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  • Amplifying the Voice of Native Hawaiian and Pacific Islander Communities Amid the COVID-19 Crisis

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    The coronavirus disease 2019 (COVID-19) pandemic has spotlighted the health inequities of Native Hawaiians and Pacific Islanders (NHPI) and provided the podium from which to amplify their voices.

    Historically, the voices of NHPI were drowned out by other numerically larger health-disparate racial/ethnic groups in the U.S. Their unique health concerns are often overlooked because their data has been aggregated—grouped together—with those of Asian Americans, an arbitrary practice that has done a disservice to both groups.1 NHPI know that resources follow the data, which is why they have been voicing their support for disaggregating—separating out—the data for NHPI and Asian Americans for decades, but to little avail.

    Along comes COVID-19 to amplify their voices as to why data disaggregation is important.

    NHPI have the highest number of COVID-19 confirmed cases of any racial/ethnic group in 14 of the 21 states that report disaggregated data, which include Arkansas, Colorado, Hawai‘i, Illinois, Oregon, Utah, and Washington.2 In the other 7 states, including California and North Carolina, NHPI are among the groups with the highest case rates. In 11 of the 16 states reporting disaggregated death data, which include Alaska, Arkansas, Iowa, Louisiana, and Tennessee, NHPI have the highest COVID-19-related death rates of any racial/ethnic group. These inequities would have been concealed from the public had NHPI data been aggregated with other racial/ethnic groups.

    Pre-existing health disparities and inequities in the social determinants of health are driving the COVID-19 risk among NHPI.3 They make up a large number of the essential workforce, such as in the tourism and food industries.4 In the military, NHPI representation is 6 times higher than in the general U.S. population.5 NHPI are more likely to live in large multi-generational households and denser communities, which further increases their exposure risk. The high rates of asthma, obesity, diabetes, heart disease, smoking, and vaping among NHPI increase the risk for severe COVID-19 symptoms.6 COVID-19 containment and mitigation measures have led to an increase in economic hardships, behavioral health issues, and difficulties in managing chronic disease for many NHPI.

    NHPI leaders and advocates have sprung into action to protect their communities.6 A National NHPI COVID-19 Response Team was formed, comprised of NHPI members from various states, each with county and state-specific groups. In Hawai‘i, the NHPI COVID-19 Response, Recovery, and Resilience Team was formed to join the national team’s efforts. These efforts have changed the policies and practices of county and state public health departments in the collection and reporting of NHPI-specific data. They have secured much-needed resources to ensure NHPI communities have personal protective equipment and food security; access to COVID-19 educational materials, testing, and places to self-quarantine; culturally-informed contact tracing; and financial assistance. NHPI communities took to social media and videoconferencing to stay connected with family and friends and to remain socially and culturally engaged during the COVID-19 containment and mitigation measures. These efforts have been independent of local, state, and federal governments.

    NHPI are resilient and thriving communities in the U.S. Although they make up only 0.4% of the entire U.S. population, they are among the fastest-growing racial/ethnic groups.7 The Native Hawaiian population alone, for example, is expected to almost double in population size from 530,000 to nearly a million by 2040.8 As their population and dispersion across the U.S. grow, so does their influence.

    The COVID-19 crisis has paved a path to health equity for NHPI. It has led to an unprecedented mobilization and the establishment of a strong national coalition. It has shown the efficacy of NHPI communities in responding to a public health crisis. NHPI communities are well organized and prepared to engage directly with county, state, and federal public health agencies to provide NHPI leadership, perspectives, and cultural assets in combating health inequities in NHPI communities.

    As an ancient Hawaiian proverb proclaims, Pūpūkahi i holomua!(Unite to progress.) NHPI are doing just that.


    1. Panapasa SV, Crabbe KM, Kaholokula JK. Efficacy of Federal Data: Revised Office of Management and Budget Standard for Native Hawaiian and Other Pacific Islanders Examined. AAPI Nexus. 2011;9(1-2):212-220.
    2. NHPI COVID-19 Data Policy Lab Dashboard. UCLA Fielding School of Public Health; 2020. Accessed November 16, 2020.
    3. Kaholokula JK, Samoa RA, Miyamoto RES, Palafox N, Daniels SA. COVID-19 Special Column: COVID-19 Hits Native Hawaiian and Pacific Islander Communities the Hardest. Hawaii J Health Soc Welf. 2020;79(5):144-146.
    4. Morey BN, Tulua A, Tanjasiri SP, et al. Structural Racism and Its Effects on Native Hawaiians and Pacific Islanders in the United States: Issues of Health Equity, Census Undercounting, and Voter Disenfranchisement. AAPI Nexus Journal: Asian Americans and Pacific Islanders Policy, Practice. 2020;17(1 & 2).
    5. 2018 Demographics Report. U.S. Department of Defense;2018. Accessed November 16, 2020.
    6. Samoa R, J.K. K, Penaia C, et al. COVID-19 and the State of Health of Pacific Islanders in the United States. AAPI Nexus: Policy, Practice and Community. 2020;17(1 & 2).
    7. Hixson L, Hepler BB, Kim MO. The Native Hawaiian and Other Pacific Islander Population: 2010. U.S. Census Bureau;2012.
    8. Goo S. After 200 Years, Native Hawaiians Make a Come Back. Pew Research Center. Published 2015. Accessed November 17, 2020, 2020.

  • National Minority Mental Health Awareness Month Blog Series

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    July Is the Best Month to Start a New Year of Working on Mental Health

    Posted on
    Harold W. Neighbors, Ph.D.

    Division of Intramural Research
    National Institute on Minority Health and Health Disparities

    Dr. Harold W. Neighbors

    When I started graduate school in the mid-1970s, I had just one seemingly simple research question. I wanted to know: “Who had the higher rate of mental illness, Black or White Americans?” I remember the puzzled looks from fellow students, as most of them already knew the answer – “Blacks of course!” Their reasoning made good sense – life was harder for Blacks in the United States, and a life spent fighting against racial discrimination can lead to emotional damage.

    So, I began my investigation, uncovering layer after layer of complexity surrounding what I thought was a simple question. My motivations were both professional and personal. Personally, like many families, Black and White, mine had revealed a few semi-private stories about “bad nerves” (the preferred language of emotional distress used to describe mental health problems) that were offered for consumption in the smallest of morsels. And even though my curiosity was never quite satisfied, I instinctively knew not to push for too many details. Professionally, there was my first “big” assignment as a graduate research assistant on a new, innovative study, the “National Survey of Black Americans”1. I wrote my dissertation on one aspect of the subject: help-seeking behavior for mental health problems, using data from the National Survey of Black Americans. My dissertation research told me that Black Americans need to stop, look, listen, and most importantly, tell the truth about our feelings. The key to sound mental health is what people of color decide to do about profound sadness, feelings of helplessness resulting from attacks on our self-esteem, and hopelessness due to unjust institutional impediments that erode aspirations for achieving one’s best life2. My investigation revealed that when feelings become unbearably painful, they are symptoms. Once you are symptomatic, you need to get help. It is just that simple; and difficult; and complicated.

    Access to Mental Health Care
    Gaining access to mental health therapy is too hard for too many, especially for people of color. I know this to be true from my own help-seeking experiences. One of the lessons I learned was that getting help meant overcoming the fear of what others will think should it ever become public knowledge that you were in therapy. I was fortunate. My work history eliminated the financial barriers and I was, eventually, able to overcome my fear of being thought less of, because I decided to exercise my right to professional therapy3. Mine is but one story. Sadly, national statistics show that we still have a long way to go to eliminate racial and ethnic inequities in mental health services4.

    Speak Up: Say Something to Somebody
    If you feel something, say something, to somebody. Cutting ourselves off from a potential confidant, or our natural support networks, increases social isolation precisely when we need other people the most. Even worse, social isolation can lead to feelings of loneliness, which is bad for our mental health5. When we step back to view the larger social context surrounding what often feels like an exclusively private choice, we see that we do not need to face these problems alone; to do so is a choice we make. The first step is to reach out to just one person. But please hear me on this – we must go public!

    Be Your Own Mental Health First Responder
    In short, we are our own mental health “first responders.” We must act upon our symptoms in a manner that starts to alleviate the distress we feel. People of color must push back against stigmatization by telling our stories, because that is one way to erase the idea that mental health is something qualitatively different and apart from health. To me, Minority Mental Health Awareness Month, now known as Black, Indigenous, and People of Color (BIPOC) Mental Health Month, is about quality of life. Sadly, compared to Whites, Black Americans remain less happy with our lives. Racial and ethnic population group comparisons have limitations and are not always subject to thoughtful explanations. But a commitment to health equity demands the accountability that comes from regularly monitoring comparative data for changes over time6.

    My Recommendations
    July 2020 is the best month for everyone, regardless of skin color, age, gender identity, sexual orientation, religious background, or disability status, to start a new year of working on mental health.

    Here are five ways to work on your mental health:

    • Listen to your heart and vow to take better care of yourself.
    • Cross your heart and promise to tell the truth.
    • Summon the courage to talk with just one person about your true feelings.
    • Try to question, or at least process, all racial micro-aggressions regardless of when the aggression occurred. Micro-aggressions, no matter how unintentional or accidental, are never “innocent,” and they certainly are not small. And because they often appear quickly, seemingly “out of nowhere,” the opportunity to respond in “real-time” also disappears quickly. A note of caution here; it is not always possible to respond directly, and it can be especially challenging to do so in the workplace.
    • Connect with people who are committed to advocating for policies that are beneficial to the mental health of all people of color. Collective action, based on a shared identity and a sense of common fate, is good for mental health.

    Acting on these recommendations will not be easy. I struggle with all of them. It is not easy precisely because our situation is so complicated. I have been around long enough to remember the family stories my elders used to tell us about what life was like when they were “coming along.” Because of them, my life has been different, less difficult, and better in many ways. They put in the hard work and made the sacrifices; now it is our turn to build upon that foundation and make it better for others.


    1. Jackson, J. S. (1979-80). Program for Research on Black Americans. National Survey of Black Americans Series.
    2. Neighbors, W., Sellers, S. L., Zhang, R., & Jackson, J. S. (2011). Goal-Striving Stress and Racial Differences in Mental Health. Race and Social Problems, 3(1), 51-62.
    3. Neighbors, H. W. (2019). AAMC. “Manning up” can often bring men down.
    4. Substance Abuse and Mental Health Services Administration. (2015). Racial/Ethnic Differences in Mental Health Service Use Among Adults.
    5. Taylor, H. O., Taylor, R. J., Nguyen, A. W., & Chatters, L. (2018). Social Isolation, Depression, and Psychological Distress Among Older Adults. Journal of Aging and Health, 30(2), 229-246.
    6. Iceland, J., & Ludwig-Dehm, S. (2019). Black-White Differences in Happiness, 1972 – 2014. Social Science Research, 77, 16-29. 10.1016/j.ssresearch.2018.10.004
  • National Minority Mental Health Awareness Month Blog Series

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    American Indian/Alaska Native Mental Health: Our Voices, Traditions and Values to Strengthen our Collective Wellness

    By Victoria M. O’Keefe, Ph.D. (Cherokee/Seminole Nations of Oklahoma)
    Mathuram Santosham Endowed Chair in Native American Health, Assistant Professor, Licensed Clinical Psychologist
    Associate Director, Center for American Indian Health
    Department of International Health, Social & Behavioral Interventions
    Johns Hopkins Bloomberg School of Public Health

    Dr. Victoria M. O’Keefe My late grandma, Virginia Feather Revas, was a Cherokee Nation citizen, a fluent speaker of ᏣᎳᎩ ᎦᏬᏂᎯᏍᏗ (Cherokee language), and a Community Health Representative (CHR) for our tribe. CHRs are embedded within their tribe and serve important roles in health promotion for their communities.1 My grandmother served our tribe proudly and instilled in me the importance of working on behalf of our people. My favorite memories with her, from visits to Oklahoma, were going to our family’s creek to catch ᏥᏍᏛᎾ (crawfish) for dinner, attending stomp dances and pow wows, and admiring her talent for beadwork and quilt making. These memories are important teachings that I value now more than ever.

    My grandma’s words to work on behalf of our people always stuck with me. As a first-generation college student and undergraduate psychology major, I quickly realized I wanted to focus my career path on mental health research with and for Native people. The urgency I felt in this decision was due to a few reasons. First, there was hardly any representation of Indigenous people or content in my education from kindergarten through my undergraduate training. Invisibility of American Indians/Alaska Natives (AI/ANs) from public discourse is a modern form of discrimination and impacts numerous areas of Native life, including mental health.2 It wasn’t until I was in a clinical psychology doctoral program that I saw and had Native role models as professors, and learned about mental health research and clinical work with Native communities. Second, I searched the empirical literature and found that the majority of published articles about AI/AN communities and mental health reflected deficit-based and Westernized narratives/methods. Tribal values and teachings, like the ones my grandma passed on to me, weren’t represented in research. Finally, I remember reading an article by Dr. Joseph Gone (Aaniiih) illuminating “the sad reality [is] that the mental health needs of this nation’s Native American citizens remain largely overlooked and ignored” (p. 10) due to the federal government’s lack of fulfilling its trust responsibility to tribes.3 These factors motivated me to use my education as a pathway to increase and improve Native representation in academia, encourage strengths-based and alternative approaches to mental health that are responsive to AI/AN community needs, and engage Indigenous knowledge and cultural strengths that promote mental health and wellness.

    Though my grandma didn’t get to see me accept my first job at Johns Hopkins Bloomberg School of Public Health at the Johns Hopkins Center for American Indian Health (JHUCAIH) in 2017, I’m constantly reminded of her teachings and her own work as a CHR. The innovative suicide prevention work developed by the White Mountain Apache Tribe and JHUCAIH, is carried out by community mental health workers (CMHWs).4 CMHWs serve their own communities, reduce barriers to, and stigma associated with, mental health care services, and provide culturally effective brief interventions and psychoeducation.5 This capacity building within tribes promotes self-determination over community mental health and overall wellness. The expansion of local mental health care by CMHWs can also promote tribal languages, values, and traditions that directly and indirectly help reduce mental health inequities.5

    To promote AI/AN mental health, we need to rely on our community strengths and traditional teachings – teachings that connect mental health with physical and spiritual health. We also need to create culturally safe spaces for AI/AN youth and scholars to lead the next generation of wellness practice with tribal communities. I hope every day that I’m making my grandma proud and that I’m passing on a bit of her legacy as a beadworker, novice Cherokee language speaker, and promoter of tribal communities’ health and wellness.

    The Center for American Indian Health is providing information on COVID-19 for Native Communities. Visit


    1. Indian Health Service. (2020). Community Health Representative.
    2. (2018). Reclaiming Native Truth.
    3. Gone, J. P. (2004). Mental health services for Native Americans in the 21st century United States. Professional Psychology: Research and Practice, 35(1), 10-18. doi: 10.1037/07357028.35.1.10
    4. Cwik, M. F., Barlow, A., Goklish, N., Larzelere-Hinton, F., Tingey, L., Craig, M., Lupe, R., & Walkup, J. (2014). Community-based surveillance and case management for suicide prevention: An American Indian tribally initiated system. American Journal of Public Health, 104(Suppl 3), e18–e23.
    5. O’Keefe, V. M., Cwik, M. F., Haroz, E. E., & Barlow, A. (Epub 2019). Increasing culturally responsive care and mental health equity with Indigenous community mental health workers. Psychological Services.
  • National Minority Mental Health Awareness Month Blog Series

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    Centering Structural Inequities in Conversations on Mental Health Among People of Color

    Margarita Alegría, Ph.D.
    Chief, Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Mongan Institute
    Professor, Departments of Medicine & Psychiatry, Harvard Medical School

    There has been tremendous attention brought to mental health as part of the coronavirus pandemic. The good news is that there is now almost universal recognition that when our mental health is precarious, costs are immeasurable. What has become more apparent is how this cost is much higher for people of color. But why is their burden of mental illness so much greater? What can help shed light on how mental illness impacts racial and ethnic minorities so adversely and profoundly, even when they have lower or similar prevalence rates of mental health disorders when compared to White people1?

    Let me offer some things to consider, some food for thought. First, we need to pivot from attributing these differences in mental health burden to the individual and recognize how they can be best understood by structural inequities attributed to policy, law, governance, and culture. They include, for example, U.S. immigration policies, voting ID laws, housing segregation regulations, drug sentencing laws, among others. They steer people of color to a plethora of unfair experiences, differences in opportunity and limitations toward accessing the beneficial social determinants of health. Together, structural inequities negatively influence the ability to recover from health problems, including mental health issues.

    There is strong evidence that chronic exposures to early stressors influence brain development. For example, the harmful impact of structural inequities can be represented by differential exposure to traumatic and chronic stressors impacting child development2. Clearly, the environmental context matters, as we see from national surveys that show 61% of Black children have experienced at least one adverse childhood event compared with 40% of White non-Hispanic children. And although we have paid attention to the role of families in these negative outcomes, we have been ignoring the influence of institutions, including schools, criminal justice systems, and governments, along with their decision-makers. These are the prominent factors that influence (or determine) whether people live in socioeconomic advantage versus disadvantage, threat versus nurturance and support, or opportunity versus hopelessness.

    Structural inequities are insufficiently addressed by academic researchers and in policy discussions of mental health among populations of color. Yet, they are the root causes of disparities in mental health. Take for example employment in the food and retailer industry, where women of color have the highest rates of work schedule unpredictability3; even higher than others within the same company, at the same rank. Daniel Schneider, Ph.D., assistant professor at the Department of Sociology, University of California, Berkeley, and Kristen Harknett, Ph.D., associate professor of Social Behavioral Sciences at the University of California, San Francisco, have shown how work unpredictability and instability, both in terms of hours and schedules, impact these women in their ability to make child-care arrangements4, and how it generates work-life conflicts in the family life5. All this instability translates to greater risk for behavioral problems in their children6, and anxiety and depression in themselves.

    Or take for example, bail setting, sentencing laws, and racial profiling for people of color, which disregard a person’s available resources to defend oneself, and create rampant distrust and perpetual anxiety7. For Black youth, feelings of constant discrimination and a sense of unfairness, in combination with a lack of mental health treatment, may lead to losing hope that may even lead to suicide8,9.

    We need to change the narrative to focus on how our institutions magnify the harms from mental illness rather than minimize them and promote well-being. It’s time to act on these structural inequities!


    1. Alvarez, K., Fillbrunn, M., Green, J. G., Jackson, J. S., Kessler, R. C., McLaughlin, K. A., Sadikova, E., Sampson, N. A., & Alegría, M. (2019). Race/ethnicity, nativity, and lifetime risk of mental disorders in US adults.Social psychiatry and psychiatric epidemiology, 54(5): 553-565.
    2. Sacks, V., Murphey, D. (2018). The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicityChild Trends.
    3. Storer, A., Schneider, D., & Harknett, K. (2019). What Explains Race/Ethnic Inequality in Job Quality in the Service Sector?Washington Center for Equitable Growth.
    4. Schneider, D., & Harknett, K. (2019). It’s About Time: How Work Schedule Instability Matters for Workers, Families, and Racial Inequality. The Shift Project.
    5. Schneider, D., & Harknett, K. (2019) Consequences of Routine Work-Schedule Instability for Worker Health and Well-Being. American Sociological Review, 84(1): 82-114.
    6. Schneider, D., & Harknett, K. (2019). Parental Exposure to Routine Work Schedule Uncertainty and Child Behavior. Washington Center for Equitable Growth.
    7. Davis, R. A., Savannah, S., Yañez, E., Fields-Johnson, D., Nelson, B., Parks, L. F., Do, R., Macaysa, A., & Rivas, R. (2016). Countering the Production of Health Inequities. Prevention Institute.
    8. Dennis, K. N. (2019). The complexities of black youth suicide. Scholars Strategy Network
    9. Lindsey, M. A.; Sheftall, A. H; Xiao, Y., & Joe, S. (Epub, 2019). Trends of suicidal behaviors among high school students in the United States, 1991-2017.Pediatrics, 144(5).