“Native Hawaiian or Other Pacific Islander” is a federally recognized racial category in the United States that encompasses the Indigenous peoples of Hawai’i, Guam, Sāmoa, Tonga, Fiji, the Marshall Islands, and dozens of other Pacific Island nations and territories. The label covers an enormous geographic and cultural range, from Melanesia in the western Pacific to Polynesia in the east, yet it compresses all of these distinct populations into a single checkbox on census forms and medical intake sheets. That compression has real consequences for health research, public policy, and the everyday visibility of communities whose needs often vanish inside aggregated data.
Who the Category Includes
The U.S. Office of Management and Budget established the NHPI category in 1997 when it split the older “Asian or Pacific Islander” grouping into two separate designations. The intent was to make Pacific Islander populations more visible in federal data. The category formally covers anyone with origins in the original peoples of Hawai’i, Guam, Sāmoa, or other Pacific Islands, a definition that sweeps in Native Hawaiians, Samoans, Chamorro (the Indigenous people of Guam and the Northern Mariana Islands), Tongans, Fijians, Marshallese, and many smaller communities.
In the 2020 U.S. Census, roughly 1.6 million people identified as NHPI alone or in combination with another race. That makes NHPI one of the smallest racial categories in the country, which is part of the problem: small sample sizes mean NHPI data frequently get folded into “Asian” totals or dropped from published results entirely. The result is a statistical disappearing act that researchers at the University of Hawai’i have described as “data genocide,” arguing that aggregated race and ethnicity standards erase the health and social realities of Pacific Islander communities.
Why Data Disaggregation Matters So Much
When Pacific Islanders are lumped together with Asian Americans in health surveys and research databases, the averaged numbers can hide severe disparities in both directions. A study using Youth Risk Behavior Surveillance data found that the combined “Asian and NHPI” group showed a suicidal ideation prevalence of about 17.5% among adolescents. But once the data were broken into subgroups, the range stretched from around 13% for some Asian subpopulations to over 21% for Filipino youth, with other Pacific Islander groups scattered across the spectrum.1PubMed Central. Unmasking Suicidal Ideation for Asian American, Native Hawaiian, and Pacific Islander Youths Via Data Disaggregation A single averaged percentage obscured meaningful differences in who was struggling most.
The same pattern plays out in diabetes statistics, cancer survival, maternal outcomes, and infectious disease. Researchers and community advocates have pushed for disaggregation at the state and federal level, arguing that without it, public health agencies cannot target interventions to the populations that need them most. Hawai’i has been at the forefront of this effort, developing statewide race and ethnicity data standards that separate NHPI subgroups rather than collapsing them into a single line item.2PubMed Central. The Hawai’i NHPI Data Disaggregation Imperative: Preventing Data Genocide Through Statewide Race and Ethnicity Standards
Migration History and Genetic Origins
The peoples grouped under the NHPI label share deep roots in one of the most remarkable migration stories in human history. Genomic research has reconstructed a branching Polynesian migration sequence that originated in Sāmoa and expanded in a series of founder events: first to the Cook Islands, then to the Society Islands around the 11th century, on to the Tuāmotu Archipelago and western Austral Islands in the 12th century, and finally reaching the most remote corners of the Pacific, including the Marquesas Islands to the north and Rapa Nui (Easter Island) to the east, settled around AD 1200 via Mangareva.3PubMed Central. Paths and timings of the peopling of Polynesia inferred from genomic networks Each new settlement involved a small founding group, which meant a progressive loss of genetic variants from west to east, a signature visible in modern DNA.
Melanesian and Micronesian populations in the western and central Pacific have their own distinct settlement histories, some stretching back tens of thousands of years. The genetic and cultural diversity within the NHPI umbrella is vast: a Marshallese family in Arkansas and a Native Hawaiian family on the Big Island share a federal racial category but have very different ancestral paths, languages, and cultural frameworks. Treating these communities as interchangeable has been a persistent blind spot in both research and policy.
Diabetes and Metabolic Health
One of the starkest health disparities facing NHPI communities involves diabetes. A large Northern California health system study found that Pacific Islanders had a diabetes prevalence of about 18%, higher than every other racial and ethnic group examined, including African Americans, Latinos, and Native Americans, all of whom are traditionally considered high-risk populations. Pacific Islanders also had the highest incidence rate, with roughly 20 new cases per 1,000 person-years.4PubMed Central. Elevated rates of diabetes in Pacific Islanders and Asian subgroups: The Diabetes Study of Northern California (DISTANCE) In Hawai’i specifically, middle-aged Native Hawaiians were found to be more than three times as likely to have diabetes compared to White residents of similar age.5PubMed Central. Prevalence of Heart Disease and Its Risk Factors Related to Age in Asians, Pacific Islanders, and Whites in Hawai’i
Cardiovascular disease, obesity, and diabetes cluster together in what researchers call the cardiometabolic syndrome, and growing evidence identifies NHPI populations as among the highest-risk groups for these conditions in the United States.6Epidemiologic Reviews. Cardiometabolic Health Disparities in Native Hawaiians and Other Pacific Islanders The causes are layered: they include the nutrition transition away from traditional diets, socioeconomic stressors, limited healthcare access, and, in some cases, genetic factors that interact with modern environments in harmful ways.
A Genetic Variant That Complicates the Story
One of the more fascinating pieces of NHPI health research involves a variant in a gene called CREBRF that is common among Samoans but rare in most other populations. This variant appears to lower fasting blood glucose, which would seem protective against diabetes. But it also increases body mass, particularly fat-free mass. Researchers studying Samoan adults found that the variant’s protective effect on glucose does not operate through changes in body composition. Instead, its effects on body size and on blood sugar seem to work through different, tissue-specific pathways.7PubMed Central. The protective effect of rs373863828 on type 2 diabetes does not operate through a body composition pathway in adult Samoans
The CREBRF story matters because it illustrates why NHPI health cannot be understood through the same lens used for other populations. A genetic variant that simultaneously increases body size while lowering diabetes risk defies the usual assumptions about the relationship between weight and metabolic disease. It also underscores the value of conducting research specifically in Pacific Islander populations rather than extrapolating from studies of Europeans or East Asians.
Cancer Survival and Comorbidity Burden
When NHPI cancer patients are studied separately from Asian American patients, the picture is grim. A large analysis using national cancer registry data found that NHPI patients had worse survival than White patients across several common cancers, including oral cavity cancer, lymphoma, endometrial cancer, prostate cancer, and breast cancer. There were no cancer types in which NHPI patients demonstrated better survival than White patients. On top of that, NHPI patients carried a significantly higher burden of other medical conditions at the time of cancer diagnosis, with women facing nearly double the odds of comorbidity compared to White women.8JAMA Network Open. Disparities in Survival and Comorbidity Burden Between Asian and Native Hawaiian and Other Pacific Islander Patients With Cancer
These findings reinforce why collapsing NHPI into the broader “Asian” category is so misleading. Asian American cancer patients as a whole often show survival rates comparable to or better than White patients. Averaging Asian and NHPI outcomes together masks the fact that NHPI patients are faring considerably worse, and it delays the kind of targeted screening and support programs that could close the gap.
Maternal Health and Preterm Birth
Pregnancy outcomes are another area where NHPI communities face disproportionate risk. A systematic review and meta-analysis pooling data from over 200,000 Pacific Islander births in the United States estimated a preterm birth prevalence of about 11.8%, and found that Pacific Islander women were roughly 45% more likely to deliver preterm compared to non-Hispanic White women.9PubMed Central. Global prevalence of preterm birth among Pacific Islanders: A systematic review and meta-analysis Interestingly, this disparity was specific to the U.S. context: in New Zealand, Pacific Islander women had preterm birth rates similar to those of European women. That geographic difference suggests that the elevated risk in the United States is shaped more by systemic and environmental factors than by inherent biological vulnerability.
Mental Health and Trauma Exposure
Mental health research that focuses specifically on NHPI populations is still relatively sparse, but the studies that do exist paint a concerning picture. In one study of Native Hawaiian and Pacific Islander adults, about 69% reported experiencing at least one traumatic event in their lifetime, with participants averaging exposure to two and a half distinct types of trauma. The most commonly reported events included childhood physical abuse, witnessing someone seriously injured or killed, sexual assault, childhood sexual abuse, and having a close friend or family member murdered.10PubMed Central. Trauma and mental health in Pacific Islanders
These trauma rates connect to broader social conditions: housing instability, multigenerational overcrowding, economic precarity, and the lingering effects of colonization. Community leaders interviewed about structural determinants of health have pointed to housing as the single most pressing issue, not just the availability of shelter, but the chronic overcrowding that occurs when multiple generations share a single-family home, with cascading effects on physical and mental well-being.11SSM – Qualitative Research in Health. Examining structural racism as the fundamental cause of health inequities among the Indigenous Māori, Native Hawaiian, and Pacific Island peoples in the U.S. and Aotearoa New Zealand
The Nutrition Transition
Across the Pacific, traditional food systems built around root crops, breadfruit, coconut, fish, and other locally grown or gathered foods have been steadily displaced by imported processed products. Researchers tracking processed food sales across Pacific Island countries found that sales were climbing fastest in lower- and middle-income Pacific nations, with baked goods and edible oils leading the increase.12PubMed Central. Processed Foods and Nutrition Transition in the Pacific: Regional Trends, Patterns and Food System Drivers Food trade is a major engine of this shift: many Pacific Island nations now depend heavily on food imports, and what arrives tends to be calorie-dense, nutrient-poor, and shelf-stable rather than fresh.13Global Food Security. The role of trade in pacific food security and nutrition
For NHPI communities in the United States, the nutrition transition takes a different form but leads to similar outcomes. Access to traditional foods is limited by geography, cost, and urbanization. Spam, white rice, and sweetened beverages have become dietary staples in many NHPI households, partly through cultural adoption during and after World War II and partly through the economics of food deserts. The result is a mismatch between metabolic systems shaped by centuries of island diets and the modern food environment, which helps explain the extraordinary rates of obesity and diabetes in these communities.
COVID-19 and Infectious Disease Vulnerability
The COVID-19 pandemic laid bare how aggregated data can obscure the disproportionate impact on NHPI communities. When a large health system broke down its testing data by subgroup, Pacific Islanders had the highest test positivity rate at about 20%, and their odds of hospitalization were more than one and a half times those of non-Hispanic White patients.14PubMed Central. Disparities in COVID-19 testing and outcomes among Asian American and Pacific Islanders: an observational study in a large health care system These outcomes were driven by many of the same factors underlying other NHPI health disparities: higher rates of underlying conditions like diabetes and cardiovascular disease, crowded housing that made isolation difficult, employment in essential jobs that could not be done remotely, and limited access to healthcare.
Compact of Free Association and Insurance Gaps
A significant and underappreciated policy issue affects migrants from the Marshall Islands, the Federated States of Micronesia, and Palau, the three nations covered by the Compact of Free Association (COFA) with the United States. COFA citizens can live and work in the U.S. without a visa, but for years they were excluded from Medicaid and many other federal benefit programs. This created a paradox: people with legal residence and work authorization who nonetheless could not access basic health coverage. Researchers have documented how these policy barriers constrain health insurance access for COFA migrants, contributing to delayed care, untreated chronic conditions, and emergency department reliance.15PubMed Central. Compact of Free Association Migrants and Health Insurance Policies: Barriers and Solutions to Improve Health Equity Federal legislation in 2020 began restoring Medicaid eligibility for some COFA residents, but gaps remain, and awareness of the issue is low outside the affected communities.
Bone Health and Body Composition
Not all NHPI health data point to disadvantage. A study of prepubertal Pacific Island children in New Zealand found that they had significantly greater bone mineral content than European children at several skeletal sites, roughly 8 to 16% higher depending on the measurement location. However, these differences largely disappeared after the researchers adjusted for lean body mass, suggesting that the larger bone measurements reflect larger overall body size rather than fundamentally different bone biology.16PubMed. Do young New Zealand Pacific Island and European children differ in bone size or bone mineral? In adults, a small study of Native Hawaiian women in rural Hawai’i found that participants generally had healthy bone density scores.17PubMed. An Exploratory Study of Bone Health Among Native Hawaiian Women in Rural Hawai’i These findings, while limited in scope, challenge the assumption that Pacific Islanders share the bone health risks seen in some other underserved populations.
Caregiving, Elders, and Cultural Values
In many NHPI cultures, care of elders is understood as a family and community responsibility rather than something outsourced to institutions. Qualitative research with Native Hawaiian elders and their family caregivers has found that core cultural values deeply shape caregiving preferences. Elders expressed a strong desire to remain in familial settings, while caregivers described the dual influence of cultural duty and social stressors, including experiences of discrimination in healthcare settings that they perceived as disrespectful.18PubMed Central. Listening to the Voices of Native Hawaiian Elders and ‘Ohana Caregivers: Discussions on Aging, Health, and Care Preferences
Research on NHPI families dealing with Alzheimer’s disease and related dementias has reinforced these themes. Caregivers described their role through concepts like kuleana (responsibility) and lōkahi (balance), framing caregiving not as a burden but as a cultural practice inseparable from honoring kūpuna (elders) as holders of cultural knowledge.19PubMed. Health and Well-being of Family (‘Ohana) Caregivers of Native Hawaiian and Pacific Islander Adults Living with Alzheimer’s Disease and Related Dementias For healthcare providers working with NHPI families, understanding these frameworks is not cultural window-dressing; it is the difference between care plans that families actually follow and ones they quietly abandon.
Language Revitalization and Education
The Hawaiian language came perilously close to extinction in the 20th century. At its lowest point, fewer than a thousand native speakers remained, most of them elderly. The establishment of Hawaiian-medium immersion schools, known as Kula Kaiapuni, beginning in the 1980s became a model that other Indigenous communities around the world have studied and adapted. These programs are built around not just language instruction but the revitalization of cultural traditions, family relationships, and Indigenous identity rooted in place.20Journal of Immersion and Content-Based Language Education. Revitalizing indigenous languages through indigenous immersion education Today, Hawaiian is one of the most successful examples of language revitalization globally, with thousands of speakers raised through immersion education and the language embedded in public signage, government proceedings, and media in Hawai’i.
Other Pacific Islander languages face their own pressures. Samoan, Tongan, and Marshallese are all spoken in diaspora communities across the mainland United States, but maintaining fluency across generations is difficult when schools, workplaces, and media operate almost entirely in English. The loss of language carries consequences beyond communication; traditional ecological knowledge, navigation techniques, and oral histories are encoded in languages that do not always translate cleanly into English.
Traditional Agriculture and Ecological Knowledge
Recent research has dramatically expanded the estimated scale of pre-contact Hawaiian land use. Earlier models suggested that Hawaiian populations cultivated roughly 3 to 6% of the land area. But when researchers analyzed historical maps and included agroforestry and arboriculture alongside the more commonly studied wetland and dry-field agriculture, the estimated footprint of landscape modification jumped to about 25%.21Ecology and Society. Forgotten forests: expanding potential land use in traditional Hawaiian agroecosystems, and the social-ecological implications Over 80% of the mapped arboriculture sites fell outside previously modeled agricultural areas, meaning that an enormous portion of managed food production had simply been invisible to earlier scholarship.
This is not just an archaeological curiosity. The rediscovery of traditional agroforestry systems has practical implications for food sovereignty, sustainability, and climate adaptation in Hawai’i. Growing breadfruit, kukui, and other tree crops in managed forest systems requires less water and less soil disturbance than conventional agriculture, and it aligns with Indigenous land management philosophies that treat food production and ecological stewardship as the same activity rather than competing priorities.
Wayfinding and the Hōkūle’a
Perhaps no single cultural practice captures Pacific Islander identity as powerfully as traditional oceanic navigation, or wayfinding. Between 2014 and 2017, the traditional voyaging canoe Hōkūle’a completed a worldwide voyage using no modern instruments, navigating by stars, ocean swells, wind patterns, and wildlife behavior.22BMJ Open. Qualitative study on voyaging and health: perspectives and insights from the medical officers during the Worldwide Voyage The voyage covered tens of thousands of nautical miles and visited dozens of countries, demonstrating that the navigational knowledge that enabled the original peopling of Polynesia is a living tradition, not a museum artifact.
For NHPI communities, the Hōkūle’a and the broader voyaging movement have served as a source of cultural pride and a vehicle for education. The canoe has become a symbol of Pacific Islander resilience, and programs connected to it teach young people not just navigation but also marine ecology, teamwork, and the Hawaiian concept of mālama honua, caring for the Earth. Researchers who accompanied the voyage found that the experience of wayfinding had measurable effects on the well-being of participants, connecting physical activity, cultural practice, and mental health in ways that conventional wellness programs rarely achieve.