As of January 31, 2021, Pacific Islanders in Hawai‘i had the highest age-adjusted mortality rate in the United States at 319.6 deaths per 100,000 persons. In comparison, the United States mortality rate during the same period was 153 deaths per 100,000, and Hawai‘i as a whole had the lowest mortality rate in the country, excluding U.S. territories, at 22 deaths per 100,000. You’re now likely asking yourself, “Who are these Pacific Islanders, and what’s going on with COVID-19 in Hawai‘i?”

Hawai‘i and COVID-19

When most people hear the word “Hawai‘i,” they usually think of beaches, world-class surfing, Waikiki, and Pearl Harbor. Others think of the lack of a racial majority in the state, where 37.6% of the population is Asian alone, and 25.5% is White alone.

Hawai‘i has mostly been absent from national news related to COVID-19 due to the overall small number of cases, 29,811 total cases as of April 2021. Due to racial diversity in Hawai‘i, COVID-19 data is broken down even further by ethnicity: White, Native Hawaiian, Pacific Islander, Filipino, Japanese, Chinese, Other Asian, Black, and Other. A brief glimpse at the Hawai'i data reveals a dramatic disparity amongst a particular racial group—the Pacific Islanders. Although Pacific Islanders only comprise 4% of the state population, they represent 22% of COVID-19 cases, 30% of COVID-related hospitalizations, and 22% of COVID-related deaths.

Racial disparities in the continental United States

In March 2021, the Centers for Disease Control and Prevention (CDC) published data showing that “Black or African American, Non-Hispanic persons” had 1.1x the case rate, 2.9x the hospitalization rate, and 1.9x the death rate of “White, Non-Hispanic” persons. Researchers have also found that “racial inequality and social exclusion existed before the COVID-19 crisis.” Public health experts have published extensively on structural violence, including a call “to engage with communities to deliver sustained upstream structural interventions that will outlast humanitarian crisis moments.”

Who are the Pacific Islanders?

In Hawai‘i, the Pacific Islander demographic primarily includes people from the United States affiliated Pacific Islands (USAPI): Guam, Commonwealth of the Northern Mariana Islands, Republic of Palau, Federated States of Micronesia, Republic of the Marshall Islands, and American Samoa.

On the Hawaii State Department of Health COVID-19 Case Report Form, the individual’s race has to be handwritten by the provider. These races include Samoan, Tongan, Chamorro, Marshallese, Chuukese, Yapese, Kosraean, Pohnpeian, and Palauan. The COVID-19 data broken down by individual race was initially unavailable due to discrimination concerns but has recently been published. Of the 4,193 COVID-19 cases in Hawai‘i between March 8, 2020, and January 31, 2021, 62% of COVID-19 cases and 52% of COVID-19 deaths were within Micronesians from The Compact of Free Association (COFA) nations.

Why COFA migrants?

The COFA is an agreement between the nations of the Republic of Palau (Palauans), Federated States of Micronesia (Chuukese, Yapese, Kosraean, and Pohnpeian), and the Republic of the Marshall Islands (Marshallese). It allows these people to freely immigrate into the United States to live and to work. Since Honolulu, Hawai‘i is the first stop for most flights leaving the USAPI, Hawai‘i has some of the largest numbers of people from these islands outside of their home island nations.

Although the COFA is a federal agreement, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 removed all COFA migrants from federal insurance coverage. It was therefore left up to individual states to determine whether COFA migrants qualify for Medicaid.

In 2015, the State of Hawai‘i (Korab v. Koller) revoked Medicaid coverage to COFA migrants that were nonblind, nondisabled, nonpregnant, and aged 18-64 years. All non-Medicaid COFA migrants were then able to enroll in Medicaid-subsidized private insurance through health insurance exchanges. Due to this Medicaid change, there was an increase in COFA migrant uninsured visits to the emergency department and a 21% increase in this population’s mortality rate by 2018. These trends continued through March 5, 2020, when Governor Ige proclaimed the first emergency proclamation related to COVID-19 and Hawai‘i had its first COVID-19 case.

COVID-19 swept through the urban community of Kalihi in Honolulu, Hawai‘i. As of April 13, 2021, there were 2,522 cases, the highest number of total cases in one zip code in the state. In August 2020, while the state had a near 10% positivity COVID-19 testing rate, a federally qualified health center (FQHC) servicing Kalihi reported a nearly 30% positive COVID-19 testing rate. This same FQHC primarily services the Pacific Islander communities in public housing.

The COFA migrants in Kalihi were the perfect target for COVID-19: uninsured, multigenerational households, dense urban living, and multiple language barriers. The result was that the COFA migrants, included within the Pacific Islander demographic, had the highest age-adjusted mortality rate in the United States.

Is there hope?

In response to these disparities, the Pacific Islander community organized. Groups such as the Native Hawaiian and Pacific Islander COVID-19 Response, Recovery, and Resilience Team, We Are Oceania, and Kōkua Kalihi Valley Comprehensive Family Services began collaborating to best serve Pacific Islander communities. Services included things like translation of COVID-19 materials into the appropriate languages.

Then, on December 27, 2020, a long-awaited fix to the Medicaid issue for COFA migrants occurred—The Consolidated Appropriations Act, 2021 reinstated Medicaid coverage to the roughly 100,000 COFA migrants in the United States. With that change in Medicaid coverage, a substantial upstream structural intervention occurred for COFA migrants. Yet, much work remains to address the structural violence experienced by this minority group in Hawai‘i.

**Feature photo provided and used with permission from author Nash Witten.

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Nash Witten, MD, is a board certified Family Medicine Physician and National Health Service Corps Scholar providing primary care services to the Kalihi community in Honolulu, Hawai‘i, through Kōkua Kalihi Valley Comprehensive Family Services. He is also an Assistant Clinical Professor in the Department of Family Medicine & Community Health and adjunct Assistant Professor in the Department of Native Hawaiian Health at the University of Hawai‘i John A. Burns School of Medicine.