivance (Vizenor, 2008). Kanaka Maoli have many cultural strengths, with capacity to effect ongoing progressive change. In their models, Wright and Balutski (2016) and Salis Reyes (2018) suggest key themes leading to decolonisation for/with Native Hawaiian communities. These models feature ola pono (wholistic health), aloha ‘aina (loving care for land and all that lives) and respect for ancestral wisdoms as transmitted through ‘olelo no’eau (proverbs and poetical sayings) and mo’olelo.

CRT has been adapted by social work, public health and other applied disciplines. Ortiz and Jani (2010) describe the need for CRT to push beyond multiculturalism. Abrams and Moio (2009) also suggest CRT can assist practitioners toward a framework that better recognises institutional and structural racism. Finally, Nakaoka and Ortiz (2018) investigate racial and gender microaggressions and encourage the adoption of CRT pedagogy to generate increased attention to structural forces that impact vulnerable populations. Pointing out the various ways in which social work is complicit in racial oppression, the authors suggest that Master of Social Work programmes adopt pedagogy that utilises CRT as a method to transform social work praxis.

Ford and Airhihenbuwa (2010a,b) enunciate public health CRT as antiracism praxis thus acknowledging racial/ethnic health disparities. These scholar/practitioners argue that CRT is instructive in examining SDOH because it focuses on structural oppression and considers socioeconomic and political constructions relevant to citizen participation, territorial status and other marginalised statuses.

Social Work and Public Health researchers and practitioners are well suited to work towards the eradication of health disparities in Indigenous communities. Without awareness of the impact of territoriality, however, their actions may be misguided. CHamoru CRT, then, may provide a starting point for discussions that both focuses on colonisation/territorialism and privileges the voices and experiences of CHamoru. Table 1 displays key CRT principles—disciplinary and Indigenous—specific tailoring of CRT and developmental questions for tailoring CRT to the CHamoru context.

Table 1.

CRT tailored models.

CRT Key concepts	Public Health CRT	Social Work CRT	Kanaka ‘Oiwi CRT (Native Hawaiian)	CHamoru CRT developmental questions
Racism and oppression are normalised and over time disadvantage certain groups	Recognise how individual prejudice and systematic discrimination are made ‘ordinary’. Practice inclusion. Commit to distributive justice in health	Focus practice and research with those living at margins of mainstream society	Seek to understand history of colonisation, collective trauma, and intergenerational marginalisation	How has colonisation impacted the personal and collective health of CHamoru? How have CHamoru been racialised in the context of US territorial ism? In what ways has CHamoru self-determination of health and healing been suppressed? Supported?
Critical Consciousness involves critique of neo-liberal system or ideologies and policies that value free market competition	Increase awareness of ‘race’ as socially constructed status and how it maintains privilege of status quo and health inequalities	Increase awareness of race/ethnicity as socially constructed status and how it functions across micro. mezzo and macro systems	Increase awareness of history of resistance, as well as ways in which negative stereotypes, micro aggressions and policies support economic interests of others	What ways of knowing are important for survivance in Guahan? How is coca-coIonisation relevant to Guahan? How does territorial status affect health? NCD prevalence?
Validate experiential knowledge. Personal narratives are important to understanding	Value and encourage local experience as viable way of knowing	Empower subjugated perspectives, strengths and voice of those with marginalised statuses	Appreciate ‘olelo no’eau and Mo’olelo. Seek to understand kaona. Attend to values of Ola Pono as influenced by lokahi, aloha ‘aina and malama ‘aina	What approaches best ensure identification and promotion of ancestral wisdoms, traditional culture and contemporary ways of knowing? How might these approaches be used in NCD prevention and control? How does the collective narrative of CHamoru contribute to their health and wellness?
Take action by addressing law and policy for social justice outcomes	Focus on action-oriented health research with marginalised groups	Practice inclusivity. Articulate and address intersectionality of diverse factors that race alone cannot explain. Commit to self-determination and justice for all	Promote strategies for de-colonisation and survivance.Extend scholarship that focuses on native needs and perspectives. Promote inter-generational discussions of new ideas in relation to traditional knowledge	What are ways for ensuring discussion inclusive of CHamoru ways of knowing in contested spaces of territorial status? Of NCD disparities? How might inter-generational, community-wide participation be encouraged? How can the process of CHamoru self-determination be central to health policies on Guahan?

Discussion

Territorial status as a social determinant of health

Social determinants have referred to both the features of and pathways by which societal conditions affect health outcomes (De Maio et al., 2013) and have been characterised as the upstream or distal factors that shape or determine individual and group behaviour. As such, advocates for the study of social determinants have argued for a broadened focus and interdisciplinary approach that transcends the impact of healthcare institutions and the medical model of individual health (Braveman et al., 2011; Palafox and Hixon, 2011; De Maio et al., 2013). While examination of social determinants more commonly include income, education, insurance status and racism (Marmot, 2005; Braveman et al., 2011; De Maio et al., 2013), significantly less acknowledged are those that impede health and health equity in the US territories (Stayman, 2009; Ka’opua et al., 2010, 2011; Palafox and Hixon, 2011; Rodriguez-Vila et al., 2014). Pacific scholars describe social determinants of health in the USA. Affiliated Pacific Islands from a more structural perspective such as US thermonuclear weapons testing, cultural disruption and climate change that give attention to colonisation, US federal policies and external influences on Indigenous Pacific Islander ways of life (Palafox and Hixon, 2011).

Political challenges

The question of how territorial status impacts health on Guahan is multifaceted. Guahan is subject to US federal health laws and directives developed primarily for implementation in USA and with little or no consideration of Pacific Island social systems and resources (Stayman, 2009; Palafox and Hixon, 2011; Rodriguez-Vila et al., 2014). Thus, laws and directives may be difficult for territories to implement. While this conundrum is noted by the US Insular Affairs, the territories remain largely unable to influence the policies that directly affect their health and well-being. When local government agencies, including health departments, fail to comply with mandated US regulations, ‘the US federal government assumes control by appointing federal receivers, who then temporarily take charge of local governments’ (Dames et al., 2013, p. 192). For instance, GMHA was accredited in 2010 after almost thirty years of unsuccessful attempts but has failed to retain its accreditation in 2018. It is currently at risk of losing Medicare funding and falling under federal receivership, prompting an urgent call from hospital authorities for more emergency government funding.

As it stands, federal policy issues concerning the territories are decided in the absence of any federal guidance or consideration of the effects on those territories. Former deputy assistant director of the Interior for Territorial and International Affairs, Allen Stayman, puts it succinctly, ‘These islands remain in a limbo neither fully domestic nor foreign—a condition that complicates the development of solutions’ (Tulafono, 2012). Territorial status, then, creates structural barriers to self-determination and resource acquisition and empowerment, setting up a patronage relationship wherein the US government controls the systems that address health disparities.

Socioeconomic challenges

Poverty is the single most robust social determinant of health and presents a cascade of urgent, yet highly complex challenges in developing nations (World Health Organization, 2018). The poverty rate on Guahan is nearly twice as high than the overall US rate (23.0 per cent versus 14.8 per cent) and effects a heavy reliance on need-based federal programmes for fundamental services (US Government Accountability Office, 2009). Compared to the United States, territories are assessed a lower federal insurance reimbursement rate that attempts to account for the disparate poverty levels between the US territories and states (Medicaid and CHIP Payment and Access Commission, 2017). Guahan and other US territories are required to contribute a non-federal share to access these funds. This has been a persistent challenge to territorial economies struggling to survive and has resulted in disparities in health care services (Stayman, 2009; Rodriguez-Vila et al., 2014).

Gross Domestic Product assesses a region’s economic health and standard of living. Guahan’s net imports are greater than its exports for every year from 2007 to 2016 thus signalling an economy in trouble (Osman, 2012). US grant assistance has offset this negative trade balance. However, such short-term assistance is insufficient to address long-term, structurally based deficits. Long-term efforts for economic revitalisation and attention to the impact of US policies on Guahan are needed to address the problem. Indeed, public debt has doubled from almost 1 billion to 2.5 billion from 2005 to 2015 and most of this debt is used to comply with federal requirements and court orders (US Government Accountability Office, 2017). Currently, tourism and the military are Guahan’s major sources of income. While important to Guahan’s economy, these income sources exacerbate issues of contented space and challenge the island’s sustainability and its impact on local residents (Crisostomo, 2013; Dames et al., 2013; Letman, 2016).

Data challenges

Inadequate health data place Guahan and other US territories at profound disadvantage when competed against US entities with more developed research infrastructure (Ka’opua et al., 2011). Epidemiological evidence albeit improved on Guahan is minimal compared to US standards and still lacks a comprehensive and increased data-driven approach to NCD response (Durand, 2013; Mummert et al., 2013). When collected, territorial statistics are analysed as an aggregate with the USA (US Department of the Interior Office of Insular Affairs, 2008), masking health impact in these islands. Furthermore, health research in the territories is limited by an epidemiological transition in which scarce funds must be used to address both chronic and communicable diseases. Data tell quantifiable stories that influence public policies, laws and funding resources. The paucity of health data obscures the unique socioeconomic and health needs of these Indigenous and territorial residents.

Non-communicable disease

The NCD Consortium has identified risk factors as diet, tobacco use, alcohol consumption and lack of physical activity associated with changes in lifestyle (Mummert et al., 2013). Coca-colonisation (‘aka’ cocacolonisation) refers to dietary changes among peoples of the developing world, including emerging nation states in the Pacific Basin (Omran, 1971; Zimmet, 2000; Fan and Le’au, 2015). The phenomenon is understood to reflect the globalisation of US capitalism, its concomitant export of unhealthy foods and the lure of the American lifestyle on the dietary preferences and practices of ethnic minority and Indigenous people (Omran, 1971). Specifically, there is a shift from diets based on traditional sources to that of more highly processed American foods like the beverage Coca-Cola, tinned foods and sugar- and fat-laden confections (Omran, 1971; Zimmet, 2000). The growing epidemic of NCD (e.g. diabetes, cardiovascular disease, colorectal cancer) is associated with cocacolonisation. Conventional bio-medical approaches that target individual behavioural modification must be augmented by inter-disciplinary interventions that seek to reverse community norms and ultimately address the more distal SDOH that perpetuate health inequity (Zimmet, 2000).

Colonial impact on CHamoru health and self-determination

Throughout neo-colonial histories, Indigenous people have struggled to cope with and survive imported diseases. The impact of US colonisation on CHamoru health and wellness is documented by CHamoru historian Anne Hattori in Colonial Dis-Ease: US Navy Health Policies and the Chamorro on Guam, 1898–1941. After the Spanish-American war, the US Department of the Navy assumed administrative and governing authority over the island in both civil and military matters. In an examination of ‘medicine as a colonial force’, Hattori asserts that the US colonial health system by its punitive and isolationist nature intrinsically discouraged participation of many CHamoru because Western health practices often contradicted CHamoru values, beliefs and practices (Hattori, 2004, p. 56). For example, healing customs of yo’åmte (traditional healers) were largely ignored and the function of the pattera (midwife) was heavily regulated through licensing laws, testing and education requirements. Scientific approaches and health policies reflected neo-colonial attempts to control CHamoru through sanitation and hospitalisation, and to dismantle CHamoru healing practices considered antiquated and uncivilised (2004).

Colonial impact on CHamoru health is deeply multi-layered with historical trauma associated with the consequences of war, genocide, depopulation, loss of ancestral land, lack of political self-determination and the erosion of CHamoru language and cultural practices (Pier, 1998). The depth and breadth of colonisation—indeed, the roots of territorial status—must be explored in examination of Indigenous health and wellness. Czyzewski (2011) underlines this significance: ‘Colonialism is the guiding force that manipulated the historic, political, social and economic contexts shaping Indigenous/state/non-Indigenous relations and account for the public erasure of political and economic marginalisation, and racism today. These combined components shape the health of Indigenous peoples’ (p. 4). Figure 1 illustrates the multiple components of territorial status as social determinant of health.

Figure 1:

Territorial status as a determinant of health in Guahan.

The way forward: Developing nations, global health and contested spaces

Attention to the unique context of developing, small island nations like Guahan is essential to achieve the UN Millennium Developmental Goals (MDGs) on NCD (Kanade, 2016). For nearly six decades, the UN has recognised Guahan as a non-self-governing island nation and continues to affirm Guahan’s right to self-determine its political status, preserve its environment and pursue endeavours for well-being (United Nations, 1960; Kanade, 2016). In principle, the USA supports Guahan’s right to self-determine its political status while simultaneously promoting Guahan as an American site of advanced militarisation. Furthermore, despite support for NCD prevention and control, US neo-liberal policies tacitly support coca-colonisation, with Guahan used as a market for cola beverages and other food products associated with NCD risk (Zimmet, 2000; Fan and Le’au, 2015). Our examination of US Constitutional law, militarisation, neo-liberal economics, global capitalism and other SDOH reveal layered issues of contested space that converge within the grander context of US territorial status as a distal social determinant of health that impedes achievement of MDGs in Guahan. This finding extends the literature on colonialism/neo-colonialism as an SDOH of Indigenous health (Czyzewski, 2011) and may be relevant to more fully understand health inequities among Indigenous residents living in other territorial entities and/or living on ancestral lands that are contested spaces.

Thomas et al. (2011) provide a conceptual framework for understanding the progression of health disparities and SDOH research, and specifically identify the work of Ford and Airhihenbuwa in public health CRT (Ford and Airhihenbuwa, 2010a,b; Thomas et al., 2011). This framework identifies four generations of disparities research that generally are chronological in knowledge accretion. The four generations include: (i) understanding data trends; (ii) identifying drivers of disparate outcomes; (iii) identifying evidence-based solutions; and (iv) engaging in participatory, action-oriented research that utilises multi-systemic interventions and notably, includes macro-level interventions that address structural issues. Our current research is situated in this fourth generation of disparities research and importantly, extends public health CRT to the cultural, socio-economic and political context of CHamoru in Guahan.

Implications for social work

The International Federation of Social Work (2012) upholds global health equity as issues of human rights and social justice. Social workers have an important role in promoting health equity and are viewed as potential ‘game changers’ (progressive social change agents) with knowledge and skills that allow for working in contested spaces of local and global health praxis (Ife, 2001; International Federation of Social Workers, 2012; Dames et al., 2013). Ife (2001) argues that in the twenty-first century, global issues affect all aspects of social work and that international social work can no longer be marginalised as a specialisation within the profession. A human rights perspective is encouraged, with local and global applications that attend to social justice and self-determination. Social workers are called upon to promote the relevance of the profession in global health and leverage multi-systemic interventions.

Next steps for social work in Guahan

Our developmental efforts attempt to ‘weave’ strands of public health, social work and Indigenous Pacific Islander with Indigenous CHamoru perspectives. The CHamoru CRT was derived from public research, however, and has yet to be vetted for sociocultural relevance with diverse stakeholders from the CHamoru community. Therefore, use of the model as currently iterated is not recommended. Notwithstanding this limitation, the authors have articulated semi-structured questions for use in community discussions in Table 1. Inspired by the writings of Salis Reyes (2018) and Wright and Balutski (2016), we propose a collective and community process for advancing a CHamoru CRT model—with community stakeholders involved as ‘weavers’. Plans to convene initial discussions should involve intersections of the CHamoru community such as elders, yo’åmte, CHamoru grassroot organisations and representatives from the task forces on decolonisation, the NCD consortium, University of Guam (UOG) CHamoru studies, Department of Chamorro Affairs and the Kumision I Fino’ CHamoru yan I Fina’nå’guen I Historia yan I Lina’la’ I Taotao Tåno’ (Commission on Chamorro Language and the Teaching of the History and Culture of the Indigenous People of Guam). Social work educators at UOG—most of whom speak CHamoru—could utilise their practice wisdom as discussants or facilitators to foster critical analyses of structural issues in culturally respectful ways (Dames et al., 2013). These discussions, which may take the form of charettes (a public meeting to plan a design), storytelling (e.g. intergenerational narratives) or focus groups, can fully develop a CHamoru CRT model.

Conclusion

Health disparities and SDOH are pertinent to social welfare as issues of social justice and population survival. Addressing disparities can be further understood in the context of CRT, Indigenous rights and the effects of colonisation. As a consequence of colonisation, Indigenous peoples such as the CHamoru have experienced personal and political loss of Indigenous lands that are inextricably bound to kinship, livelihood and well-being. Global recognition of the historical grievances and rights of CHamoru is documented in the Declaration of the Rights of Indigenous Peoples, among which are the individual and collective rights to be recognised as distinct peoples entitled to full participation in all decisions affecting their lives, inclusive of health and health-related interventions in their communities (United Nations, 2008). Making these connections allow social work practitioners to better focus on interventions that explore self-determination, colonial status, structural realities and Indigenous narratives when addressing NCDs among CHamoru and other Indigenous peoples. Our CHamoru CRT developmental questions can serve as a base for community-led discussions on the relevance of this tool in addressing territorial status as a social determinant of health and may be tailored for other Indigenous communities.

To weave back to the story of a CHamoru grandmother’s strength in a time of great consequence, decisions of health and wellness must lie in Indigenous hands. We posit a developmental CHamoru CRT framework to examine the broader impact of territorial status on CHamoru health with the understanding that it is the Indigenous people and allied social workers who will carry this framework forward with an eye towards social justice, healthy equity and Indigenous rights.