Advocacy

I am a Native Hawaiian family physician, a wife, a mother and an Associate Professor here in the Department of Native Hawaiian Health at the John A. Burns School of Medicine. I’ve been a faculty member at the School of Medicine for 20 years. I came to the medical school from private practice and although I’m a full time faculty member now, I continue to have a small clinical practice 1 day a week.

My work here at the medical school is focused on cultural competency training, and one of the things I realized, especially when I was practicing medicine in the continental US, was that culture really does matter. When I was in medical school in the 80s, I was taught to treat everyone the same and be colorblind, but I realized in practice that you can’t do that. There are differences between different groups of people such as in the ways that you communicate with them… I realized that culture was actually quite important, that was something that was downplayed when I was in medical school. And it wasn’t just communication style – it also had something to do with traditional healing practices and how that interfaces with the Western medicine system.

I’ve had some good experiences with Chinese acupuncture personally and that peaked my interest in using traditional Hawaiian medicine. I began working with our traditional Native Hawaiian healers here in Hawai’i for myself and my family and then wanted to add learning about traditional Native Hawaiian medicine to the medical school curriculum. I realized that this is an important component of healthcare, and we need to train our physicians to be open to it, to be able to offer those kinds of options to our patients, and to be able to communicate with our traditional and complementary medicine healers. We have a whole longitudinal cultural competency curriculum here and we bring in healers and talk about traditional healing practices, but we especially focus on improving student communication skills.

Finally, health disparities in our communities is a travesty. For being as advanced a society as we are, that we have these kinds of health disparities in our country is just really sad. I mean there are multiple factors that contribute to health disparities, and what I’m passionate about is making sure that students understand what the health disparities are and the possible causes for them. For example, in our indigenous communities – Native Hawaiian, Native American and Alaska Natives – the impact of colonization is huge and must be addressed. But we also have all the issues that come with our immigrant populations – they will have other reasons for their health disparities. In general, many of these disparities involve the social determinants of health, for example poverty and the way our institutions are structured. So it’s really important for students to have an understanding of the origins of health disparities. Obviously as physicians we can’t, for example, fix the secondary education system of our children by ourselves, but we have a very powerful voice as advocates.

I grew up in Hawaii in a town called Kaneohe on the island of Oahu. I got my undergraduate degree from the University of Notre Dame, in South Bend, Indiana and then I came back home to the John A. Burns School of Medicine for medical school. After that I went to Lancaster, Pennsylvania for my family medicine residency. I always thought I would come back home to practice, because I knew there was a real need for Native Hawaiian physicians, particularly female Native Hawaiian physicians. I just wasn’t sure when. I started in a small private practice in Lancaster, but I started feeling more and more like I really needed to come back home and do more. So I did come home and I was in private practice for a while when I became involved with the Association of Native Hawaiian Physicians. It was that connection that led to my current work at the School of Medicine.

You know, I just submitted a testimony to the state legislature – and that is something we can do to impact policy. I think students need to understand that when we have an MD behind our name, that is really powerful. People will listen to you. And so I think it’s important for students, especially those who come from marginalized communities, that we use our voice for our communities. We get really busy in our clinics, but we can’t separate what our patients are suffering from, from what’s going on in our communities. It’s incredibly important and we need to do what we can to try to rectify that, even if it’s just using our voice on a piece of legislation or speaking out on one policy that we’re passionate about that can make a difference in our community – if we all do that kind of thing, with every small action we take, we can be really successful collectively.

We can’t keep practicing medicine in this country the way we’ve been doing in the last 20, 30, 40 years. I’ve been practicing since 1989, and the health disparities of our communities haven’t gotten any better – in fact, some of them have gotten worse. And that shouldn’t be in a country like ours.

Being a female and a Native Hawaiian was huge because when I came to medical school, there weren’t many Native Hawaiian doctors. When I was trained – in the 80s – I was really trained in the Western model of education – very evidence-based, scientific. And then when I moved back home, and I opened up practice, all of a sudden I had a lot of Native Hawaiian patients. With that came the realization that I really didn’t know as much about my culture as I should have known. My patients were expecting me to know and yet, here I was, a Native Hawaiian who was so Western oriented.

For Native Hawaiians, we went through a cultural renaissance in the mid to late 1970s. For example, our language was almost lost. For my father’s generation, it was very shameful to speak Hawaiian. They were punished in school for speaking Hawaiian. It was also shameful to be a cultural practitioner – a lot of our traditional healing practices went underground. Then we went through this renaissance and our language came back and our cultural practices came back. I mean, we had hula before – but even that, what a lot of people thought of as hula was super different from our traditional hula – it was given a Hollywood slant. But our traditional hula came back, as did things like wayfinding (traditional navigation), eating our traditional foods, our martial arts, traditional healing practices…all of that came back. But it was around this time that I went away to college on the continent. I went to Notre Dame, and then medical school, and I was very “cocooned” in med school. I didn’t learn about cultural practices or the Hawaiian language. Remember, my father was punished for speaking Hawaiian and so he did not speak the language growing up. As a result, growing up, my family really didn’t do that many cultural things except for eating our traditional foods on special occasions as well as dancing hula and playing and singing Hawaiian music.

When I came home, there were so many expectations on the part of my patients that I was a Native Hawaiian physician, and I should know these things. When I started with the Ahahui o na Kauka (Association of Native Hawaiian Physicians) as a young doc, we tried to network with other young Native Hawaiian docs – we realized we all had the same issue, that we were raised very Western, but yet our patients were expecting more of us, and we were feeling kind of lost. We realized we needed to reconnect with our culture. We needed to connect with our land and our traditions.

I was lucky that I was able to combine this realization of the need to reconnect with our culture and land with the work that I was doing at the medical school. As the Ahahui o na Kauka got very serious about trying to help Native Hawaiian physicians reconnect to culture, my work at the Native Hawaiian Center of Excellence at the medical school was focusing on developing a cultural competency curriculum for faculty and physicians that targeted Native Hawaiians and their health disparities. We worked together – we embarked on conferences, immersions, and various activities to reconnect us as physicians to our culture, reconnect us to our land, our ancestors, our communities and also to open our minds. Traditional healing doesn’t always have “evidence” to justify how it works. All of the practices have a large prayer and spiritual component, and how do you measure that? You can’t measure that well. These are things that our ancestors have done for thousands of years and they work. For example, as Asian physicians, we don’t need someone to tell us that acupuncture works or not, we know, right?! So as a Western trained physicians, how do we bring these things together? How do we close health disparities? We want optimal health for our communities. Not just average – we want better than average. We want optimal. And how do we do that?

My first challenge was having the confidence to even think that I could be a physician. I’m the first in my family in the healthcare field, and although my father was lucky enough to go to college, my mother did not. I was the first one to get an advanced degree. I wouldn’t say my family discouraged me, I just didn’t have that confidence that I was smart enough to do it. But the thing that made me decide to go for it – apply to medical school – was that I didn’t want to be 65 and look back on my life and say, “I wish I had.” I didn’t want to have regrets. And so my attitude was, “okay, I’m gonna go for it, but I also have to have Plan B ready,” because I honestly didn’t think I was smart enough.

And I kind of struggled with that feeling of am I smart enough, am I good enough, even when I did get into med school. There were very few Native Hawaiians. And so you feel like there’s a little more attention paid to you, and you feel like you have to prove yourself. That is a little more of an extra burden and you feel like you have to work a little harder. “Yes, I belong here!” I try to work with pre meds now, and I hope I’m able to change that mindset. You have to get past the stereotypes that Hawaiians are dumb – the stuff you hear when you are little.

I was probably lucky – as a woman, I never experienced really bad gender bias. In residency, I had a couple surgeons who would call me “sweetie” or something like that, but I never really felt harassed. However, even in residency, I still felt like I had to prove myself, like “who’s this Native Hawaiian woman?” In Lancaster, they had Mennonite, Amish, African American and Puerto Rican communities – these were very different from the communities in Hawaii. But being Native Hawaiian had it’s benefits. It made it easier for colleagues and patients to start conversations with me. Luckily, people were always curious about Hawaii which made it easier for them to ask me questions and start a conversation, like “Wow, you’re from Hawaii!” Once you start a conversation with a patient, you’re already opening the door to building rapport and trust, and this makes it easier to have a good therapeutic relationship.

Also, when you’re a physician coming from a minority background – interacting with other minorities, you have something in common. You may come from a very different culture, but some of the struggles are the same. You can connect somehow, and open up conversations.

I’m active in the Association of Native Hawaiian Physicians, so I find out about issues from my colleagues when they need support. So my advice would be to get active, in your school, in organizations, or in communities back home – what are the issues coming up? What are the battles being fought? There are so many things out there – so the way you find it is to find something you’re interested in, do it, and then you’ll get introduced to more. There’s so much need everywhere!

An easy thing to do is to submit testimony. For example, there’s usually a government website for this. The hard thing is that there’s usually not a lot of time to submit it – – so you have to have an active network that will send you alerts when the testimony is needed. .

A lot of students come to medical school and already have passions from before – so you can go back to that. But if not, through rotations and electives you do get exposed to communities. I really encourage you to do at least one elective in an underserved community, because that kind of experience will really help you understand what issues affect their lives and you may find the thing you want to start advocating for.

I’m continuing my work for JABSOM in the area of improving health disparities through focusing on physician training. The IOM report, Unequal Treatment, talks about the importance of cross cultural communication in addressing health disparities… the patient – health provider communication, their interaction, is a contributor to maintaining health disparities. When we don’t know, as providers how to interact with people from different cultures, or when we have unconscious biases, those things contribute to health disparities. So it’s not just poverty, access to insurance, lack of providers, bad schools, lack of access to good jobs contributing to health disparities, but it’s also the communications between patients and the healthcare system and the providers that’s contributing. Institutional biases, our personal biases all play a role. For medical schools and residency programs, that’s one thing we can directly address – how our future providers interact with patients and to make sure that we as providers don’t contribute to the worsening of healthcare disparities and that we actually make them better.

I am very approachable by email (which I know is not the favorite form of communication for a lot of students anymore) – martinak@hawaii.edu. I’m really happy to support students, answer any questions and I am willing to help mentor. It’s one thing I didn’t have a lot of early in my training – which would’ve helped a lot with my confidence. So I’m hoping to be that person for other people!

I’m a clinical investigator and professor of medicine at UC San Francisco.

I am passionate about having representation of Asian Americans in medical research and about having data to guide our health policy and what we do in medicine, based on people who are represented in studies. And so my goal with my research is to generate data to show how different Asian American groups are – we have been aggregated in one monolith when there are over 20 different groups, and those groups are very different from each other individually! I’m in the business of generating data to make these distinctions between different Asian groups clear. Overall, my passion is to give voices to Asian American subgroups that have been neglected.

I’m the first of my family to go into medicine. I was interested in medicine primarily for clinical patient care, and I’ve been at UCSF since medical school; I chose to go into primary care because I liked having longitudinal relationships with my patients and their families, and getting to know the whole person over many decades.

Really, my patient care experiences have fueled my interest in research, because I saw many patients who were having terrible complications with diabetes as a med student and resident, many of whom were ethnic minority group members, many from Asian American communities. And we really didn’t know much about how these groups, if treatments should be tailored any differently, how to prevent these chronic diseases in the community. That just struck me as a major gap in knowledge, and I just thought we have to do something about this, because we can’t do anything without proper information.

I took a major turn in my career as a resident, when I worked on a research project to understand how we can predict TB where the sputum stain is negative, and it was a great introduction for how we can answer a question with data – it just opened up a whole new experience for me. I decided to do a research fellowship in general internal medicine also at UCSF, and I knew I wanted to focus my research on diabetes: it’s a passion for me because it is so prevalent in my family, my community, and in my patients. I have seen a lot of devastation caused by type 2 diabetes.

I found it hard to get started because there weren’t very many faculty in UCSF who do clinical research around diabetes. There’s a lot of basic science research on type 1, but not much in clinical research around type 2. So I had to cast a wide net to find research mentors outside of UCSF, and I found one at UCSD, even though it was long distance. From then it’s been a tireless effort to keep going in this track – it took a total of 5 tries to get my first grant on South Asians. Since then, I have been working on developing what we need to know, and what we can do together with this community and for this community.

It’s about disseminating the research and educating people about different ways of understanding risk factors for different groups. It’s not just about generating the data about this ethnic group that is very different than other groups, but it’s about using the data to inform the community about how to make better decisions around their healthcare and the lifestyle choices they make. And then, having that data to help guide health policy.

What we found in our study to change the way doctors and health policy makers think about risk in Asian American communities. We recently published a paper in JAMA where we disaggregated Asian American groups in a national study that’s done every 2 years, and we showed that there’s so much variation among Asian Americans and you have to disaggregate this to see who’s at really high risk for diabetes. This kind of work has really opened the eyes of many people, because Asian Americans are not thought to be high risk because of smaller and slimmer body sizes, and that’s so far from the truth – South Asians, Filipinos, and some Southeast Asian groups as well, are actually some of the highest risk groups.

We’ve also done a big Screen at 23 campaign working with the National Council of Asian Pacific Islander Physicians; when we put our data from South Asians, East Asians, and Southeast Asians together, we showed that Asians develop diabetes at a much lower BMI – 23 instead of 25, and we really need to screen Asians at 23. We had health organizations adopt this resolution that they’re spreading through their community and educating health providers about. The American Diabetes Association has adopted this guideline of using 23 as the BMI cut-point for screening Asian Americans for diabetes.

My role in medicine is to be a clinician and also be an educator to my peers and to my community at large, to help people. It’s not just about the papers you write, the citations you get, the tweets that get retweeted, or the Facebook posts that get liked. It’s about really affecting people’s lives and making them healthier.

I’m an immigrant – I was born in India and moved to the US when I was 6 years old, and I identify as Asian American. I think growing up bicultural and adopting the best of both worlds has really influenced my advocacy, because I see people who do live in both worlds or in only one of those worlds and how their culture or their society can influence their health. with that perspective, I’m able to code switch – which I do often when I’m working in the community, I can be an insider.

The challenge is constant. It’s having people take you seriously and what you’re doing seriously, and having funding for the work you want to do and having it sustained. I just received a bad score on another grant today – it’s all about persistence in this academic line of research that we’re in. You’re constantly getting bad news, tough criticism, and you have to develop resilience in the biggest way. I’m thankful to be able to laugh after a bad score now, because it’s crushed me many times! It’s all about the passion that drives you.

Get involved as soon as possible, because you don’t know if it’s for you unless you try it out – seeing what work with the community is like, what the day to day academic research life is like. Whether it’s for outreach or education, or it’s actual research recruitment or follow up, or just other advocacy work, there are so many different ways you can get involved in whatever community is of most interest to you.

Reach out to people not too far away or even those across the country – I have people reaching out to me from all over the country to spend a summer working with our group, and you can even schedule it as part of your training to have an elective month or two away. Reach out to people who you want to emulate or who you think could be a potential role model or mentor for you! And you’ll be surprised – I always respond with an email to any student or trainee, and if I just don’t have space I let them know, but we’ve taken many many student research interns over the years. It’s really about just putting yourself out there.

Well, we’re constantly working on our cohort of over 1,100 South Asians from the San Francisco Bay Area and the greater Chicago Area, MASALA – writing papers, disseminating our findings, and thinking of new ways to prevent diabetes as well as cardiovascular disease. The cohort is going to be 10 years old this year – it’s my number one biggest project.

The second new project is an Asian American research registry called CARE: we will be recruiting 10,000 Asian American community members in California who are interested in being in research that’s involved with aging, cognition, and dementia. These are Asian American groups with adults of any age, and I’m helping with the South Asian registration. The point of this registry is that when future researchers want to do research and include Asian Americans, they have a really rich registry of 10,000 names with different demographic characteristics, and all the barriers for getting better representation are lowered.

I’m on Twitter as @alka_kanaya; you can also follow the results of the MASALA cohort at @masala_study or at our website. Our website also has a great South Asian community health resources page with tips about how to stay healthy!