CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 15 • Number 2 • Spring/Summer 2002

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Health Disparities Among Native Hawaiians and Other Pacific Islanders Garner Little Attention

Located on beautiful tropical islands 2,400 miles off the coast of the Western United States, Hawai'i promotes itself as the “health state” because of low mortality and disease rates among its overall population and a health care industry that boasts more physicians per capita than the rest of the country. Unfortunately, Hawai'i is not the health state for full-blooded Native Hawaiians, who will be extinct in their own homeland by 2044 if current trends in mortality rates continue. 

This alarming prediction was made in 1987 in a report issued by the Congressional Office of Technology Assessment, and little has changed since. 

“After that report came out, it just fell on deaf ears and went away,” said Claire K. Hughes, DrPH, RD, of the Hawai'i State Department of Health’s Office of Health Equity. “It’s just those of us who are Native Hawaiian who are saying, ‘This is not right, and we need to do something about it.’ But not enough is being done, and the death rate is continuing.” 

Native Hawaiians, who call themselves Kanaka Maoli, include both full-blooded and part Hawaiians, and most data available on Hawaiians include both categories. Among the 1.2 million people living in Hawai'i, 239,655 identified themselves as Native Hawaiian and one or more other race on the 2000 U.S. census. Full-blooded Native Hawaiians are believed to number about 5,000. 

In 1999, the overall age-adjusted death rate for Native Hawaiians was 901 per 100,000, compared with 524 per 100,000 for the total U.S. population (Department of Health and Human Services data). In 1990, census data indicated that death rates for full-blooded Native Hawaiians were nearly four times higher than the rates for all other racial and ethnic groups in Hawai'i combined. 

Cardiovascular disease is the biggest killer, with cancer a close second. Mortality rates for all cancers for both men and women are the highest in Hawai'i and the second highest in the United States among all racial/ethnic groups.¹ These rates increased 62% for men and 123% for women from 1976 through 1990. Broken down by cancer site, death rates for women increased 158% for breast cancer, 293% for lung cancer, and 313% for endometrial cancer. 

Native Hawaiian women have the second highest incidence of breast cancer among all U.S. women. Although their overall rate is lower than that of white women living in Hawai'i, they are 2.6 times more likely to die. This is true for both male and female Native Hawaiians—once disease is diagnosed, their 5-year relative survival rate for all cancers is 47%, compared with 57% for whites and 55% for all races. 

Health problems are widespread in the U.S.-associated Pacific Islands, which are geographically isolated from the United States and have been used for years as military outposts. Hundreds of small islands and atolls are spread across 5 million square miles of ocean.

Hypertension, obesity, tooth decay, and poor maternal and infant health are common among Native Hawaiians, and rates of cardiovascular disorders, obstructive lung disease, and diabetes are high. For example, 80% of Native Hawaiian children aged 6–8 had at least one cavity in 1999, compared with 55% of white children living in Hawai'i (oral health survey data, Hawai'i State Department of Health). During 1996– 2000, diabetes incidence was 2.5 times higher for Native Hawaiians than for white residents of Hawai'i of similar age.² 

However, finding hard statistics for most diseases and behavioral risk factors is difficult, and that is one of the biggest problems facing this long-ignored group. Until recently, national data collected on Native Hawaiians were lumped under the category “Asian or Pacific Islander” or “Other” if they were reported at all. 

“The whole data issue is a systematic problem,” said JoAnn Tsark, MPH, Research and Education Director, Papa Ola Lokahi, a nonprofit consortium of agencies that focuses on improving the health and wellness of Native Hawaiians. “The category of Asian or Pacific Islander was convenient for small populations, but it has masked Native Hawaiian health problems. The advertising for our tourism promotes health, but indigenous people are suffering large disparities, not just with cancer, but across the chronic diseases.”

 
Pacific Island Populations Suffer “Third World” Conditions 
As bad as things are for Native Hawaiians, they are worse for people living on the other Pacific Islands for which the United States has some jurisdiction or political relationship. 

“When we talk about the disparate health rates for Native Hawaiians, people gasp,” said Ms. Tsark. “But people would faint if they heard the numbers for the other Pacific Islands. I would classify conditions on many of those islands as third world.” 

The U.S.-associated Pacific Islands include American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI), and the Republic of Palau (see map above and highlight box "Hawai'i and the Pacific Islands" below). These island countries and U.S. territories are made up of hundreds of small islands and atolls spread across about 5 million square miles of ocean—nearly half the size of the United States—with a total population of 469,356 (1999 and 2000 estimates). Residents belong to at least 19 different subgroups, speak more than a dozen languages and dialects, and have vastly differing cultures.

Health problems are widespread, including high rates of childhood malnutrition, chronic diseases such as heart disease and diabetes, and infectious diseases such as hepatitis B, cholera, dengue fever, and Hansen disease (leprosy). Health care services and infrastructures are limited, with some islands having no doctors or equipment. 

“It’s so severe that it’s somewhat hard to describe,” Ms. Tsark said. “In some areas, we’re talking about hospitals that don’t even have an emergency crash cart to respond to cardiac arrests.” 

One hospital in the RMI, for example, receives about $2.7 million a year in U.S. funding, which translates to $71 per acute care bed per day. In the United States, approximately $1,000–$1,500 per acute care bed per day is needed to run a second-tier community hospital, according to Neal Palafox, MD, a professor in the John A. Burns School of Medicine at the University of Hawai'i. Worse, U.S. compacts with the RMI and FSM are currently being renegotiated, and funding is likely to decrease substantially. 

“If the negotiations go the way they’re looking, things will go from bad to really bad because you can’t run a hospital on the amount of money they receive now,” said Dr. Palafox, who has worked extensively in the Pacific Islands. “The health disparities that we see now are going to get much worse.” 

Preventive services like disease screening are practically nonexistent. For example, only a handful of mammography machines are located in the entire region, and continued operational funds are not guaranteed. For some residents, saving enough money to fly to another island for a mammogram would take a lifetime. Even when screening or testing is available, laboratory results can take months or years to process. And if a disease is diagnosed, the person usually must be referred to Hawai'i or the continental United States for treatment—creating a financial burden on the islands’ already underfunded health care systems. 

Disease and risk behavior surveillance is also nearly nonexistent, meaning few data exist to identify the specific problems and needs of these populations. The few statistics that have been recorded suggest that extensive research and health services are needed, particularly for cancer. 

Cancer is one of the top three causes of death on all of the islands except the FSM, according to a 1999 Institute of Medicine report. The worst incidence rates have been recorded in the RMI, where the United States tested thermonuclear weapons during the 1940s and 1950s. 

Compared with U.S. rates, age-adjusted data from the RMI for 1985–1994 indicate that incidence for 

• lung cancer was 3.8 times higher for males and 3.0 times higher for females.
• cervical and urinary tract cancer was 5.8 times higher for females. 
• gastrointestinal tract cancer was 8.5 times higher for females. 
• thyroid cancer was 7.2 times higher for females. 
• liver cancer was 15.3 times higher for males and 40.0 times higher for females.³ 

Although the history of weapons testing by the United States in this area is suspected to be a major contributing factor to these alarmingly high cancer rates, no national surveillance program exists in the RMI. Even the data that are collected do little good because they are not disseminated to the communities or used to develop treatment programs or services, explained A. Sam Gerber, MS, RD, a public health analyst in CDC’s Office of the Associate Director of Minority Health. 

Ms. Tsark agreed, noting that “CDC goes every year to record the problems, and there have been some monetary reparations placed in trusts, but we’ve left that population pretty much hanging.” 

Advocates for the Pacific Islands believe the United States has an obligation to this area because of the history of using it for military outposts and because of political commitments to provide for the health, education, and welfare of these populations. 

“There is no doubt in my mind that the United States is obligated to help the Pacific Islands, not only because of radiation, but because people were moved out of their homes and they had to change their diets because the land was radiated and they couldn’t grow their native foods,” Dr. Palafox said. “Their traditions are based in the land, so when they’re moved off, all the lineages are destroyed. It’s not just a matter of the radiation, it’s a matter of truly destroying a culture, and all of that leads to health problems.” 

But addressing these problems depends, in part, on clearly identifying them. Health disparities among Pacific Islanders, like those among Native Hawaiians, have been masked for years by federal data collection practices that lump them with Asian Americans—who, as an overall group, have fewer or at least different health problems. 

Beginning in 2003, all federal agencies are supposed to begin using the new Office of Management and Budget categories of “Asian” and “Native Hawaiian or Other Pacific Islander” (see "Public Health Puzzle" for complete list of racial/ethnic categories). This change is designed to improve data collection on these communities by better reflecting their diversity. It will also allow data to be disaggregated (i.e., broken out into more detail) at state and national levels. 

“We cannot really identify the needs of Asian Americans, Native Hawaiians, or other Pacific Islanders separately until we disaggregate the data,” Ms. Gerber said. “The problems are hidden.”

Tackling the Problems Means Respecting Cultural Diversity
Healthy People 2010, the nation’s health promotion and disease prevention agenda, seeks to eliminate health disparities among all minority populations. It also states that intervention programs should value the cultural diversity of the populations they serve and understand that cultural differences can affect health and the effectiveness of health care delivery. Fortunately, many people already working with Native Hawaiians and Pacific Islanders understand that their programs must be culturally and linguistically appropriate. 

Members of the Jaluit Atoll Diabetes Group in the Republic of the Marshall Islands receive training from the Pacific Diabetes Today program, which is designed to teach them how to plan and conduct community-based diabetes activities. This program is part of the CDC-funded Pacific Diabetes Today Resource Center.   Photo courtesy of Papa Ola Lokahi

One such project is Ka Lokahi Wahine (meaning “healthy women” in Hawaiian), which works to ensure good health among all Native Hawaiian women through a partnership with the American Cancer Society. It includes representatives from several health care, cancer, and community-based organizations in Hawai'i. 

Ka Lokahi Wahine currently is working to reduce breast cancer among Native Hawaiian women by increasing their use of screening and treatment services. Activities include public service announcements, chart reminders for health care providers, and a training video and manual (with continuing education credits) for health care providers. The video, called “Caring for Native Hawaiian Women,” is designed to positively influence attitudes, environments, and cultural interaction in clinics. Suggestions include making waiting rooms less sterile (e.g., adding live plants and Hawaiian artwork), using Native Hawaiian language, and working to create a friendlier environment.

“For example, the physician could say, ‘Aloha,’ to a woman coming in and feel very comfortable knowing that he was saying ‘Good morning’ or ‘Welcome,’ ” said Dr. Hughes, a member of the Ka Lokahi Wahine project. “One of the key things women said to us was that as long as the doctor was OK, they would go back. But when the doctor himself was a bit cold and standoffish and maybe communicated less than 100% caring, they would say, ‘No use going back there for help.’ ” 

Women who participated in Ka Lokahi Wahine focus groups said that if they visited a clinic or hospital and were treated rudely—which they said was common, especially when they brought children—they would not return for test results or treatment. They also described their experiences with Western health care as impersonal, confusing, and intimidating, leaving them feeling vulnerable and stupid. 

The training video recommends that health care professionals (1) be open to patients bringing their family members to appointments, which is a normal part of their culture and might be necessary if they lack child care; (2) use simplified language because many Native Hawaiians do not speak standard English or understand medical terms; and (3) appeal to a woman’s need to stay healthy so she can care for her family. 

The latter approach is particularly important for this population, something Ms. Tsark helped communicate to the American Cancer Society on another project 10 years ago. 

“All of our messages were, ‘You deserve to have a mammogram,’ and ‘You need to put yourself first,’ ” she explained. “That is very un-Hawaiian. A woman would be considered very selfish to put herself above her family or above the community.” 

Instead, project staff members asked Native Hawaiian women to help them understand why breast cancer was such a serious problem in their community. In turn, the staff members communicated to the women that they need to stay healthy to care for their families. The response was overwhelming, Ms. Tsark said, because it invoked two major Hawaiian values: “kokua,” which means to help without expecting anything in return, and a woman’s central role in the family. 

The Ka Lokahi Wahine project has garnered positive reactions from health care professionals and increased by 60% the possibility that women would get necessary follow-up care.

Penny's Story Many Native Hawaiians receive inadequate health care and suffer high rates of diseases such as diabetes, cancer, and cardiovascular disease. Factors that influence this problem include low socioeconomic status, distrust of Western medical practices, and geographic isolation (travel between Hawai'i’s eight islands is expensive, and nearly 90% of specialists work on one island). Native Hawaiians have also suffered decades of racism, disenfranchisement, and neglect since their once independent kingdom was seized by the U.S. government in 1893.  Penny Keli‘i is a Native Hawaiian woman who works in the Hawai'i State Department of Health. At the 16th National Conference on Chronic Disease Prevention and Control in February 2002, Penny shared the following thoughts about her experiences and those of other Hawaiian women with the U.S. health care system.  Aloha. My name is Penny Keli'i. I was born and grew up in a small town called Hilo, in what was then known as the Territory of Hawai'i. I am 57 years old, nearly 58.  I am normally a fairly brave sort, not easily intimidated or frightened. For the most part, of a rather cheerful and positive nature.  Approximately 1 year ago, after a battery of tests at a well-known medical clinic in Honolulu, it was determined that I, quite possibly, had lung cancer. At first, I was numb with disbelief. After all, within a five-generation span of the women in my family, none had a history of cancer.  So I went outside to have a cigarette and think about this horrid discovery.  The testing relentlessly continued, and the conclusion was reached to remove a third of my lung. My precious lung. I suddenly became an unhappy camper. But I kept it all inside. I had to be brave for my family. They were on the verge of “freak out,” and I knew that wouldn’t help me. So I kept up a cheerful front, even when consulting with my doctors. Outreach Aide Penny L. Keli’i (left) and other Native Hawaiian women attend a “train-the-trainer” workshop to learn how health care and medicine must account for cultural factors to improve services to diverse populations. Photo courtesy of Ka Lokahi Wahine My doctors—what a dismal lot they were. Determined to professionally “lay everything on the line,” they left out none of the grisly details. If there was anything positive in this whole thing, they meticulously left it out. How I needed to hear something positive. A dear friend, who happened to be my boss at the time, sat with me during most of the consultations and held my hand even through some minor surgery. I am so very grateful for her comforting presence. As is our culture, I was stoic throughout all the procedures and, carefully watching my face, so was my friend. She knew I was doing what I had to so I could just make it through these painful—both mentally and physically—events.  A biopsy was performed on the nodule on my right lung. I was very conscious and could feel everything. Though I commented that I could feel them digging around, they just said, “Wait! Hold on! Almost through!” and kept going. Suddenly, I distinctly heard the technician say, “Oh, oh, quick, turn her over!” Immediately, I felt them cut an incision in my chest and insert about six inches of tube into my lung area. My lung had collapsed, and the pain was excruciating.  Just before the biopsy, the surgeon had come to tell me how the procedure would go and what to expect. He told me of the risks and emphasized that he’d done “hundreds of these biopsies and maybe only once had anything gone wrong, such as a collapsed lung.” After they inserted the tubing, I never saw him again. I was told that the clinic wasn’t open on a date when I should have my tube taken out, so I would have to wait nearly 2 weeks to see them again. They gave me morphine and sent me home. After about 1 week, my friend said, “This is ridiculous! I’m taking you to emergency to have this tube removed!”  And so we very determinedly went to emergency and, after suffering through a great deal of frustration, I finally stood up for myself and told them that I felt totally victimized and had had enough. Why did I have to suffer being treated so poorly until I got so angry that I felt physically ill again?  Mammograms. I had my first one last year. I’m not proud of that, but I was scared. My doctor would tell me, “Make sure you go and get your mammogram done.” “Yes, yes,” I’d say, and I’d leave and forget about it. Year after year, same thing. Then my doctor changed. She was young, intuitive, and a local girl. Last year, Dr. Jan said, “Penny, when was your last mammogram?” “I’ve never had one,” I answered. She didn’t scold me or put me down. I could tell she understood—that I was afraid. There really are some horrid stories about mammograms out there, and whenever you have one of those “female” examinations, you have cause to feel so vulnerable. In my case, she knew just how to handle me. She picked up the phone and called the woman’s imaging center directly across from her office and made an appointment for me. She didn’t leave it up to me to do it; obviously, it wouldn’t get done.  So I finally went. I was so nervous, my daughter and niece came with me. The technician was a young Hawaiian girl named Mahina. My blood pressure immediately went down. Mahina could see I wasn’t thrilled about this process. She was very calm and understanding. First, she explained everything to me about what was going to happen (fear of the unknown is the worst). I asked, “Will it hurt?” She said, “It isn’t supposed to hurt. It will be uncomfortable, but if it begins to hurt, we will stop immediately.” She repeated, “Mammograms should never hurt. There are other ways of getting this information without hurting your patient.” Wow! Took a load off me. And, it didn’t hurt. Yes, it was uncomfortable, but not painful. I can do it again, but I want Mahina’s table. She helped make it bearable!  I was on a plane recently traveling from Honolulu to my hometown of Hilo. I began a conversation with one of my long-time friends from Kalapana, a very small, remote community on our island. Caroline is a lovely Hawaiian woman, and she was sitting next to me. She said she was just coming home from burying her 29-year-old daughter who died of breast cancer. I was stunned—I hadn’t heard. Caroline said, “She died because she was too scared to go to the doctor, and once she finally did, it was too late.” It traveled from her breasts to her uterus and then to her brain. This young lady was 29 years old and a mother of three young children. I wept for my friend’s loss.  We buried one of my best friends last year, a victim of breast cancer. She was a lovely Hawaiian woman, just 60 years old. She didn’t like the way she was treated by the doctors. They “talked down” to her and acted very disgusted because she was afraid of losing her hair. So she stopped going to the doctor. She stopped her treatment. We buried her a year ago.... with a full head of hair. I miss her so. We scattered her ashes on the slopes of our great mountain, Mauna Kea, exactly as she requested. We were up there a few weeks ago. As is our custom, we brought leis of fresh, sweet, native flowers and ferns and placed them on tree branches where her ashes were. We could feel her energy. It was quite amazing. I still can’t believe she’s not here. I miss my buddy so painfully.

Different Islands Have Different Cultures and Lifestyles 
Another project that uses a culturally sensitive approach is the Malama A Ho‘opili Pono (MAHP) Project on the Big Island of Hawai'i (one of the state’s eight islands; see highlight box "Hawai'i and the Pacific Islands," above). Since 1999, this project has worked with other public and private partners to improve maternal and child health and to reduce the high infant mortality rates among the island’s Native Hawaiian, Filipino, and other Pacific Islander populations. MAHP’s Hawaiian name means “to care for as a mother cares for her child, to hold close these values, and to do these things in a correct and culturally sensitive manner.” 

MAHP offers prenatal, postpartum, and infant and toddler care services, including those related to mental health, human immunodeficiency virus (HIV) infection, and alcohol and tobacco use. Staff members conduct extensive research on the cultures of the targeted populations and strive to enhance the women’s own traditional practices, not override them. 

“Native Hawaiian and other Pacific Island cultures are very different,” said Penny L. Keli‘i, an outreach aide with the Hawai'i State Department of Health. “You can’t just say, ‘They’re all brown, so they all have the same values and the same manner of doing things.’ To be culturally sensitive, you really have to study and learn.” 

Many Pacific Island traditions—including strong familial ties, highly organized communities, traditional health practices, and powerful religious beliefs—have survived despite years of foreign occupation and influence. In the past, Ms. Keli‘i said, traditional pregnancy and child care practices were largely successful, and doctors were not common or necessary. 

But as people moved from lifestyles based on communal farming and fishing to ones that were more urban and consumer-oriented, they often faced new economic pressures, drug problems, limited access to nutritious foods, and loss of family support systems—all of which contribute to unhealthy lifestyles. 

“People are getting more independent of their culture, which is sad,” Ms. Keli‘i said. “We’re there to reinforce the wonderfulness of the diversity of culture and to tell people not to lose sight of it. We’re also trying to bridge the gap between Western medicine and traditional cultures so we don’t lose our own people to fear or to the ignorance of others.” 

CDC is also helping to bridge this gap by partnering with Pacific Island organizations such as the Pacific Resources for Education and Learning (PREL), a nonprofit group striving to maintain traditional cultures and improve the lives of island populations. Although its main focus is on educational programs, PREL also administers primary prevention and health promotion projects with support from the U.S. government, including CDC. 

PREL programs aimed at increasing literacy in this area are also important because language can be a significant barrier to accessing health care services. Although English is the official language for most government and commercial activity throughout the U.S.-associated Pacific Islands, indigenous languages are more common in people’s everyday lives. Many of these languages are not written, and older adults on some islands speak little or no English. 

“People often don’t have culturally competent interpreters when they visit a doctor,” Ms. Gerber said. “Sometimes a 6-year-old has to describe his mother’s problem to the doctor, and that’s really not appropriate.” 

Language has also been a challenge in the RMI, where people need to be educated about the effects of radiation from U.S. nuclear testing. 

“For years, they’ve been trying to figure out how to meaningfully educate people on the damages that have been done and what nuclear radiation is,” said Dr. Palafox. “It’s hard enough in the United States, but imagine trying to teach people about protons, neutrons, or atomic mass when there is not a written language or any vocabulary for these words. It’s very difficult to do.” 

Outreach Programs Work to Improve Access to Care 
Cultural and linguistic differences are not the only challenges to health care for Native Hawaiians and Pacific Islanders. Low income, high unemployment, low educational attainment, inadequate insurance, and geographic isolation are also major factors. According to the 1990 U.S. census, Native Hawaiians had the lowest mean personal and family incomes of the five major racial and ethnic groups in Hawai'i—Chinese, Filipinos, Japanese, Native Hawaiians, and whites. Poverty rates among these groups were 14.1% for Native Hawaiians, 6.4% for Filipinos, 5.0% for Chinese, 5.0% for whites, and 1.7% for Japanese. 

In addition, the cost of living in Hawai'i is approximately 27% higher than the U.S. average for a family of four, making basic necessities like food, housing, clothing, and health services sometimes difficult to afford. Housing shortages are acute in the state, particularly for low-income residents. 

Although most Native Hawaiians live on the more urban island of O‘ahu, many others live in rural, isolated communities on Ni'ihau, Kaua'i, Maui, Moloka'i, and Lana'i (the eighth island of Kaho'olawe was used for U.S. military training for nearly 50 years and has no permanent population). Few medical specialists work in these remote areas, and itinerant doctors may visit only once a month. If people need specialized testing or if a disease is diagnosed, they usually must travel to O'ahu for care. If they don’t have relatives or friends to stay with, expenses add up quickly: round-trip airfare between the islands is $120, and hotels and taxi services are expensive. 

“When you come from a neighbor island to O'ahu, just getting to and from the major treatment centers is costly,” Dr. Hughes said. “If you need to stay overnight for treatment, it’s beyond the reach of median-income or low-income people.” 

In 1988, the Native Hawaiian Health Care Improvement Act created a system to address the health problems facing Native Hawaiians. As the coordinating agency for the Native Hawaiian Health Care System, Papa Ola Lokahi advocates for five health care clinics throughout the state and works with other state and private agencies to offer or support a range of services. Examples include disease screening and health promotion activities, such as encouraging people to return to the traditional Hawaiian diet, which includes poi (taro root), fish, sweet potatoes, and fruit. This diet is much healthier than the high-fat, low-fiber, and high-sugar Westernized diet many have adopted over the years. 

Papa Ola Lokahi also operates the CDC-funded Pacific Diabetes Today Resource Center (PDTRC) to provide training and support for community-based diabetes prevention and control activities in Hawai'i and the U.S.-associated Pacific Islands. 

Projects like PDTRC help address health problems among Pacific Islanders, who face many of the same socioeconomic problems as Native Hawaiians. According to the 1990 U.S. census, Pacific Islanders have a per capita annual income of $10,342, compared with a national average of $14,143, and 17% live in poverty. High school dropout rates are high, and only 11% graduate from college. 

Much of the Pacific Island region is economically and socially unstable after years of heavy dependence on U.S. and other foreign aid. Most items, including food, must be imported. Tourism and the U.S. military are the biggest industries, and economic development is limited by small markets and increased migration, as thousands of people seek opportunities elsewhere. As in Hawai'i, geographic isolation can be a significant barrier to health care. 

“It takes 30 days to get around all the atolls on the Marshall Islands if you don’t catch the tides correctly,” Ms. Gerber said. “People just die if they need care quickly.” 

In addition to local and regional efforts to address these problems, more attention is coming from the national level as part of the White House Initiative on Asian Americans and Pacific Islanders (WHIAAPI). This initiative seeks to improve quality of life for these populations by increasing research and data collection, promoting greater access to government services (including language programs), and increasing outreach and partnerships with community groups. Other groups working to address health disparities among Pacific Islanders include the Asian and Pacific Islander American Health Forum (APIAHF) and the Association of Asian Pacific Community Health Organizations (AAPCHO). 

More Data and More Funding Needed to Address Problems
Although current efforts are helping, health care professionals and advocates who work in the Pacific Islands say much more is needed. Many hope that the new federal racial and ethnic categories will prompt greater awareness of the region, as well as additional research and access to funding. Even today, much of the funding available never reaches the Pacific Islands because limited resources and infrastructure make it impossible to meet federal deadlines and grant requirements. 

In January 2001, the WHIAAPI President’s Advisory Commission on Asian Americans and Pacific Islanders called on the federal government to form partnerships in affected communities that maximize resources and increase the effectiveness and efficiency of government programs and services. The commission also asserted the ability of these communities to help solve their own problems and called for more protection of civil rights and equal opportunities. Many of these communities have historically suffered exclusion and discrimination, which has also played a role in the lack of meaningful data on Native Hawaiians and Pacific Islanders. 

“When statistics are sitting in data sets but aren’t accurately presented, I think we need to call it racism,” Ms. Tsark said. “We are hard pressed to get Native Hawaiian numbers even in our own state. Sometimes the numbers are small, but you can aggregate the data over several years to get more accurate figures. 

“And even when the state has Native Hawaiian data, when they are remitted to a national data set like the Behavioral Risk Factors Surveillance System, they are lumped together as ‘Asian American and Pacific Islander,’ ” she continued. “That’s totally meaningless to us, and it’s hurtful. Our Asian population, unlike the continental United States, which reflects more immigrant and refugee populations, are fourth- and fifth-generation residents. They are generally very healthy, which accounts for Hawai'i having one of the highest life expectancies in the nation. But it totally masks the problems of Native Hawaiians.” 

Ms. Tsark looks forward to the day when data on Native Hawaiians and Pacific Islanders are fully disaggregated so they are meaningful to smaller groups, particularly for the latter population. 

“We keep feeding the norm about the Asian American and Pacific Islander group,” Tsark added. “I would like to see the day when Pacific Islanders say, ‘We don’t want to be the ‘other’ Pacific Islanders,’ and I think they deserve that.” 

 
References 

1. Intercultural Cancer Council. Available at http://iccnetwork.org/cancerfacts.* Accessed October 4, 2002. 
2. CDC. National Health Interview Survey, 1997–1999, and National Health and Nutrition Examination Study, 1988–1994 (estimates and projections). 
3. Palafox NA, Johnston DB, Katz AR, Minami JS, Briand K. Site specific cancer incidence in the Republic of the Marshall Islands. Cancer 1998;83:1821–4.

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