He ‘A‘ali‘i Kū Makani Mai Au: Developing a Cultural Framework for Advancing COVID-19 Related, Community-informed Health Policies

Abstract

The Native Hawaiian and Pacific Islander community found itself on the front pages of national news when the COVID-19 pandemic struck the United States. By April 2020, the small, frequently overlooked community experienced the highest COVID-19 case rates in 5 states including Hawai‘i. In response, Native Hawaiian and Pacific Islander networks across the US were mobilized to address the crisis. In Hawai‘i, the Native Hawaiian Pacific Islander COVID-19 Response, Recovery, and Resilience Team was created. Framed by Indigenous Pacific based cultural values, protocols, and practices, the team consists of multiple committees that examine policy; testing, contract tracing, and isolation; communications; social supports and resources; and data and research. Inherent in this work are the shared core values of pono (righteousness, goodness), aloha (love, compassion), laulima (cooperation), and imua (moving forward with strength) as well as an ‘ohana/aiga (family)-based, kuleana (responsibility)-centric approach that acknowledges, honors, and values ‘ike kūpuna (ancestral knowledge). With the burden of not only COVID-19 disparities, but also chronic diseases and socioeconomic disparities that place Native Hawaiian and Pacific Islander communities at increased risk for adverse impacts from COVID-19, an effective response is critical. This article, authored by members of the Team's Policy Committee, discusses the development of a cultural framework that guides its advocacy efforts. The Policy Committee's work presents a cultural framework that grounds and guides their efforts for effectively promoting a strong voice in governmental and agency policies which would ultimately contribute to a healthy and thriving Native Hawaiian and Pacific Islander community.

Highlights

• COVID-19 highlighted NHPI health disparities.

• NHPI COVID-19 health disparities need culturally informed policy advocacy.

• Culturally relevant policy advocacy for NHPI incorporates Pacific core values.

• Pacific-focused framework enables effective NHPI policy advocacy.

He ‘a‘ali‘i kū makani mai au; ‘a‘ohe makani nana e kula‘i.

I am a wind-resting ‘a‘ali‘i; no gale can push me over.¹

(Meaning: “I can hold my own even in the face of difficulties.”)

Introduction

Voyaging across the 12.5 million square miles of the Pacific was common practice among Pacific people. Utilizing non-instrument navigation (wayfinding) required observation and Indigenous knowledge of the movements of the stars, moon, sun, as well as the ocean currents, winds, and other elements of nature. In order to survive the long ocean voyages on double hulled canoes, Pacific ancestors worked collaboratively and interdependently with each other and all the elements of nature. The shared core values of pono (righteousness, goodness), aloha (love, compassion), laulima (cooperation), and imua (moving forward with strength) enabled Indigenous peoples of the Pacific to survive and thrive. These core values are the basis for an ‘ohana/aiga (family)-based, kuleana (responsibility)-centric approach to policy advocacy and decision making that acknowledges, honors, and values ‘ike kūpuna (ancestral knowledge) as a sustaining force.

Like the a‘ali‘i plant, Native Hawaiians and Pacific Islanders (NHPI) have consistently proven their resilience when facing adversity. Over the centuries, Pacific communities have faced formidable adversaries. Most have come from distant lands, including population-decimating infectious diseases, world wars, and the devastating impacts of colonization with its associated upending of policies and social structures and values that directly contrasted the ancestral values of collectivism, communal subsistence, caretaking of sacred environment, and mutual respect.^2,3 The adverse results of these exposures and conflicts have resulted in lived experiences of racism and prejudice; loss of land, sovereignty, and culture; as well as disparate poverty, poor physical and mental health, food and housing insecurity, and underperforming school systems which negatively impact employment opportunities for NHPI. There have been insufficient relevant and responsive policy and resource interventions to address these inequities and the associated structural racism. As a result, health disparities across a multitude of chronic conditions and inequities in the social determinants of health (SDOH) have continued to worsen for NHPI for many generations with specific data emerging in the past 5 decades.^2–6

The latest adversary to be imported onto Pacific shores is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).⁷ First detected in Wuhan, China in Fall 2019, the emerging disease pattern caused by this virus prompted the Chinese government on December 31, 2019 to inform their US counterparts and the World Health Organization (WHO).^8,9 Although Chinese scientists were able to isolate the virus a few days later, the viral outbreak was not contained and foreign cases were soon detected in Korea, Japan, and Thailand.^10,11 This outbreak led the WHO to declare a “Public Health Emergency of International Concern.”¹² Unfortunately, the virus was already present in the US.¹³ On January 20, 2020, a laboratory confirmed the first case of SARS-CoV-2 caused disease, now called COVID-19, in the state of Washington.^14,15 By mid-March, the virus had spread to all 50 states.¹⁶ COVID-19 was now no longer an outbreak; it was a pandemic.¹⁷

As COVID-19 spread across the US, it became apparent that minority communities were suffering disproportionally from COVID-19 infections.^18–20 The NHPI community, whose small population is rarely included in national diversity and inclusion efforts, in terms of policy inclusion or otherwise, now found its community similarly impacted. By early April, NHPI communities were experiencing the highest age-adjusted death rates of all racial/ethnic groups in the state of Washington.²¹ Seattle's King County reported NHPI had the highest case rates at 189.5/100 000.²² By mid-April, 5 states reported NHPI cases were greater than the percentages of NHPI in their respective populations (I. Bau, JD, email communication, April 21, 2020). This included Hawai‘i, where NHPI make-up 26.7% of the state's population.^23,24 Stories about NHPI communities suffering from disproportionately higher case rates of COVID-19 than any other minority group in several US states and counties began appearing in media outlets.^25,26

Since the first COVID-19 case was diagnosed in Hawai‘i in early March 2020, the state has been collecting racial/ethnicity data on COVID-19 cases. On June 26, 2020, Hawai‘i became the first state to publicly disaggregate NH and PI data.²⁷ Although PIs make up about 4% of the state's population, they accounted for 23% of the COVID-19 cases in the June 26, 2020 cumulative incidence data set. The next most-impacted group, comprising 16% of the state population, were Filipinos, with 21% of the cases.²⁷ In Hawai‘i, the data showing that the PI population bore the brunt of COVID-19 persisted throughout 2020.²³

Nationally, NHPIs continued to be impacted adversely throughout the summer of 2020 and by mid-August, NHPIs had the highest case rates in 9 US states and the highest death rates in 6 states.^28,29 Remarkably, many states were not reporting race data, even fewer were reporting disaggregated NHPI data in their COVID-19 reports.³⁰ For example, in June of 2020, “twenty-seven state health departments are not reporting COVID-19 cases for Native Hawaiians and Pacific Islanders, and thirty-two state health departments are not reporting COVID-19 deaths for Native Hawaiians and Pacific Islanders.”³⁰ As a consequence, it was impossible to know the exact burden of COVID-19 borne by NHPI communities across the US.³⁰

The April 2020 COVID-19 data were a call to action for NHPI. Word quickly spread throughout national NHPI health provider networks. As the scale of the problem became clearer, it also became more evident there was a paucity of programs, policies, and organizations focused on addressing the disparate number of COVID-19 cases that NHPI communities were enduring. The community rallied to address the crisis leading to the establishment of a national collaborative NHPI response.²⁵ About the same time, the Native Hawaiian and Pacific Islander Hawai‘i COVID-19 Response, Recovery, and Resilience Team (NHPI 3R Team) was created in Hawai‘i.

The literature suggests that there is a strong association between socioeconomic inequalities and the burden of infectious diseases.³¹ It is therefore not surprising that socially disadvantaged communities bear a disproportionate share of the burden of the COVID-19 disease in the US.^32,33 These disadvantaged communities also suffer from the highest chronic disease disparities in the US, putting them at substantial risk for higher morbidity and mortality from COVID-19.^{30–32,34–36} NHPI communities were no exception. Lack of prior effective policy interventions addressing the inequities in the SDOH for minority communities, particularly NHPI communities, compounded the impacts of COVID-19.^34–36 For example, approximately 8.3% of NHPI are uninsured compared with 5.9% of non-Hispanic whites.³⁷ Consequently, the formation of the NHPI 3R Team was motivated by a concern for the lack of culturally-responsive policy interventions to address COVID-19 as well as long-term recovery that incorporates the SDOH.

Methodology: A Culturally Framed NHPI Policy Response

Equitable representation and engagement in generating comprehensive policy solutions are imperative for ensuring an appropriate response and recovery plan for NHPI that extends beyond COVID-19 to addressing longstanding NHPI disparities. Intentionally designed by and for NHPI, the Hawai‘i NHPI 3R Team was formed in early May 2020 at the urging of national and local NHPI leaders. The NHPI 3R Team has kuleana for improving accuracy of data collection and reporting, assessing community needs and resources, supporting existing and new initiatives to foster health and resilience, and providing expertise and resources for partnerships with policy makers and funders. The NHPI 3R Team comprises more than 40 NHPI-serving organizations in Hawai‘i including community and grassroots organizations, nonprofits, churches, government, healthcare, industry, and academia. Members of these organizations constitute the 5 committees under the NHPI 3R Team: (1) policy; (2) testing, contract tracing, and isolation; (3) communications; (4) social supports and resources; and (5) data and research.

The authors are all members of the NHPI 3R Policy Committee which represents a wide range of organizations ranging from government to academia to healthcare to grassroots community as seen in Table 1. Utilizing NHPI Indigenous protocols and processes while embracing NHPI cultural values, the Policy Committee (PC) identified community needs and advocated, negotiated, and mediated on behalf of NHPI communities, while remaining a strong influential voice for ‘ohana/aiga-based, kuleana-centric policies at the local, state, and federal levels. An adaptation of the “3 Piko Model” for Indigenous health provides the framework for the PC's approach to the COVID-19 crisis as illustrated in Figure 1.^38,39 Piko is literally defined as one's navel, or more poetically, one's life-giving connection to its source. The 3 components of this framework come together to ensure ‘ohana/aiga-based, kuleana-centric positive policy changes and outcomes. The core of the framework is the “Piko I” which is the connection to ‘ike kūpuna and traditional and cultural ways of knowing. The self-awareness of each individual and group, “Piko O”, is rooted in culture and spirituality, and the decision to accept the kuleana of addressing current and future needs of the lāhui (nation, people) shapes all relationships. These relationships—with individuals, to ‘āina (land, place), and to community—are critical in the establishment of the shared vision and progress of the PC. Relationships connect both current policy efforts (“Piko O”) and outcomes and future initiatives impacting generations to come (“Piko A”).

Table 1.

Policy Committee Representation

Organization	Type
Office of Hawaiian Affairs	Government
Hawai‘i State Department of Health	Government
Hawaiian Homelands	Government
Papa Ola Lokahi	Non-profit
We Are Oceania	Non-profit
‘Ahahui o nā Kauka	Non-profit
Project Vision Hawai‘i & Hawaiian Eye Foundation	Non-profit
Nā Pu‘uwai	Health Services Provider
Kōkua Kalihi Valley	Health Services Provider
Queens Health Systems	Health Services Provider
American Red Cross, Pacific Islands Region	Non-profit
Islands Society	Non-profit
‘Ekolu Mea Nui	Non-profit
Aloha Care	Industry (Insurer)
Aloha ‘Āina Legal Group, LLLC	Industry
Kahuku Consulting	Industry (Consulting)
Hawai‘i Pacific University	Academic
University of Hawai‘i at Mānoa, John A. Burns School of Medicine, Department of Native Hawaiian Health	Academic
Nā Limahana O Lonopūhā	Consortium

Figure 1.

Pacific-Centered Framework for ‘Ohana/Aiga-Centric Communal Outcomes

The PC naturally emerged as a spiritually and culturally grounded entity, which was always mindful of being inclusive and representative of a collective NHPI community. Given the extreme importance of representation, committee composition was organic, fluid, and informed by assessing connections that could assist in addressing current policy advocacy needs. The broad representation of NHPI organizations and communities underscored the strong sense of relationship and kuleana that guides the PC (see Table 1). The PC weekly gatherings were deliverable-focused and intentional and always began with cultural protocols of a pule (prayer) or spiritual intention setting. Collaborative talanoa (discussion) about current events on COVID-19 and presentations on relevant NHPI topics, endeavors and commitments are featured and meetings end with the identification of policy action items relative to community needs. These gatherings provided a consistent space to nurture relationships and for community organizing and strategizing where the environment and priorities of the community were continuously monitored through the networking offered by the PC. These actions allowed the group to assess the best time to take action and advocate, as well as identify gaps, resources, and additional players who may be better suited to create needed policy change.

Results: Navigating Toward Change

Since June 2020, the PC has deliberated over the intersection of policy and multiple issues from education and training to the provision and distribution of immediate essential needs and other important policy issues for community, government, and educational partners. The PC collective talanoa always considers issues through an SDOH lens. Policy advocacy outcomes thus far include submission of testimonies for state meetings and county resolutions, general letters and statements on public health and safety, small group discussion with government leaders, reporting to the community, and planning and informational sessions to prepare for policy advocacy for the 2021 state legislative session. Table 2 outlines the outcomes and achievements of the PC to date. A few examples of the efforts and the use of the framework are discussed as follows:

Table 2.

Policy Committee Outcomes and Achievements through December 2020

Date (2020)	Item	Description	Impact
June 19	Support testimony	Maui County Resolution 20-84, “SUPPORTING AND URGING THE MAYOR TO SUPPORT A FEMINIST ECONOMIC RECOVERY PLAN FOR COVID-19”	Resolution adopted by the Council of theCounty of Maui
July 30	General testimony	State of Hawai‘i Board of Education Special Meeting re: COVID-19 concerns	Support for Hawai‘i State Teachers Association (HSTA)
August 4	Statement	Denouncing recent illegal evictions of NHPI in violation of the current eviction moratorium during the coronavirus pandemic	Ongoing eviction moratorium
August 6	Meeting	Meeting with Lieutenant Governor, Dr. Josh Green	Connections with Pacific Islander leaders;discussion of Pacific Islander pandemiceffects and needs
August 11	Letter	Questions and Concerns Regarding Rim of the Pacific (RIMPAC) Maritime Exercises in August 2020	Response from U.S. Navy Admiral Aquilino
August 12	Meeting	Meeting with Dr. Sarah Park, Department of Health lead for contract tracing	Development of Pacific Islander contacttracing team
August 24	Support testimony	Proposed Adoption of Hawai‘i Administrative Rules Chapter 13-60.9, “Mo‘omomi Community-Based Subsistence Fishing Area”	No update as of Jan.1, 2021
August 26	Support with comments testimony	Honolulu City & County Council, Resolution 20-206, “Proclaiming Honolulu City Council's Commitment to Equity and Social Justice”	Resolution adopted by the Honolulu CityCouncil
August 31	Letter and Petition	“Standing in Support with the Call to Action to Stop Spread of COVID-19 in Prisons and Jails”	Ongoing campaign from ACLU Hawai‘i#FreeOurOhana
October 12	Letter	.Ahahui o nā Kauka letter to the Governor advocating for two step COVID-19 testing requirement for incoming travelers	NHPI 3R sent separate letter. No responseor update as of Jan. 1, 2021 to either letter
November-Dec	Legislative preparation	Planning and informational presentations for 2021 State Legislative Session	State Legislative tracking, discussion, andtestimonies planned

(1) The cultural framework allowed for the PC to identify, discuss, and act upon NHPI health factors that were negatively impacted during the pandemic such as food insecurity. For example, the PC supported the creation of the Mo‘omomi Community-Based Subsistence Fishing Area (CBSFA) through a letter of support indicating the significant impact of the pandemic on sustainability and the Indigenous food systems of Hawai‘i. This action highlighted the use of an indigenous cultural lens to recognize how culture, COVID-19 related policy, and SDOH are woven together for NHPI. Promoting culturally-informed subsistence and lifestyles, the CBSFA acknowledged the positive impact on mental and physical health outcomes particularly for NHPI who rely on Mo‘omomi as an Indigenous subsistence fishery. Community-driven management efforts such as the Mo‘omomi CBSFA contribute to resilience, self-sufficiency, cultural perpetuation, and public health benefits for NHPI communities throughout the islands, a critical new reality for the post-COVID-19 era.

(2) As a result of regular gatherings, discussions, and a collaborative framework grounded on shared cultural values, the PC advocated for appropriate and specific representation of NHPI communities. For example, testimony was submitted in support of the Honolulu City & County's equity and social justice resolution. The PC expressed concern about a lack of specific focus on NHPI disparities in the areas of housing and education and urged a specific acknowledgment of the state's role in reconciling inequities in SDOH impacting Micronesian communities, which are an important PI community in Hawai‘i. Previously, NHPI voices as individual organizations have gone unheard, but the NHPI collective voice has now gained strength and courage.

(3) A final example of the impact and utility of the cultural framework can be seen in the advocacy work of the ‘Ahahui o nā Kauka (Association of Native Hawaiian Physicians), a partner in the PC team. Spurred by the concerns of NH physicians on islands other than O‘ahu who represented communities that feared being placed at undo risk with unclear COVID-19 travel and testing guidelines, this physician group embraced a leadership and advocacy kuleana that advocated for policies that were both scientifically sound and respectful of community values and desires. As seen in the physicians' letter to the Governor and several Mayors, motivation for this work was a “deep sense of kuleana” for protecting Hawai‘i and NHPI communities with a more thoughtful, sustainable, future oriented, and culturally relevant response to the COVID-19 epidemic and the related impacts on tourism, travel, and people (K. Chong-Hanssen, MD, email communication, July 21, 2020). The physicians' letter was shared with the PC soliciting feedback and support. As a result, an additional letter was submitted by the NHPI 3R Team.

Discussion: Setting Sail

Amidst a worldwide pandemic, the story of the NHPI community is one of resilience in navigating uncharted waters. The Policy Committee within the NHPI 3R Team embodies fundamental Pacific core values that foster both a team and an environment from which culturally relevant policy advocacy approaches naturally emerged. Policy advocacy was navigated through relationships of trust and respect that were informed and reinforced through deep ties and kuleana for the NHPI community. The systems-level leadership skills and expertise represented on the PC facilitated policy strategies to confront health inequities disparately impacting NHPI during the COVID-19 pandemic. The outcomes and achievements of the PC thus far have contributed to the overall NHPI 3R Team's position and reputation as a valuable asset for the COVID-19 response and post-pandemic recovery efforts in NHPI communities. Similar to a lei (wreath) of ‘a‘ali‘i, a complete circle weaving together the many facets of culture and shared history of resiliency, this framework was born out of aloha and kuleana for kūpuna (elders), ‘ohana, lāhui, and a sacred ‘āina.

Hawaiian Master Navigator Nainoa Thompson, trained by Micronesian Master Navigator Mau Piailug, emphasized the importance of seeing Tahiti before leaving Hawai‘i as he prepared for his first sail there as the navigator on the the Hōkūle‘a (a double hulled Hawaiian voyaging canoe). Mau told him, “don‘t ever lose that image or you will be lost.”⁴⁰ In a parallel navigation process, the NHPI 3R Team amidst the COVID-19 pandemic must envision a healthy and thriving NHPI community and develop strategies to effectuate policy changes that support resiliency today and for generations to come. The inseverable connection to one's ancestors has enabled this NHPI 3R Team to come together and lean on cultural foundations to inform policy responses and actions aimed at ensuring that an ‘āina-based, ‘ohana/aiga-focused, kuleana-centric approach is leveraged for the future of NHPI peoples.

Practical Implications

The cultural framework that emerged from this community-based collective effort has important implications for both policy and practice within NHPI and other Indigenous communities. The PC and the broader NHPI 3R Team represent how Indigenous communities can organize and take collective action for complex public health and policy outcomes. The PC and the broader NHPI 3R Team have acted within a flexible, inclusive cultural framework to evaluate and respond to issues that the pandemic has caused, or exacerbated, by providing a structural mechanism that brings organizations together in pursuit of measurable and “sustained, scalable, systemic change” through policy advocacy.^41,42 Ongoing systemic change will be accomplished through collectively clarifying and refocusing on challenges new and old, redefining policy approaches and strategies for dual identity NHPI communities, and recreating a shared vision for health equity.

The prioritization of ‘ike kūpuna, spiritual and cultural grounding, and the establishment of ‘āina and ‘ohana/aiga-based, kuleana-centric relationships specific to a local context are unique to this framework. Future endeavors utilizing this cultural framework could shed new light on how the peculiarities of local context can inform variations in policy interventions and contribute to knowledge on more effective practices within NHPI communities. Moreover, NHPI culture-related strengths and assets that positively contribute to resilience among NHPI despite overwhelming experiences with the COVID pandemic are not well-understood, nor documented, nor used to inform policies. The use of the concepts within this cultural framework has the potential to contribute to culturally-relevant policy responses to health and well-being moving forward to the future for NHPI and all indigenous communities.

Abbreviations

CBSFA

Community-Based Subsistence Fishing Area

COVID-19

Corona Virus Disease caused by SARS-CoV-2 virus

NH

Native Hawaiian

NHPI

Native Hawaiian and Pacific Islander

NHPI 3R Team

Hawai‘i Native Hawaiian and Pacific Islander COVID-19 Response, Recovery, and Resilience Team

PC

Policy Committee

PI

Pacific Islander

SARS-CoV-2

severe acute respiratory syndrome coronavirus 2

SDOH

Social Determinants of Health

US

United States

WHO

World Health Organization

Conflict of Interest

None of the authors identify any conflict of interest.