STATEMENT OF U.S. SENATOR DANIEL K. AKAKA NATIVE HAWAIIAN HEART DISEASE WORKSHOP AND INITIATIVE Kaluakoi, Molokai December 5, 1998 [Delivered via videotape] Aloha kakou and Welcome. I want to offer my Aloha to all who have gathered for this strategy workshop examining cardiovascular disease and Native Hawaiians. I would like to commend Molokai General Hospital, Ahahui O Na Kauka, The Queen's Health Systems, Office of Hawaiian Affairs, Na Pu`uwai Native Hawaiian Health Care System, Papa Ola Lokahi, and the National Heart Lung and Blood Institute at NIH for sponsoring this important convocation. In particular, I want to recognize Doctors Emmett Aluli and Philip Reyes for their hard work and vision in bringing this conference forward. I am heartened that Native Hawaiian physicians and health care providers have recognized the need for a cardiovascular initiative targeting Native Hawaiians and are taking the lead to identify risk factors, treatment, and prevention for heart disease in Hawaiians. Gatherings like this are important, and I hope this represents the start of a coordinated effort led by kaukas, health care specialists, and traditional practitioners, working closely with federal and local policymakers, private institutions, and national health agencies and organizations. It is imperative that we, as Native Hawaiians, continue to initiate health care solutions and proposals to address the concerns of our people despite some of the progress that has been made at the federal level. As many of you know, one of my deepest frustrations has come from dealing with federal policies, including health care policy, toward Native Hawaiians and Pacific islanders. This can only be prevented if we clarify the issues, support common goals and educate others on our needs and concerns. Of all the ethnic groups in Hawaii, Native Hawaiians have the highest health risk. We know that disease incidence and mortality are strongly associated with lifestyle and risk factors. Hawaiians have the highest proportion of multiple risk factors leading to illness, disability, and premature death. These primary risk factors include sedentary lifestyle, obesity, hypertension, smoking, and acute drinking. I am pleased that the focus of the conference is on cardiovascular disease. In Hawaii, coronary heart disease and stroke are the first and third leading causes of death. The mortality rates for Native Hawaiians continue to be significantly higher than the rest of Hawaii's population. As policymakers and health care providers, we need to promote wellness through physical fitness, improved nutrition, and smoking cessation and prevention. In order to be successful, services that are linguistically and culturally appropriate must be made available. In this regard, cultural competency programs should be further developed and implemented. Essential to this endeavor, is the professional health education of Hawaiians. Efforts to strengthen and expand the recruitment and retention of Hawaiian students at the University of Hawaii schools of public health, medicine, nursing, and social work should be augmented. We must also do more to help our students at a younger age. Your activism should not be limited to involvement in our local communities. There are important national issues facing our country that will impact Hawaii. This past year, two comprehensive health issues were debated by Congress and dropped: tobacco settlement legislation and managed care reform. Both of these have significant ramifications for Hawaii. In the case of tobacco, cigarette smoking is the single most preventable cause of morbidity and mortality in Hawaii and the rest of the United States. Again, smoking rates among Hawaiians are much higher than the average among the state's population. Addressing America's diversity and the challenges it poses to health care continues to be a major problem, particularly for services provided under managed care arrangements. We in Hawaii are in a more unique situation given our multicultural composition. As we contemplate managed care reform and cultural competency concerns at the federal and state levels, we must be vigilant in ensuring that Hawaii's multicultural population and their unique and often divergent health care needs are met. In addition to Western health practices, we must also continue to promote Native Hawaiian traditional healing methods or alternative treatments. That is why I am pleased that alternative medicine has become more widely accepted. I am also encouraged by the openness of many physicians to work in cooperation and coordination with alternative health practitioners. Most recently, the Journal of the American Medical Association dedicated a special issue on alternative medicine. At the end of the 105th Congress, we also passed legislation to improve research on complementary and alternative medicine. The new law elevates the status of the Office of Alternative Medicine to a center for complementary and alternative medicine at the National Institutes of Health. The change in status will allow the center to set up a peer review process and have its own grant-making authority. This is important because Americans are increasingly turning to alternative medicine to manage their health and treat their illnesses. Along with providing research funding opportunities, the center also provides project development and grant preparation assistance. I raise this as a potential resource, as we promote traditional healing practices and look to find safe and effective treatments and preventive methods for chronic conditions for our people. There are a number of policy issues that we need to educate officials about at the national level. At the U.S. Department of Health, various agency offices deal with minority health issues, including the Health Resources and Services Administration, the Office of the General Counsel, Administration on Aging, Office of the Assistant Secretary, Food and Drug Administration, Agency for Health Care Policy and Research, Centers for Disease Control, and the National Institutes of Health. However, one of the biggest problems that we face is inadequate data collection and dissemination of information on the health status of Native Hawaiians by federal policymakers. This has not been an easy task as policymakers have traditionally treated Native Hawaiians like any other minority group. While administrators for the Native Hawaiian Health Care Act and other federal health programs tailored for Native Hawaiians have been sensitive, I have tried over the years to effect change on a wider basis within the Department of Health and Human Services and other federal agencies. A good start has been the 1997 decision by the Office of Management and Budget to create a new category for Native Hawaiians and other Pacific islanders under Directive No. 15, the federal guideline governing civil rights compliance and statistical and administrative reporting. As many of you know, since the establishment of Directive No. 15 in 1977, Native Hawaiians have been part of the "Asian or Pacific Islander" category. This has been a major impediment for advancing Native Hawaiian needs. If one simply looks at health statistics, for example, Native Hawaiians are more comparable to American Indians and Alaskan Natives rather than the healthier Asian populations in infant mortality, cancer, and life expectancy rates. If you look at other federal statistics like immigration, you might wonder what use the current Asian or Pacific Islander category serves federal officials when it comes to Native Hawaiians. According to the 1990 Census, over 63 percent of the aggregate Asian or Pacific Islander population were foreign born. This means that this category is largely comprised of individuals who have immigrated to the United States. Comparatively, only 1.3 percent of Native Hawaiians were foreign born. The 1990 Census also revealed that over 63 percent of the Asian or Pacific Islander population speak an Asian or Pacific Islander language at home, compared to 7.7 percent of Native Hawaiians. In education, 37 percent of the total Asian or Pacific Islander population over the age of 25 had completed college, compared to 12 percent of Native Hawaiians. Now that OMB has made a decision to create a new category for Native Hawaiians and Pacific islanders, the question is when and how will this impact Native Hawaiians. As a follow-up to OMB's 1997 decision, you may be interested to know that I have been working with the Census Bureau, OMB, and other federal agencies on the implementation of the new proposal. All new and revised recordkeeping or reporting requirements that include racial and/or ethnic information are supposed to reflect the new decision as of October 30, 1997. All existing record keeping or reporting requirements must be updated by January 1, 2003. I remain concerned, however, that federal officials and administrators, including at the Department of Health and Human Services, have not adequately considered the circumstances, interests, or needs of Native Hawaiians. For example, the U.S. Department of Health and Human Services instituted an Asian American and Pacific Islander Initiative aimed at eliminating the disparities in the health status of Asian Pacific Americans and improving access to health services. The department recently issued an action agenda for the initiative that includes agency-specific plans to carry out activities and measure progress in serving the A-P-I community. They are soliciting comments on the proposal through December 15th. I would encourage your active participation in the review process. The action agenda is available online at the Office of Minority Health Resource Center website: www.omhrc.gov. While I certainly support the intent of the initiative, my concern is that health officials have inadequately addressed the needs of Native Hawaiians and other Pacific islanders in the report as it pertains to our status as indigenous peoples. Another initiative that warrants review is the President's Initiative on Race, which barely mentioned the existence and perceptions of indigenous peoples. It is imperative for federal policymakers to understand that the health needs of Native Hawaiians must be differentiated from Asian immigrant populations and other minority groups. This goes back to the whole issue of political status for Native Hawaiians and our relationship with the federal government. We should not address Native Hawaiian health care needs as an issue separate from political issues. Native Hawaiian health is very much connected to who we are as a people as we struggle to preserve our language and culture and redress the wrongs arising out of the 1893 overthrow. Therefore, I was pleased to learn that the Native Hawaiian Health & Wellness Summit last March provided a forum to discuss these issues. Most recently, we commemorated the 5th anniversary of Public Law 103-150, the joint resolution which offers a U.S. apology to Native Hawaiians for the 1893 overthrow of the Kingdom of Hawaii. The question most often asked has been how do we as Native Hawaiians shape the process of reconciliation as called for under the resolution. As far as I'm concerned, efforts toward this end have already begun. It began with the 1994 return of Kahoolawe, the 1995 Hawaiian Home Lands Recovery Act, and the 1997 OMB decision to create a new federal category for Native Hawaiians and other Pacific Islanders. These efforts continue to be reflected in consideration of U.S. policy on the U.N. Draft Declaration on the Rights of Indigenous Peoples and the Clinton Administration's yet to be defined policy toward Native Hawaiians. However, reconciliation should not be viewed as one particular issue or a narrowly defined process. It should be viewed as a multitude of positive steps between Native Hawaiians and the federal government to improve the understanding between each party, to improve the social, economic, and health conditions of Native Hawaiians, and to resolve longstanding matters of political status and land claims. The initiatives proposed at this conference for joint partnerships with federal health agencies and institutions can be considered a form of reconciliation. As Native Hawaiian physicians, I call upon each of you individually and as a group to contribute to such a process. You have already contributed to our community by becoming physicians. It is now time to support each other and to find out how you can best help at the local, state, or federal levels in improving the health needs of our people, whether it be working with government officials, becoming members of non-profit organizations, or sitting on the boards of institutions. Every little bit helps. I am pleased that you have established Ahahui O Na Kauka, the Native Hawaiian Physicians' Association. I am certain that you can play a pivotal role even beyond health issues. The participation of Hawaiians in leadership positions in business, academia, law, politics and medicine are all important to advance the interests of our people. At all levels of government--federal, state, and county--let your political leaders know of your and your patients' needs and concerns. Remember--public officials are elected or appointed to serve their constituencies. Sometimes it is very easy to say, "He or she is not doing enough for us." But it is just as easy to say, "This is what you can do for us." Or, even better, "This is what we need to do together." If we all work together on this Native Hawaiian heart initiative and other Hawaiian health issues, we can make headway on one of the most pressing health care concerns for Native Hawaiians and establish a community-based model to respond to the many health care, policy, and political issues that are important to Hawaiians and our island community. I believe with all my heart that an individual's health and well-being are linked to their spiritual fulfillment and economic security. I look forward to working with you to promote heart-healthy lifestyles in our communities, and I am confident that this is just the start for great progress to come. Imua! Aloha and God Bless You! A hui hou.