2 I Native Hawaiians—Don't tell me you went on a "vacation" to Hawaii (Maile Tauali‘i, )

Greeting:

• Self-Identification: Rather than Native Hawaiians or Polynesians, consider acknowledging that people may self-identify as kānaka ʻōiwi or kānaka maoli
  • 200 years to Native Hawaiians, who have been inter marrying and creating lives with coastal Indian tribes
• Pronunciation: Aim to pronounce Hawaii correctly:
  • The W is sometimes pronounced as a V, but there's definitely what we call an Okina between the two eyes that make it an e sound on the end of it
• Rapport Building: Avoid using your vacation to build rapport
  • When your provider says something like, "Hey, you're from Hawaii, I'm going there for vacation next week may not be like, what that island person really wants to hear". Washington became a place where they could afford to live, but they will never be home. People miss home and your vacation reminds some folks about how they've been displaced and can't live in their own homes. 

PMH/FH

Sources of Mistrust: 

• Historical Events: Consider how historical injustices lead to distrust of promises
  • 1778: James Cook “discovered” Hawaii and subsequent explorers brought diseases that led to 90% drop in population in a period of less than 60 to 70 years
  • 1893: Illegal overthrow of Hawaiin government (formal apology signed by Bill Clinton for this)
• Consumerism and Capitalism/Land Displacement: Acknowledge how these larger forces may affect the mental health of your patients. 
  • The desire for Hawaii and what it offers takes precedent over the needs of those whose homes are those islands. Hawaii viewed as entertainment, subject of people's fascination versus a place that is sacred that should be respected and upheld.
  • Hawaii is the most expensive state in the entire country to live and families are not able to afford to live there. This part of the mental health crisis 
  • Loss of "manaa, a life source, that connects people to the land and connects them to 1000 generations of Hawaiians of ancestors

Social History:

Nutrition:

• Sacredness of Food: Understand that food is sacred and part of the Hawaiin story of creation.
  • Wakea (the sky father), and Hoʻohokukalani (the heavenly one who made the stars), wished to have a child. Their first attempt led to still birth which was buried and turned into a taro plant. The second attempt led to a human, from which the Hawaiin race descended.
  • The second child is the first human being and the relationship between younger brother and older sibling is that nutrient relationship when you care for the land, the land will care for you. It’s not just like a really nice thing to eat. It's our body of our ancestor.
• Traditional Diet: Ask "Your basic foods may not be available to you, what are you replacing it with?
  • Spam is native Hawaiian food but was introduced by the military.
  • Rice is not a native food of the Pacific Islander populations and comes from an Asian influence
  • Poke is cubed fish but there’s shortage in Pacific due to demand elsewhere

Nutrition Counseling:

• Discuss that Instapot can be used to cook breadfruit and kalo in raw form quickly
• Review that a salad of macaroni and mayonnaise may not be nourishing

Addressing Mental Health Crisis: Help patients connect to their home: music (nahenahe), community celebrations. See list of resources below 

Transcription

• Timespan: 40:24 Min
• Transcription Type: Cleaned Verbatim
• Speakers: 2 (Maile & Raj)

00:00

Raj: I think people should say Hawaii correctly too. So let's just say it correctly. Let's just repeat it.

00:05

Maile: Hawa ee. It's (Hawa, ee). The W is sometimes pronounced as a V, but here's what we call an Okina between the two I(s) that make it an ee sound on end "Hawa ee."

00:20

Raj:

Hey everyone, welcome to the healthcare for humans podcast, the show dedicated to exploring the history and culture of Washington's diverse communities. So, clinicians have the proper knowledge to care for all patients.

This episode is about Native Hawaiians and Pacific Islanders. Being in Washington, when you hear Hawaii, you probably think about your next vacation. I'm there with you. After we had our first child, that's the first place we went after the pandemic's peak. We often fall into this trap of thinking it's a place to visit and escape from our own lives. But it's a place with its own history, culture, and people that have been overshadowed by tourism and harmed by economic exploitation and militarism. Think about this, due to economic factors and disproportionately high rates of chronic diseases in 14 of 27 states with available data, Native Hawaiians and Pacific Islanders had the highest death rates from COVID compared with any other racial or ethnic group. Specifically in Washington State. At one point, if you were Native Hawaiian or Pacific Islander compared to white populations, you had four times higher risk of getting COVID, a ten times higher risk of being hospitalized, and a six times higher risk of dying. This is where more native Hawaiians and Pacific Islanders live than anywhere in the US outside of Hawaii and California. King County is home to the eighth largest population of Native Hawaiians, and Pacific Islanders, out of all US counties. We must know how to care for the people of Hawaii better. We'll be talking about Native Hawaiians and Pacific Islanders today, with more of an emphasis on Native Hawaiians. I want to briefly review the history of Hawaii and the enduring effects of militarism and capitalism in Hawaii before we get started today.

Some brief statistics about Hawaii. There are eight main islands. It has the largest population of multiracial people and the highest percentage of Asian Americans. Of the total population, 15% are Native Hawaiians,14% are Filipino Americans, and 13% are Japanese Americans. Now let's review the history of Hawaii, the Cliff Notes version. Remember, the history of Hawaii is recent. Around 400 to 1200 CE, people from the surrounding islands slowly migrated to what's known as current Hawaii. There was a creation of Chief dumps and slow growth of population based on agriculture and ocean fishing. In 1778, James Cook arrived. For those who don't remember, James Cook was a British explorer and Captain in the British Royal Navy. After his arrival, word got out, and there was an influx of European and American explorers. And, of course, they didn't come alone. They brought syphilis, gonorrhea, TB, smallpox, and others. In combination, this reduced the native population from about a million to 40,000 by 1890. Yes, you heard that right; it reduced the population by more than 90%. In 1893, Western businessmen decided that Hawaii was too valuable to be independent and overthrew the Hawaiian monarch. In 1898, Hawaii was officially annexed to the US. In 1959, Hawaii became the 50th state. And in 1993, US Congress passed a joint Apology Resolution, a formal apology signed by the President of the United States, Bill Clinton, for the US his role in the overthrow. So, where does Washington's history connect to this? In the early 1800s, Pacific Islanders came to Washington state. Many came to support early missionaries and provide labor for early business ventures and other enterprises such as the Hudson Bay Company. You'll hear more about this history in this episode. The last thing to review before this episode is about the bigger forces of our society that have affected Hawaii as a land. The history of Hawaii is a history that shows the consequences of economic exploitation and militarism. I think this is important to understand because it directly affects the mental and spiritual health of people from Hawaii. First, let's start with militarism. Military presence in Hawaii began to expand the US trade with Asia and expand its influence in the Pacific. That was a primary reason for the US interest in Hawaii in the first place, which led to the overthrow and the annexation. At one point, the military population, including dependents and veterans, reach 16% of Hawaii's population, and its presence continues to this day. Right now, the US has a large naval command with approximately 50,000 military personnel in Hawaii, and they control 5% of the land. What does this mean to the people of Hawaii? Military presence and activity have led to contamination of the land with toxic waste, unexploded ordinance, and radiation has led to the loss of cultural sites such as religious sites, Imperial sites; at the root of it has led to the loss of Aina. Aina in Hawaii is a literal definition of land. But it means so much more. It often translates to loving the lead and our need to respect it, care for it and honour it. The native Hawaiian relationship with Aina is defined by a mutually caring relationship with the land. In contrast to the European American concept of land to be used for human recreation and progress. As I said, this is recent history, and our patients remember it. The second large force that has affected Hawaii is economic exploitation. There was a succession of dominant industries in Hawaii. Sandalwood, wailing, sugarcane, pineapple, and then finally, tourism. Often, this wasn't a symbiotic relationship. For example, sugarcane plantations were tightly controlled by American missionary families, who monopolized the sugar industry profits. Since Hawaii became a state in 1959, tourism has been the largest industry; we all know that. Of course, it has provided jobs and tax revenue for the state, but that has come with a cost. Tourism has damaging effects on the environment, leading to problems such as water shortages, overcrowding, and rising living costs. These are real life-changing consequences for Native Hawaiians. It's important to remember that. Today we'll hear from Dr. Maile Towa Lee about Native Hawaiian history and culture. Dr. Miley Towa Lee is an assistant clinical investigator for Hawaii Permanente Medical Group. She's a Washington native. She received her Ph.D. in health services and MPH from the University of Washington. She's an innovator and national leader. She established the world's first global indigenous MPH program in Hawaii and was awarded the University of Hawaii Board of Regents Excellence in Teaching Award. As a national leader, she serves as a member of the National Advisory Committee on racial, ethnic, and other populations. She's also a member of the all of us Research Program and multiple other projects. In this episode, we talk about the categorization of Native Hawaiian and Pacific Islander communities and how it came to be the history of Hawaii and the history of Native Hawaiians in Washington. How that history has led to a distrust of healthcare systems. What we mean when we say nourishing food and avoiding a common mistake, many providers make with people from Hawaii. Of note, you'll hear that Hawaiian breeze in the background of our wonderful guests throughout this episode. That cannot be edited out. It was probably best to leave it in any way. Without further delay, here's Dr. Maile Towa Lee. Alright, welcome to the show Maile.

09:26

Maile: Thank you for having me. It's very exciting and wonderful to have this opportunity.

09:32

Raj: Thank you for joining us, and I want you to say your full name because we need to get it right.

09:36

Maile: Maile Tawa Lee

09:39

Raj: Okay, thank you so much. It would be helpful for people to understand what Native Hawaiian and other Pacific Islanders mean. Because We often lump together Native Hawaiian and Pacific Islander with the Asian American Pacific Islander community, people get lumped into these bigger and bigger groups. But let's just break down native Hawaiian and Pacific Islanders know what that means?

10:02

Maile: Okay, sure, we could spend the entire time just talking about this because there are so many pervasive differences between federal government categorization of colonial terms and how we, as Pacific people, identify. So, I'll start with the legal definition, which you see in the census, Native Hawaiian and capital O Other Pacific Islander, which you see in legal documents. That is an Office of Management and Budget category, created in 1997 as a significant push to separate Native Hawaiians and other Pacific Islanders from the broader Asian Pacific Islander category. This was a huge ordeal. Anytime a category gets created at the United States government level, there's a lot of conversation about whether this is the correct definition and who was included. How is it defined, specifically using the words and others in not just Native Hawaiians Pacific Islanders because of the legal relationship that Native Hawaiians have with the federal government?

As a result of the illegal overthrow of the native Hawaiian nation by the United States, native Hawaiians, American Samoans, and Chamorros from the island of Guam are also under the category of Native American. So, when people say Native American, they're saying American Indians, Alaska, Native Hawaiians, Samoans from American Samoa, and tomorrow. Most people don't know that, and that has to do with specific legislation. However, we Pacific people don't use any of those terms. So, we have particular names that are for ourselves. Native Hawaiians don't consider themselves necessarily Native Hawaiians. We call ourselves Kanaka Maoli or Conoco EV; this concept of native Hawaiian has to do with colonial impact and just creating a state Hawaii as a state and those who are native in that state or Native Hawaiians. There're these other terms, Polynesian Melanesian, Micronesian, and also terms never used by Pacific peoples. We are in one giant ocean, the largest highway in the world. And we are connective voyaging people who have always interacted with each other. And so, this idea that there's Micronesia and there's Melanesia are not things that people of the Pacific identify as those definitions. And those terms are, I think, a way to show some political boundaries. So, these words are just weird, and how they defined us based on these terms are not terms any of us in the Pacific use. You'll hear Oceania as a term that we call ourselves, Pacifica or Pacific peoples, but this idea of the difference between Polynesian, Melanesian, and Micronesian. No one should ever use those terms.

12:52

Raj: Okay, that's good to know because anytime I look up information, that's what comes up. So, with that context, tell me your story. You grew up in Seattle, but now you're in Hawaii, right?

13:02

Maile: Yeah, I made the return home. This ties into the history of why people are up there in Washington States. Hawaiians have been traveling to Washington and the west coast for 200 years. My father, a kawaii boy who grew up in a tiny town, decided he was going to leave the islands to be successful and to make a go at it because being from a small town on kawaii and being brown, you don't have a lot of options back in the 40s and 50s. So, he left and worked at Boeing for several years and met my mom over there, who is one of the Buckley family, like the family from Buckley, Washington, the rose family that is, I think, been there since the wagon train days. So two pioneer families came together. And I was born there in Seattle. So yeah, that's my story. I moved back after finishing my Ph.D. at the University of Washington. I came back home to Hawaii to build a native Hawaiian master's degree program in public health as well as to open a native fine Epidemiology Center to try to help with data collection on Native people.

14:04

Raj: I don't want to undersell your achievements as the first global indigenous Master of Public Health degree program. And you're given an award at the University of Hawaii. I want to call that out.

14:15

Maile: Yeah, thanks. Yeah, it was a program to help combine the idea of data being so important and being visible in data. I worked with the tribes and Indian people in cities to ensure visibility for urban Indians. I wanted to continue that work and ensure visibility, especially with so much being conflated with the Asian Pacific Islander category. The work that I did at the university was to help create sort of a public health army of native professionals who were skilled and trained in the area of looking at the law to ensure visibility among Native Hawaiians and other Pacific Islanders.

14:55

Raj: Yeah, yeah. And you are also working in research and partnership talking about cultural safety with Kaiser; they're in Hawaii. Is that right?

15:05

Maile: I am an employee of Hawaii Permanente Medical Group. So, I do a lot of talking to people about how you do a better job for your patient. How do you connect with them? How do you understand their needs to get them to be a partner in taking care of their health? At the end of the day, they're going to walk out, and what you say may or may not matter. And then, I also do research. My job is I've got to end health disparities. That's like me; I wake up every morning going list and health disparities. I'm a strong believer that Kaiser medicine, Kaiser Permanente medicine, is the only way we can do that. Not many healthcare systems think about social needs along with healthcare and that they walk hand in hand. So, it's a fantastic place.

15:51

Raj: Okay, let's start with history.

15:54

Maile: Sure

15:54

Raj: I strongly believe that understanding history is important to understand the context of a patient's health, background, and what they've been through. I don't know where to start with history. Should we start with Captain Cook?

16:06

Maile: It's so hard to because there's native Hawaiian history. There's the Pacific history. And then there's like the history of Pacific people in Washington State. And so, I think where I'd start with the past is just to let people know that Native Hawaiians and Pacific Islanders are very well represented in Washington State, and they've been there for over 200 plus years. Captain Vancouver, actually not Captain Cook, brought some of the first Native Hawaiians to the Washington area. They boarded his ship because they were voyagers, and they said, "Let's go check this out. And we have a lot of families who trace their genealogy back 200 years to Native Hawaiians, who have been intermarrying and creating lives with a lot of the coastal Indian tribes. There's even a city in Washington State that everybody pronounces incorrectly by calling it Kalambo. Washington, but it's Kalama; Washington and Kalama are a very large, strong multifamily. The Columbia people, the Columbia family, is from Maui, and that history goes back a long time. The history here in Hawaii is what we've seen for hundreds of years; big trees wash up on our shore. So even before Captain Cook, it talks about our history as a people long before colonialism. And these captains who were sailing around, I was just going to say other things about them, but let's just skip it to our people. We were sailors and navigators and saw things like the sweet potato in our diet. We know that didn't come from the islands. We know that it comes from Chile. So, our people have been long before these captains picked up Islanders. I believe our people navigated back and forth because they saw these logs arrive. And they probably were like, hey, let's go see where these logs are coming from. It wasn't hard for the Pacific people because they could navigate the oceans quickly. And like the trip to Tahiti, like seven to 10 days, that's like a weekend trip, we're pretty positive that our people were all over the Pacific. And you can see that in some of the artwork on the northwest coast. It looks very similar to a lot of Pacific Island artwork. And so, I think our people interacted long before Captain Cook and Captain Vancouver started getting in our hair. But the history of Hawaiian people to know just a little bit about Hawaii. Just a quick sort of nutshell.

18:27

Raj: And I think people should say Hawaii correctly to say. Let's just say it correctly. Again, let's just repeat it.

18:33

Maile: Hawa ee. It's Hawa ee. the W is sometimes pronounced as a V, but there's definitely what we call an Okina between the two I(s) that make it an ee sound on the end of it.

18:46

Raj: Thank you for that moment.

18:49

Maile: So, Hawaii, the history here in the islands, we know that when Captain Cook arrived, there was probably a million Kanaka in the islands. Hawaiians have been here since 400, some AD long. Just amazing, rich culture, strong democracies, a powerful elite, a strong monarchy, and many very well-structured governing systems. And then, we talk about the arrival of the Western world and its impact on our shores. Valentine's Day is sometimes referred to as Captain Cook’s Day because that's the day he was murdered and killed on our shores by Hawaiians because he violated our protocol and promises made to native Hawaiian people. The rest of the Pacific kind of goes, yeah, that's the history with him in 1778. And then we're talking hundreds of years later, those who came as missionaries were given land to start churches. Their children, such as Sanford Beadle and others, illegally overthrew our nation and dethroned our queen in prison in her palace for the sake of American consumerism. And our Queen Liliuokalani looks at international law, knowing that this is the United States First illegal act of war on a peaceful people, and it goes down in history.

Fast forward to 1993, Clinton apologized, saying, "My bad, our bad, we did illegally take your land. And that has always been established that Hawaii should never have been part of the United States. So anyway, that creates a lot of distrust. That's the beginning stages of the distrust of the word of the Western world. Contact for Hawaiians was 1778. Illegal overthrow 1893 - 1993, a hundred years later, which all of us remember 93. This is recent history, a history that people still remember. And they carry that forward in their relationships with the Western world and the systems like education and policing, and medical systems. And the idea that not every promise that's made to you is a promise that will be kept. And so that history is incredibly relevant, not just to Native Hawaiians Pacific people. Suppose you look at the Compact of Free Association areas, which are large, the Micronesian population in Washington State. They have also been promised that we will not bomb your lands. Some pretty horrible instances of nuclear testing done in the Pacific and just the fallout of nuclear poisons have impacted the health of those people. That gives you a little perspective on history. There's some distrust there, and a lot of it has to do with the military, consumerism, and capitalism, and that the outsides desire for our islands takes precedence over the needs of those whose homes are on those islands. It's set up for us to be the entertainment and be the subject of people's fascination versus a sacred place that should be respected and upheld. There's a lot of hurts and a lot of frustration. And that carries through in how we engage with systems we don't necessarily feel are set up to care for us. They're set up to deal with us, not nurture us.

22:10

Raj: Yeah, that's an excellent way to encompass that we mentioned the hurt and frustration. But there were lives lost. I mean, one statistic I saw because of the introduction of diseases and the contact from Western folks, like at 1.1, in eight, Native Hawaiians had died from first contact to the lowest demographic in 1950. Is that right?

22:30

Maile: Yep. Yep, we believe a 90% drop in population in less than 60 to 70 years. And that's like within a memory within the lifespan, and you see your population decline dramatically. And Hawaii wasn't the only place that was impacted by that. We know that French Polynesia and Tahiti also experienced similar drops in population. So that legacy of infectious disease is very remembered and still happening today, as we look at the statistics of Pacific Island people impacted by COVID-19. And the death rates in our population.

23:07

Raj: Yeah, its long-lasting and devastating effects on mental health as one, you mentioned, testing of nuclear weapons, and I think you mentioned Micronesia, but I think specifically was Marshall Islands had such a high mortality rate from COVID and have higher cancer rates all because we know of the introduction, nuclear waste in the entire island for strategic purposes, that's right.

23:28

Maile: Yep. So, when you say we're here to help you as a health care system, we've heard we're here to help you before. We are here to offer you something you don't have when many folks are in the Pacific. We're a little bit leery of what the West has to offer us.

23:43

Raj: Yeah. And you mentioned the immigration to Washington. So, there are communities here in Washington. Do you feel like you had a tight network in the Pacific Islander community? Are there specific neighborhoods that people should know about? I'm sure that's constantly changing.

23:58

Maile: Yeah, I think, like every community in Washington State as Seattle, its outskirts. I grew up in Seattle, where the central districts were where people of color grew up. My family lived on Beacon Hill because my parents couldn't live elsewhere. So South ends were where people of color resided. And that currently, the South End is like pushing further south as gentrification and just the cost of homes in the Seattle area are moving more and more communities south who are communities of color, those are really strong populations of Pacific Islanders, and therefore resources have popped up. And then the more resources you have there, the more Pacific Islander communities tap in and feel like those are places where they are welcomed and have a support system.

24:48

Raj: Yeah. Okay. Let's talk about food.

24:51

Maile: Sure

24:52

Raj: I think for specifically native Hawaiian food, we need to be careful about, as you mentioned, both commercialism, militarism, and capitalism have tainted the culture and made it entertainment. But a lot of things are sacred. And the food is for nourishing purposes, not just for tourists to come and enjoy and comment on. We just review the history of how Western countries, different people coming there to visit, overwhelmingly change the social structure and lifestyle. Change the land from subsistence agriculture and commuter lands to something commercialized. But talk about what is a nourishing diet for you. In a traditional diet, what do you still eat? What do you crave? Like, what does that mean? Well, we're counseling about nutrition,

25:41

Maile: I think the most important place to start, and I just have to be clear now, we're getting into cultural histories that are native Hawaiians. And not necessarily the same for your Samoan population. There are some similarities. But a huge part of cultural practices is influenced by who did the colonizing. And so, Hawaii was colonized by a different set of missionaries than those in Samoa Tahiti, Micronesia. So, there are differences in how our culture has come through; culture is food, food is culture, and they're tied together. So, from a Hawaiian perspective, the most important thing to start with when it comes to food is that food is the most sacred aspect of our culture. It is our origins. So, the stories we live by are not necessarily just stories but our genealogy, and they define who we are as Kanaka. So Native Hawaiians trace their genealogy back to the sky father and the earth and their daughter, and the firstborn child that is stillborn, a stillborn child placed in the earth. It becomes Kahlo Taro, the staple of the native Hawaiian diet and many Pacific Islands diets. Taro Kahlo is our word for it. The firstborn child from that child's body comes from Kahlo. The second child is the first human being, and the relationship between the younger brother and older sibling is that neutering relationship. When you care for the land, the land will care for you. And that's not just a nice thing to eat. It's the body of our ancestors. It's who we are genetically as a people; we trace our genealogy to a plant eaten every meal every day by all Hawaiians. It's not just a plant, so when you eat it, you're eating and being nourished by your sibling. So, not having that is a huge impact on people's health. So, when you talk to Hawaiians or anyone from the Pacific, they will speak about their craving for native foods or their traditional foods. And they're not just like, oh, I like how it tastes. That Manna, that life source connects me to the land and 1000 generations of Hawaiian ancestors. It's our cultural food; it's our spirituality. It's who we are as a people. It's our philosophy of life. And that's why we grow it today, and we work so hard to ensure access to this traditional food. I remember being in Seattle and just trying to figure out when the poi was delivered to uwajimaya in Chinatown and just be like, Okay, I think it's Thursday. And like you get there in 15 minutes, all these happy Polynesians are standing in line and no more poi the shelves. And it's devastating. And it was growing up in Seattle in the 80s and 90s. It was not that common that you could access many of our foods, and it was uwajimaya or different Asian grocery stores that might bring it in from Hawaii. But today, it's a little bit more accessible. Because the population is so much more significant. There's a demand and a market for it, so you can get more access to native groceries, native produce, traditional foods, and replacement stuff that'll work. It's close enough, and I'll prepare it the same way that I did traditionally. Food is really important. Food is not just something you're craving; it is a connection to your ancestors. And people have big ono for that. Ono is like craving delicious. And they want that because it feeds them emotionally as well as spiritually. So that's the traditional aspect of food. Then some things have been twisted, like the idea that spam is part of our native diet. It's like, oh, let's unpack that a bit of spam. And I told my children early on it meant spare parts from anonymous meats because I was trying to gross them out. But not for Hawaii people; like doesn't matter what Hawaii people are. We're the largest consumers of spam on the planet. And this idea like that's traditional. It's like real meat in a can. I'm pretty sure that's military rations. And that's what it was. It was World War Two military rations that native people were exchanging, like these beautiful foods, the hunting, and cooking and preparing to cook meat in Hawaiian and a traditional Hawaiian way. That's like a dig a hole and starting a fire. It's a 12-hour process. And then these military guys come with spam in a can. They're like, what? Look, just pop it open. And Hawaiians are, like, holy, that's amazing. I'll give you all my delicious, amazing Island food in exchange for your meat in a can. Yeah, so there's a rumor that there are hidden warehouses of spam on the island in case of a hurricane so that we, as a people, will sustain ourselves on spare parts from anonymous meats. But yeah, those are…

30:47

Raj: I think that was an abuse of trust, right? with the military rations of somebody saying you can trust us. This is good. This is good food. What we're doing is the right thing linking to the mistrust.

30:59

Maile: Yeah. Yeah. And then the other aspect, too, is now Hawaiian food, or Hawaii food is becoming increasingly popular. I don't know anybody in Washington state who hasn't tried the poke bowl. It's usually mispronounced up there. But it's Poke. Okay.

31:16

Raj: Poke. That's what people say I am saying.

31:18

Maile: Yeah. And just to let you know, whether you want to edit this, poke means penis in Samoan. So, it's not good.

31:26

Raj: Yeah, I need to leave that in. So, people don't say it.

31:31

Maile: But poke is cubed fish, and it's created a sort of a shortage in the Pacific because places all over the United States want tropical, raw fish. And that's how we sustain ourselves. But even here in Hawaii, I live in a remote town on Oahu. A tourist bus will stop at our local, tiny grocery store with some of the best poke, and I won't say the name because I don't want more tourists. But there's like

32:02

Raj: Keep off flying from Washington.

32:03

Maile: Oh, yeah. To go get our raw fish, and it's a shortage on the islands. It's pretty crazy. But that's how our culture becomes popular, creating a vacuum hole in the Pacific. And yeah, it might increase those fishing to fill their pockets, but those aren't necessarily Hawaiian fishermen. They're people who live in Hawaii fishing and then exporting our traditional staple foods out to other places because everyone else has it figured out that eating it like that is like sushi on living. You don't have to fill up on rice; you can just eat the good part.

32:39

Raj: I agree with that. So, you mentioned a few foods. Are there any other foods that we should know about? Or if somebody comes to me in Washington and has just been diagnosed with diabetes, or heart disease, what is a culturally appropriate way of providing diet education?

32:56

Maile: It depends on how the provider can comfortably navigate a conversation. Because in this conversation, there's a conversation about losing connections to islands. But the message that should come across is that rice is not a native food for Pacific Islander populations. Rice comes from an Asian influence that is huge and prominent in our culture. And many of our people are both Hawaiian and Asian, and there's a lot of mixed population. But rice is cheap compared to our native foods. And so, there's the idea that the typical plate needs two scoops of rice, two scoops of mac salad, and then a bigger portion of meat. And salad is like I always remind people that we have to use that word loosely because macaroni and mayonnaise do not make the salad. This is that local style. And so, this idea of providers talking to patients about that rice is a big contributor to our diabetes. It is a very simple sugar that breaks down in the body quickly.

When we lived on a traditional diet of breadfruit of starches, those are complex carbohydrates. When you don't have access to it because of cost because of geography. You replace it with something that just has, over the years, become a cultural replacement. So, I think a provider reminding or having a conversation about traditional foods and just saying some foods are very common in Pacific Islander families are replacement foods. So, when people think about why are Native Hawaiians and Pacific Islanders? Why do we see such high rates of diabetes, cardiovascular disease, and obesity? It's because of the replacement foods. It's not because of the native foods. And we've done a lot of research looking at the indigenous native Hawaiian diet, which does not have rice, and it is incredible as far as how the body responds and reacts to it.

So, in Washington State, you have additional challenges meaning that poi and Kahlo aren't as available at every grocery store. You got to go to that one place early on a Thursday to get access to it. And not every family has that ability. So, talking to families about the things that they choose to replace that whole of that traditional food that's not there anymore, I think, is a good conversation starter to save the basic foods that may not be available to you; what are you replacing it with? And are those things as good for you as your native foods? Maybe even think about Pacific Islander communities working with industry to say, look, there's a market for us to bring in some of these native foods. Bring in Frozen breadfruit and Frozen Kahlo because we should be able to utilize that. In Washington state, they could access it, and you have the numbers to demand it. Just informing and having providers be aware that having access to traditional food is not so easy and that the replacement ones are causing all of the problems we're seeing show up in the medical record.

36:06

Raj: Yeah, yeah, it's an important question to ask. Let's break down some of this because everybody will know about poke.

36:12

Maile: Good job.

36:12

Raj: So, but poi is cooked and mashed. I think it's lightly fermented taro, too, right?

36:19

Maile: Yeah

36:20

Raj: yeah, it's good. I've had it. But is that what it is? Did I get it right?

36:23

Maile: It's not necessarily fermented by the time it gets to Washington State; it usually is. But we're spoiled and a little bougie. Here in Hawaii, we have significantly advanced our access to traditional foods. But in Washington State, you're dealing with whatever comes your way. Kahlo is the raw form. It's slightly poisonous when not appropriately cooked because it has a crystalline structure that can make you have an itchy mouth and throat, which is irritating. And so people are a little hesitant to cook it if they don't know how to cook it correctly. And so, I always tell people, the Insta pot is your best friend. When it comes to cooking traditional food. You could put the whole breadfruit in there, Kahlo in there, and Kahlo in its raw form lasts a long time. So, we could ship that to you folks and do a class on Insta potting cooking of traditional foods, which is still harder than rice and a lot more expensive. And a lot more work. Poi is how you'll see it many times in the Hawaiian community in Washington State because it's a lot of work to get it to that place, and poi is marketed pretty well. And it's gotten out. But by the time it gets to you folks, it's not nearly as good as the way that it is here in the islands. We have a lot of fresh poi and many folks who moved away like my dad when they were kids. It just doesn't fill the hole in the same way. It's watery old, and this is that mental health piece. People are filling their homes with something else because they just can't get the same things. And it's not just the Kahlo on the poi. It's also just the fresh produce. Here in Hawaii, we eat a lot of tropical fruit. Pineapple is not a native food, and mangoes are not a native food; guavas, none of that stuff that are thought about as native foods are. But they've been part of our culture for so long. And a lot of people grew up with a mango tree in their backyard. And a fresh, warm sun-ripened mango is very different and so good for you. And here in Washington State, I'm pretty sure your mangoes are coming from Mexico,

38:23

Raj: it's hard to find a good mango, not Mexican mangoes, but also Yes, like sweet, and you don't want it to be sour, bitter,

38:32

Maile: mango juice should go down your elbow. It wasn't a good mango if it didn't get to your elbow. It's mental health training because food is so special and so important. So not having it, you fill the hole with other things. But it never satisfies the same way. And so, you keep trying to fulfill that desire for connections to home. And I think providers must try to talk to their patients about other ways to connect to home. Because the food is just never going to be the same. There's music, there's culture, and there are different ways that we celebrate connecting that will fill that emotional hole. That may not satisfy the craving for a juicy warm mango or fresh poi. Reminding folks there are other ways to connect to home, I think, is a good thing for providers to think about too. It is put on some beautiful Hawaiian music; we call it Na hey Na hey, which just makes you cry. When you listen to it

 You're like, oh, I miss home. And it just folks know how beautiful the islands are. And most of the people who are up there in Washington State, I can guarantee you probably about half of them wasn’t like, I'm looking for some grey, little less sun, fewer beaches. Let's move to Washington. That's not probably what caused the move. Hawaii is the most expensive state in the country, and families cannot afford to live here, so they're looking for other places to start a life and support their families, jobs, and industry. Hawaii is a hard place to live financially. And people leave because they can't afford to be here anymore. So, when they show up in Washington state, not all of them are super happy to be there. And that's another mental health crisis. I was not able to live in my land. So, when your provider says, "Hey, you're from Hawaii, I'm going there for vacation next week. It may not be what that island person wants to hear. So, I mean, that's common. I can't tell you how many times I've had someone tell me, like, oh, you went to Hawaii last Christmas for a holiday. It's like, that's nice. But that's not an experience I can afford to do so. You know, reminding providers to think about the fact that many people who are up there are not there because they chose Washington State as their home. It became a place where they could afford to live, but they will never be home. Because it's not Hawaii, it's not the Pacific. The ocean isn't around you. Those tropical breezes that are coming in every window they don't happen in Washington State. So, providers should consider what they said to Island people when they tried to connect with them. We most of the time don't want to hear about your vacation in Waikiki.

41:22

Raj: I think that's a good pearl. Well-intentioned; maybe sometimes they are current providers. Yeah.

Thanks for joining me, Raj Sundar, and this episode, the healthcare for humans podcast. I hope you enjoyed today's episode. Remember to check out part two of this conversation in the next episode. Show notes and links can be found over at healthcare for humans.org. Feel free to comment or send me a message there. If you prefer email, email me at healthcareforhumans@yahoo.com for feedback and any guest ideas. And lastly, make sure you hit the subscribe button and tell a friend. See you next time.

Disclaimer:

This podcast is intended for educational and entertainment purposes only. Views and opinions expressed in this podcast do not represent any of the participant's past, current, or future employers unless explicitly expressed, so always seek the advice of your physician or other qualified healthcare providers concerning your personal questions about medical conditions you may be experiencing. This Healthcare for Humans project is based on Duwamish land and makes a regular commitment to Real Rent Duwamish.

The transcript ends here.

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• https://geriatrics.stanford.edu/ethnomed/hawaiian_pacific_islander/fund/health_beliefs.html
• https://ethnomed.org/resource/marshallese-culture-and-health-information/
• http://manoa.hawaii.edu/hakupuna/wordpress/wp-content/uploads/2017/12/Annotated-Bibliography-2017.pdf
• https://psychcentral.com/health/asian-pacific-islander-mental-health#challenges
• https://core.ac.uk/download/pdf/223237757.pdf