In this episode, Dr. Liao speaks with Raynald Samoa, MD, an endocrinologist at the City of Hope and national leader in several national organizations representing the Pacific Islander community.
Joshua Liao: Before we jump in, tell us a little bit about your journey and how you got to your current career as a research endocrinologist at the City of Hope.Raynald Samoa: I didn’t really plan on going to medicine when I started college. It was something that I had to grow into. You know Pacific Islanders really aren’t encouraged to go into science and those fields, when I was in high school. It wasn’t in college when you’re left to your own devices, and you have to find what you’re interested in, that’s when the Life Sciences started to become more interesting to me. I actually gravitated towards it, it made more sense. I didn’t have to study as hard because things came naturally. With that, I was trying to find what kind of career I could pursue with that and my family has always been one that was very oriented to serve the community.
So, a lot of the activities that I participated in as a young adult and adolescent were things that helped communities. I did some (it’s generous to call it translating) language work as a young adult in clinics. Through that, I saw more patient-physician interaction and thought, you know this is something I might be intersted in. I was able to go to some minority medical education programs, I don’t know if they still have those, but that was instrumental in getting me into medicine. Once that took off, it was a straight shot.
I went to LA County, USC, for residency. There, the medical training was excellent but what was even more special to me about my training there was the front view of health equity, or inequities if you will. And how as a physician you had to be social worker, mental health professional, all these other disciplines just to get your patients the care that they deserved. Even that, probably, still wasn’t equitable. So, that was sort of my first taste of health inequities and training there for endocrinology. I did my endocrinology fellowships there, and at Children’s Hospital Los Angeles, and there I got to see a lot of dysfunctional care just because that’s what our system was doing. That’s what we could do, you know? A lot of it was convention, a lot of it was driven by insurance companies and what they would pay for. A lot of it was just sort of resources amenable to those indigent populations. So, when I graduated fellowship, diabetes became something I became more passionate about, and a lot of my younger years as an attending was sort of spent just trying to get the lay of the land of vulnerable communities.
You know, I practice here in Southern California so that generally means Latino and Hispanic communities. But I also kept trying to see how I can help Pacific Island communities as well. And in that [vulnerable population] group, also cancer survivors because I landed at a cancer research hospital that does a lot of diabetes research. So, that’s when I started doing more community outreach, and when I mean community outreach, I mean everybody: schools, churches, friends’ groups, community health clinics, I used to do CME talks for the US affiliated Pacific Island community health clinics. Those are clinics that in Ebeye, Majuro, you know the Marshall Islands, that coalition of clinics because there was no other endocrinologist.
I am the only Pacific Islander endocrinologist on the continent. And I think I am the only Samoan endocrinologist in the world. So, a lot of these Pacific Islander communities, although I don’t come from there, I am the closest. I spent a fair amount of time pro bono giving CME talks to these clinics and the time difference, you know, if they had their didactics on a Monday, that meant it was a Sunday for me. Often times, I would be putting laundry in my kitchen and delivering a CME talk to the Pacific. And they were so unbelievably grateful. I knew that was just one touch point for equity. You know it’s kind of like you chip away where you can chip away and at that point, that’s all I could do.
Raynald Samoa, MD
City of Hope
JL: Wow, thank you for sharing that. I believe that when we’re talking about working on equity and advocacy, that ultimately our best efforts and our more durable efforts are close to our strengths. So, I really appreciated how you talked about how it was more aligned with you, it made sense. I really liked your approach about community with a capital C.
Amid the pandemic you’ve taken on some roles in in helping lead and thinking about equity, the Advisory Commission on Asian Americans, Native Hawai’ians and Pacific Islanders, and the National Pacific Islander COVID-19 Response Team. Why has this team been necessary in your view and in what was are you driving impact for the community that maybe wasn’t present before?
RS: The group came about when we started to see the first reports come out, I think it was the Sacramento Bee, that published the first report of NHPIs having the highest rate of COVID in California at the time. I had just recovered from COVID, like literally two days, and then somebody sends me the article. So, I was a statistic. I think like anyone else your immediate response was to help. I think that’s why a lot of physicians become physicians because we’re in it to help people. When I kept trying to find ways to help, I couldn’t find it. I looked toward other groups that traditionally advocated for Pacific Islanders and wasn’t seeing anything. And so, in true Pacific fashion when you’re in that situation you go and find people you know and you gather them. So, I reached out to all my colleagues who were Public Health professionals, professors, community health advocates, health workers, everything and asked them to come together on a Zoom call to say, “hey can we form something to advocate together?”
Immediately when we came together, we found out we don’t have a really strong federal voice. We had almost zero national presence. And it’s not for a lack of trying. There were people who had been in those places trying to push for that but it was just nowhere to be found during the pandemic. So, the first thing we knew was that we need to see how far this problem reached. That meant getting data. I think that’s why NHPI and Asian Americans, and Native Americans work so hard together, that we’re often in ally ship, because of this data disaggregation problem that renders us invisible. We found that there was very little data being reported at the start of the pandemic. I reached out to groups that had been sort of advocating and working with us in the past. I think we teamed up with UCLA with Ninez Ponce’s team and they were able to put together an NHPI data lab. We referred a couple graduate students to help work with them because you want to work toward equity; that you can do this on your own. I believed that Ninez could foster that kind of mentorship and improve the capacity. And so, what they found out was that 16 out of the 22 states at the time, NHPI had the highest rates of COVID. Then in 11 of the 19 that reported mortality data, NHPI had the highest mortality rate. So, you can see how this is problematic, right? And there wasn’t really anything be published about it. We had to put together a full-fledged strategy. A lot of this painstaking work was done outside of any type of payment. A lot of us, who volunteered our time, talent, and treasure, put some painstaking effort into putting together a strategy that would be implemented throughout the regions.
Our first line item was to get people to push their local public health departments to start publishing data, to start reporting disaggregated data, and finding a way around the usual statistical limitations that restrict that type of reporting. I think that’s how Oregon got their data out, that’s how Arkansas got their data out, that’s how Hawai’i got ther data out. It was a model that was working and getting community-based organizations into the conversations with public health departments because they were going to be the agents that would do all the leg work for everything. When the county or the public health departments wanted to do testing, when they wanted to do public outreach, when they wanted to do vaccination clinics, this would be the group that they would work with. So, entering those conversations by advocating for data was the way in with them.
The one thing we wanted to make sure was, when people started reporting it, I think it was Yancy in JAMA that started reporting the disproportionate burden of COVID on communities of color and that a lot of this is driven due to long standing social economic inequities, that that’s basically what was driving our high diabetes rates, our poor cancer screening, and our poor cancer survival rates. So, these long-standing inequities have already caused much harm to our communities, so we knew that the COVID-19 Response Team was just that. It was meant to respond to COVID. But if we were going to do anything worth doing we needed to have something in place to go way past COVID. The Response Team evolved into the National Association of Pasifika Organizations, or NAOPO. NAOPO is now this collection of community-based organizations, NHPI serving community-based organizations that have put their resources to gether to advocate together. They’re growing pretty rapidly and they’re national. They reach all across the continent and including Hawai’i, to do a lot of the foundational equity work. A lot of it was pertinent to COVID and some of it’s not. So, you need a good structure to carry past COVID such as developing a community health worker model, being in the conversation in regards to insurance especially for COFA [Compact of Free Association Migrants] communities, and putting people at the table.
I think my job now is not to speak for our community, but to put people in places where they can speak for themselves. That has been where I have been transitioning out of the Response Team to NAOPO and the national scene.
JL: What jumps out to me that I’ll articulate for our listeners is, one, this idea of the passion for a topic leads to the effort. It’s very hard to manufacture that. You’re describing a lot of sweat and energy from a lot of people that care deeply for a problem. You mention this idea of the Response Team being that. So, I was going to ask you what comes next? Certainly, there are a lot of issues related to COVID, but what happens next? You’ve answered that with NAOPO and what’s coming. Let’s shift there, if we think about either sequala or longer things of COVID, or just other issues, where are you seeing the biggest gaps now? And what are you trying to do to fill those gaps? You’ve mentioned a few of them. Are there other gaps there that you think NAOPO can help address?
RS: What we’re still struggling under is data disaggregation to do more granular policy recommendations. We’re about to publish a paper in regards to a survey we did for Asian Americans, Native Hawaiians and Pacific Islanders’ COVID experience that was charged by Congress. We worked with the Asian American Psychology [Lab], AAPA, led by Anne Saw at DePaul. Dr. Nia Aitaoto and myself, we handled the NHPI part of the survey and one of the things we found was that there were some things that were consistent with what is seen in other communities of color, such as the socioeconomic health gradient. That gradient that says the more you make the more education you’ve received, the better your health will be or the better health access you have. And the vaccine hesitation followed that for a lot of Pacific Island communities where we noticed that vaccine hesitancy was higher in people who had less educational attainment and lower income, but it wasn’t uniform. It wasn’t across all Pacific Island communities. There were some groups regardless of their education and their income that they still had high hesitancy. When you’re talking to a community about trying to improve, some of it is socioeconomic, some of it is some upstream factors of improving one’s strata if you will. But then in other communities it’s about the messenger where it doesn’t matter where they went to school or how much they make. They’re getting their information that’s making them afraid of vaccines. It’s really important that we don’t treat our communities like a monolith. That’s the same for education. Health is just the most commonly used example, but in business, in small business ownership, in education, in Department of Justice statistics, in incarceration rates, all of those need to be flushed out more thoroughly. I get that there are some obstacles in regards to getting more granular disaggregated data, but the answer cannot be “we cannot do it” because we know now from COVID that we can. You have to be more innovative. You also have to be very intentional. Secondary analysis on datasets that already exist is a very low hanging fruit. Unfortunately, communities have to rely on academic institutions or academic researchers who feel like it’s time to look at that, right? Some one is going on sabbatical and they feel like they’re going to focus their energies on this, and health equity cannot be at the whim of an investigator. It has to be intentional. And so, I know that the equity data work group that was put forth by President Biden’s order is working on trying to improve those types of situations and that there’s more data equity throughout all federal agencies. They still got a lot of work to do.
One of those things that I think needs to be discussed is the updating of OMB [Office of Management and Budget] categories. I can speak for Native Hawaiian and Pacific Islanders that our data needs to be further disaggregated, and you can see how that work in Hawai’i when the Department of Public Health in Hawai’i started to further disaggregate their NHPI subgroups and their Asian American subgroups. The data they were able to collect from that helped do focused policy recommendations or policy changes. The updating of OMB minimum standards, I think, has to be on the table now because we need that data. I don’t know how many examples you need. The 2014, NHIS, the National Health Interview Survey, that was done by NYU with doctor Stella Yi showed very detailed indicators on Asian American and NHPI subgroups helped detail health policy. You’re able to see which specific subgroup were more likely to smoke, which one’s that were more likely to not get cancer screening so that you could focus your efforts on reaching out to those smaller subgroups instead of doing a blanket “something” for everyone when it only pertains to a certain group.
Joshua Liao: This series of conversations is often focused around systems of how we pay for and deliver care. If we were to focus on that systems piece for a second, are there two or three areas where you think these are really key health systems changes that would really help address equity for the Pacific Islander community, be it payment, care deliver, something else?
Raynald Samoa: There’s a ton so I’ll try to be succinct. One of the things we noticed from the survey too was that there was a big delay in seeing their provider. Before the pandemic, the delay in seeing a provider kind of broke more socioeconomic lines, it was people who had higher education and made more, seemed to have less problems seeing their providers. But after, or during the pandemic, it was across the board. It was about 2/3 across all ethnic groups were having problems seeing their provider. When asked, “what was the biggest obstacle?”, one of the responses was the conversion to telehealth. And, everywhere I go, telemedicine is being touted as the answer to health equity and here I am looking at data saying that that's the opposite. There’s a lot to be said about how one community perceives telemedicine, whether a phone call or video is given as much weight as a face to face visit as far as changing one’s behavior. When you’re talking about diabetes and lifestyle modification, that point is unbelievably crucial. On top of access issues as we talked about with, it is extremely frustrating.
Currently our COFA community can access health benefits but it’s very random. It depends on the administration and where they’re at, and these are communities that come from the South Pacific. They pack their family’s up to move out here, and they support the agricultural industry heavily so. Their presence here is a major benefit to this country and often times they are treated as if they’re a burden. I think that’s something we need more solid determination on, access, that goes for our immigrant populations as well. But also, our health literacy makes it difficult for communities to make sure that they have adequate access to medial services. The medical literacy goes hand in hand with our education and the fact that we have very low rates of college entrance or college completion, means that that’s going to plague us. That’s going to continue to plague us. I think for generations, we weren’t able to speak to our problems with access and our problems with health because we could not articulate it.
I’m the first Samoan that went to the University of Washington School of Medicine. I don’t want to take this lightly, I love that school. It’s the reason why I am a physician today. But it was very different being the first one there. Almost every example that had to do with where weight was a risk factor, the case was Samoan, specifically Samoan. In that situation, you start to see inequity in real time. You’re so far removed from seeing what the triggers are to the increased incidence of these conditions that what I saw providers doing was blaming lifestyle behaviors on culture and not understanding how racist that is; that the socioeconomic factors that contributed to their health inequity is not really being looked at very strongly.
There’s nothing wrong with trying to improve your cultural competency but your perspective of cultural competency should expand outside of what you perceive as their rituals around food and physical activity. It should take into account their historical presence in that community you are at. It should take into account their historical access issues and why that is. I know that is a lot to put on a provider’s desktop but I think at least having the conversations about this. I’m the interim fellowship site director here at my institution so I’m staring to see more discussion, more health equity infused into curriculums so I’m hoping that this lends itself to policy changes that will help Pacific Islanders.
JL: What I hear the loudest in what you’re saying here is that policy needs to be multidimensional so there is a facet of it that is clinical care, it needs to cascade to clinicians because that’s where health care is figured out. There needs to be an educational component, if you let people go through an educational system and then wait to address it later, you’re behind at that point. At the most distal point, there’s also these policy things that probably there are things that you don’t want to put in the hands of individuals and clinics. You want to use system redesign, and those are simultaneous, it should happen at the same time.
I’m really glad you brought up this question about telemedicine. On its face, it can do certain things, but telemedicine is not one monolithic thing. It’s different things, and even if it increases access you have to ask the question, “access to what?” So, one of the themes here is to peel back that next layer, not just say cultural competence but what is informing that competence; redesign, what is informing that? And in this case, if you think access to what, you might imagine certain modalities of telemedicine are well intended but actually create these separate and unequal tracks where you’re comfortable allowing people to use health care that might not be equitable. I think that type of framework is very useful and I appreciate you sharing that.
I want to follow-up on one other thing which I consider as part of systems and my team and I think about a lot, is this idea of trust and who is doing the communication around preventive and other care. You mentioned community health workers earlier. Is there a systems or policy approach, at least for the Pacific Islander community or others that you work with, that would be particularly promising? Because I think in different communities, people have talked about CHWs and there’s definitely energy, yet I think there’s still room to improve how we design policy around that. Not a policy prescription, but what are some early steps we can take to think about CHWs and their effectiveness in Pacific Islander or other communities?
RS: Well, definitely using them as an extension to reiterate messaging that’s done in the clinic. You talked about cultural competency, they can help translate the context of your messaging so that it has a more cultural relevant basis. When you talk about systems it’s tough because the current system is not working. I can say that because the health disparities that are experienced by NHPI are partly in result because of our system, it’s not an individual Pacific Islander that is getting sick. It is a population which means systematically it’s not working for us. I think it’s that whole understanding of what is care. As our understanding of health care and health care models, and influences of health expand, our system of delivery needs to expand with it.
The diabetes from the Western stand point is, and I’ll save you my longer spiel about it, the popular understanding about type II diabetes is that it’s a result of not eating healthy and not exercising. So, laden upon that is a lot of guilt and self-blame. We use medications to help lower blood sugars, even though the root causes of it, poor stress management, poor sleep, inadequate nutrition, and insufficient physical activity, are laden upon other stressors such as how much time we have to exercise because we work too much, having food available 24/7, and mostly calorie dense foods and being stressed all the time and not sleeping well. So, we make up for what we cannot change in someone’s real life with medications. You can see how all we’re doing is trying to put out a fire by pouring gas on it. It’s that, that structure needs to somewhat change in trying to address roots in some fashion. I know as physicians we can’t do that a lot. I try to do it, which is why I notoriously go over time, but it’s because our model is focused on getting information, examination, and prescribing. That’s why those visits are timed the way they are and reimbursed the way they are because that’s the model.
But when we talk about physician satisfaction and what will change physicians’ motivation to make changes, that medical inertia that often times plague patient outcomes, the competing demands on a physician during a visit tells us that we need to change the way the visit operates, and the resources available to the physician, to do their work. I think, currently we think about increasing reimbursement and I do think physicians are worthy of their salaries. But the salary part of the job is just one small aspect of it. If you’re going to treat chronic disease then you need to have a system that is set up to treat chronic disease from top to bottom. I just haven’t seen a lot of movement in that regard. Your paper was a nice refreshing, little take on it that, there are some models being discussed. But if we’re really going to take a stab at health equity and maintain physician satisfaction, we’re going to really have to try to explore models that look at reimbursing from a different perspective.
JL: This is my bias because this series of conversations is about recognizing the connection between what we see in communities and in health care settings as inequities, and tying it back to the system. This tension between the fact that there are certain drivers that are systems level, and yet in other ways, systems are just collective values and policies from collections of people. I think a lot of what you’re describing give a lot of that texture given your experience and I really appreciate that.
I hope that the ideas and the suggestions, and the work that I and colleagues are doing represent, one, maybe a little drop but what I hope becomes a bucket, and becomes much bigger here. I really appreciate you taking the time, Raynald Samoa, thank you for joining us today on this health equity conversation. I really enjoyed this conversation and I think a lot of the things you shared our listeners will as well.
RS: Thanks Josh, thanks for having me.