Embracing diversity in rehabilitation in Pacific cultures.

This paper presents a unique and personal view of rehabilitation issues, needs, and expectations of individuals with disabilities in seven diverse Pacific jurisdictions. The vastness of the Pacific and its unique cultures offer a glimpse of island living unlike any other geographic area of the United States. Presented are the authors' views drawn from their experience and observations in rehabilitation services.

The Pacific is unique with regard to geographic, familial, political, economic, and social issues that impact both rehabilitation services and individuals with disabilities. The island environments, influenced by political, economic, and social change, are in a constant state of evolution. Island communities are being impacted by change at all levels--at the local level in each unique Pacific area; at the regional level with all island entities competing for the same dollars, programs, and services; and at the national level where changes impacting the future of island entities continue to be discussed, argued, and negotiated.

In the political arena, change has resulted in new nations and government structures. United States Government levels of funding are being reexamined and, in some cases, reduced. Reductions have occurred in the Federated States of Micronesia, the Republic of Marshall Islands, and the Republic of Palau. Economic stability is a goal rather than a reality in a geographic area that has long been dependent upon subsidies from the United States, foreign governments, and private business enterprises. With limited local resources and capacities to develop a sustaining economy, the islands have become more dependent on a "cash economy." The traditional custom of a subsistence economy is a thing of the past for most of the island entities in the Pacific.

Social environments of family and community have affected this process of change with traditional practices and cultural values being challenged, reexamined, and modified. For example: Hull (1991) noted there is an "increased dependence on imported foods, the expropriation of healthcare by specialists, and more generally, the far-reaching transformation of lifestyle making incalculable changes to both physical and cultural health in the region". Health-indicated challenges throughout the Pacific are dominated by diseases of affluence (the effects of tobacco, alcohol, drug abuse, stress, poor nutrition, and lack of exercise). Oneison (1991) indicated "one major cultural change is the transfer of resources from land and water to cash, a change that breaks up the unity of the clan and enhances individual family independence culminating in changes in one's identity". Finally, Marcus (1991) observed that "the breakdown of the family structure is drastic and people do not know how to cope with the changes taking place. Everyone wants change but we do not know how to deal with the problems that result from changes".

Change in the Pacific is inevitable. As the American historian Charles Beard stated, "History is irreversible. Sovereign or not, no island people can return to their condition at discovery. All of what they are today is because of what they have been through. . ." (in Grattan, 1981). The impact of environmental (social and communal) change on an individual with a disability in the Pacific is both exhausting and promising. Opportunities for inclusion in all levels of the culture and community are enhanced, although often slow to fruition. Examining established systems and institutions, such as rehabilitation services, medical care, education programs and opportunities, and political and social systems, as well as valuing the local practices that drive these systems, is essential prior to suggesting change. The challenge is for the people anywhere particularly in the Pacific communities--to be prepared to deal with change firsthand, evaluate its impact on individuals and environments (cultural, social, economic, and political), and determine how to fully integrate change into their day-to-day life.

Understanding Rehabilitation in the Pacific

Any approach to a rehabilitation service, research, and training provision must be developed and implemented within the unique context of the geographic area. To be successful each approach must reflect each island's cultural uniqueness.

To understand and appreciate the diversity of issues impacting individuals with disabilities in the Pacific, one must comprehend the size and uniqueness of the Pacific area, which covers in excess of 5 million square miles of the Pacific Ocean and includes numerous political entities as well as many cultural and social groups.

Each of the seven entities served by the Rehabilitation Research and Training Center of the Pacific (RRTCP) is unique and diverse in geography, culture, and people, as well as in political, economic, social, and kinship systems. To group these entities together is a disservice to indigenous Pacific cultures.

Before we expand on the issues, we need to consider the differences of the State of Hawaii in relationship to the other Pacific islands and communities. Hawaii achieved statehood in 1960, and is truly a state that represents a culturally diverse and complex environment. It has a large urban population in the city of Honolulu as well as many rural communities in the outer islands and the North Shore of Oahu. Hawaii is afforded the same accountability for its resources, services, and future directions as the other 49 states. The availability of rehabilitation related services and resources are more expansive and sophisticated (although surely not without need for further development and refinement) than the other Pacific entities.

Geographic Issues

The geographic differences and environments that exist among the island entities cannot be overemphasized. The seven island entities--Hawaii, American Samoa, Marshall Islands (RMI), Federated States of Micronesia (FSM), Northern Marianas Islands (CNMI), Guam, and Palau--that comprise RRTCP in the Pacific lie scattered throughout thousands of square miles of the Pacific Ocean. The islands range from a variety of small reef islands to large mountainous, volcanic islands. The Pacific is frequently exposed to natural disasters which alter the quality of life of its residents. Earthquakes, typhoons, drought, power outages, and dependence on imported goods affect daily living.

Associated difficulties include infrequent or inconsistent air transportation (inter-island as well as mainland connections). For example, American Samoa is served by one air carrier with limited (usually one flight) and inconsistent schedules during any given week, limiting delivery of food items, mail, and air freight. Some islands are not easily accessible by air or by sea, especially in the outlying islands. Availability of essential or emergency medical care and equipment is impeded by insufficient air/land/sea cargo and transport. A common practice in the Pacific is to transport emergency related critical medical care cases to Hawaii or the U.S. mainland for treatment. These cases usually include individuals with life threatening disabilities (i.e., spinal cord injuries, head trauma, stroke, heart disease, and renal failure). The infrequency and inconsistency of air service hamper this practice as does the cost of transport service.

Geographic conditions affect the use, maintenance, and assistive devices affordable for individuals with disabilities. Sidewalks in most of the Pacific are clusters of cement, coral, sand, or dirt. Tropical rains often overwhelm local sewer lines and drainage capacities become overextended. Pot holes are commonplace and, in many of the local villages, roads are paved with crushed coral or volcanic rock. The island environment fosters corrosion of metals and the rapid breakdown of plastic or rubber. Most assistive technology devices are made of metal (wheelchairs, canes) and break down in the Pacific within months of purchase and consequently have limited value. There are no local facilities currently available to provide maintenance or repair services for this equipment in Pacific areas beyond Hawaii.

Other environmental factors contributing to the incidence of disability in the Pacific include poor sanitation, tropical diseases, infections, lack of preventive awareness, limited medical care, lack of or limited communitywide social and rehabilitation services, and cultural stigmas related to disability.

The questions need to be asked, "What can be done locally to improve necessary services and, more importantly, how can these necessary services improve the quality of life for individuals with disabilities?"

Each island entity has a population center or capital where most human services are provided. The outlying islands are infrequently served by health officials and social service providers, including vocational rehabilitation. The availability of services and resources for individuals with disabilities on these outlying islands is virtually nonexistent. Outreach to these islands fosters frustration on the part of the individual with a disability and his/her family because of unfulfilled promises made for medical and rehabilitation services, equipment, and opportunities. Subsistence living on the outer islands is the norm, while in the population centers there is a heavy reliance on imported goods. The "cash economy" takes precedence in the population centers.

For an individual with a disability, a wheelchair user, or an individual who is homebased, the Pacific climate plays host to increased risks for a number of otherwise preventative health conditions (Seeking et al., 1993). Such secondary conditions are receiving significant attention from the public health sector as part of national disability prevention initiatives (National Council on Disability, 1986; Houk & Thacker, 1989; Pope & Tarlov, 1991). Marge (1988) defined secondary conditions as those conditions that may be experienced by an individual after they have a primary (or first) disability. They may range from such medical complications as pressure sores and urinary tract infections to problems of psycho-social adjustment, such as depression, to environmental issues, such as access problems (Seeking et al., 1991; Graitcer & Maynard, 1991). In this framework, having a disability is viewed as increasing one's risk for a variety of preventable problems that can limit good health, functional capacity, and independence.

The tropical environment plays host to a number of secondary complications resulting in more severe, acute disabilities, such as diabetes, which in turn often results in the amputation of extremities. With changes in the Pacific diet and lifestyle, there has been an increase in stress-related disorders, hypertension, gout, and arthritis. Mental illness and substance abuse cases are on the rise as are complications arising from accidents (i.e., head trauma accidents and injuries) and acts of violence.

To illustrate, a young man from San Diego who was a wheelchair user, was called to his home island because his mother was ill and needed assistance. He returned to the island, built an accessible home, and provided his mother with food, money, and a car. He was receiving social security benefits from California and made yearly trips to sign the necessary forms to continue to receive this benefit as a California resident. (This benefit for individuals with disabilities is not available in the islands outside of Hawaii at this time.) The tropical environment and the limited rehabilitation and medical services caused difficulties. His wheelchair broke down frequently. He was a heavy man and needed daily personal care and support services. He was proud and did not want to burden his mother or young siblings with his personal care. He had extreme bed sores that worsened. In the heat and tropic climate, he was prone to complications as his immune system did not allow him to perspire. Air conditioning was unaffordable. He suffered constantly from systemic swelling. The available medical services were ineffective in minimizing his infections and other complications. Within 3 years of his return to the island, he died.

Stories of this type might be viewed as one-time, single case scenarios. However, they can, and do occur in all of the Pacific islands. The implications are obvious. Questions need to be raised. Why did this happen? What could and / or should have been done for this individual considering his situation and its numerous complications?

From a Western perspective, the first thought that comes to mind is the need for services available through independent living and the need for empowerment.

Yet larger issues loom: What services did this individual need to sustain himself and his disability? What support services were available for him and his family? What could have been done for him to enable him to sustain his lifestyle on the island? What training was needed or could have been implemented to assist his family and the medical, vocational rehabilitation, or independent living personnel that visited him periodically? What medical information could have been provided to all involved in this young man's life? What policies could have been implemented to ensure he had equal access to affordable equipment, quality and equitable services, and appropriate care? Who should have been advocating for this young man's life? What types of benefits can provide economic assistance?

These are very real issues impacting individuals with disabilities living in the Pacific.

Ethnic and Social Diversity

The richness of ethnic diversity and social differences are evident throughout the Pacific. This diversity significantly impacts the development, planning, and implementation of rehabilitation service systems throughout the area. Each ethnic community provides a unique opportunity for collecting informative data on culturally relevant rehabilitation beliefs, practices, strategies, and solutions. The island communities are trying to hold onto traditional values and, at the same time, compete and function within a changing society.

The Pacific offers a complex environment for the study and identification of ethnic and social uniqueness, practices, and beliefs with regard to disability. Put in the context of "how to best serve" individuals from unique cultural settings, these differences provide an opportunity to identify or develop culturally appropriate services and strategies that will work with diverse populations. Such diversity provides a challenging environment to address best practices in rehabilitation in the Pacific as well as to explore the transfer of knowledge to mainland ethnic groups facing isolating or cultural conditions (e.g., rural communities, Alaskan natives, and American Indians).

The 1990 census population data for the State of Hawaii, shown in Table 1, provides an indication of the diversity of its strategic location or "gateway" status in and around the Pacific. It is truly a gathering pot of people, cultures, and social practices.

Table 1
Hawaii Population by Race & Ethnicity


Race/Ethnicity              1990 Population   Percent of Total

White                           369,616             33.4
Black                            27,195              2.5
American Indian                   5,099              0.5
Asian                           522,967             47.2
   Chinese                       68,804              6.2
   Filipino                     168,682             15.2
   Japanese                     247,486             22.3
   Asian Indian                   1,015              0.1
   Korean                        24,454              2.2
   Cambodian                        119              0.0
   Vietnamese                     5,468              0.5
   Hmong                              6              0.0
   Laotian                        1,677              0.2
   Thai                           1,220              0.1
   Other Asian                    4,036              0.4
Pacific Islander                162,269             14.6
   Polynesian                   157,749             14.2
    Hawaiian                    138,742             12.5
    Samoan                       15,034              1.4
    Tongan                        3,088              0.3
    Other Polynesian                885              0.1
   Micronesian                    3,968              0.4
    Guamanian                     2,120              0.2
    Other Micronesian             1,848              0.2
   Melanesian                       291              0.0
   Other Pacific Islander           261              0.0
Other Ethnicities                21,083              1.9

Total Population              1,108,229            100

Source: U.S. Census Bureau, 1990 Census, Summary Tape file 1A.

The ethnic populations throughout the Pacific have differing customs, beliefs, and lifestyles that need to be considered in introducing concepts such as consumer involvement, independent living, supported employment, and vocational rehabilitation. Traditional customs differ as the scattered and often isolated islands produce local adaptations and inventions to fit into a mainstream of the host island.

The challenges facing rehabilitation service providers in identifying the unserved and underserved within their island communities have begun to surface, and many are not prepared to address these needs. Consequently, many people from these remote island communities have relocated to Hawaii in search of education, employment, and healthcare. This and the ongoing immigration of individuals from the Pacific Rim (i.e., Japan, Korea, China, the Philippines, and countries of Southeast Asia), each trying to preserve their traditional culture, assure that the diversity of cultures in Hawaii will continue to exist; and diversity issues significantly influence the provision of rehabilitation services.

Communication and Language

Although most individuals in island communities speak English--as a second language--communication through out the Pacific is difficult because of the variety of languages in each island entity. Vash (1994) stated that ". . . language is a critical factor in understanding culture. When you try to understand and analyze beliefs, ethical values, and convictions, there are deep concepts that are very much tied to language. When you rely on translators, you lose a great deal. Individuals who can speak two languages are almost essential."

At least nine major languages, with regional dialect variations, can be distinguished within the geographic region of Micronesia alone (Carter, 1984). For individuals with disabilities and their families, the cultural practices and language differences may present problems if services are only provided within a Western context. Issues may arise for service providers in trying to fit a Western rehabilitation practice (i.e., the concept of independent living) into a cultural mindset or framework that is not compatible with local custom. The suggested practice may be beneficial only if it can be modified to fit the cultural context and be fully described in the mother language. For example, the concept of independent living when described by such terms as empowerment, advocacy, personal choice, and living independently, goes against Pacific Island cultural practices of respect, being humble (Fa'a aloalo--Samoan; mal muri--Palauan), family choice and involvement, and living and being with the family. Descriptive words in the English language do not always mean the same in the local language. Words that mainland rehabilitation practitioners use to describe the work they do takes on a very different meaning if not shaped and presented with consideration of the language variances of the Pacific. For example, in most Pacific languages there is no word for "rehabilitation," but rather a cluster of descriptive terms that define a function or nonfunction of the body or mind to describe the disability. Since the word "disability" describes a wide range of conditions, there is the possibility of misinformation. Cultural and linguistic diversities present unique challenges for the provision of comprehensive rehabilitation services as viewed from mainland and U.S. Governmental perspectives.

Familial, and Kinship Systems

The richness and diversity of the social, familial, and kinship systems throughout the Pacific are the essence of the various cultures. Within these cultures, the concept of the extended family is basic to the nature of its people and has evolved over centuries. Nearly every family owns or has the use of land in its community. A subsistence existence has long been a way of life throughout most of the outlying Pacific. The belief is that there is no need for a welfare system, because everyone has a family and is cared for by that family.

The value placed on the family unit has a strong impact on how individuals with disabilities are treated and viewed by the Pacific family and the community. The principle of interdependence is an important aspect of family and community living. It has been said that the Micronesian attitude toward people with disabilities is humane and wholesome. Sixteen years ago, Sanchez (1979) observed that ". . . persons with disabilities are basically accepted for what they are and what they can do. They are not looked down upon, or considered a burden to society. They are cared for just like anyone in the culture." This observation remains true today.

As with many ethnic groups on the mainland and worldwide, the family plays an integral part in the life of the family member with a disability. The concept of independent living is different from that demonstrated on the mainland United States. In many of these entities the concept of interdependence among family members and members of the extended family is more socially desirable than being fully independent.

Western civilization has focused on the individual as the primary unit of experience. Samoan culture has always seen the aiga potopoto (extended family) as the most important agent in the human equation. Western philosophy emphasizes the autonomy of the person. The self-esteem, assertiveness to obtain rights or needs, and the individualization necessary to become a unique personality are all questioned values in the Samoan psychological system (Whitney, 1989). Western mental health ideology emphasizes personal functioning such as intelligence and work skills, while the Samoan world view tends to emphasize relationships to family, village, and church. A person has an identity only so far as that person can demonstrate his/her connections to the aiga. Personal needs, goals, and eccentricities must be downplayed for the good of the family group (Whitney, 1989).

In Samoa and throughout most of the Pacific, there remain strong inhibitions against airing family problems to outsiders. The status system requires the head of the household and/or the chief (matai) to take care of internal problems so the family is not caused any embarrassment in the larger community. A malu le fale e malu i fafo (what is sheltered at home, let it be sheltered outside) is a Samoan proverb which reinforces the value in keeping problems within the family. The matai represents the family in any formal public gathering and represents the extended family in the village council or chief's council. Individuals do not represent themselves (Whitney, 1989).

Even as these island communities continue to evolve and function in a technologically sophisticated world, three systems are ingrained in their social and cultural makeup:

* the maintenance of land tenure systems that protect the local people and families;

* a strong alliance to church and religion; and

* loyalty to government, village, and family.

The social and kinship relationships are intricate and require consideration when introducing new health-related concepts and rehabilitation services. With increasing emphasis placed on family involvement and natural supports in mainland rehabilitation services, the knowledge gained and practices developed in the Pacific may provide expanded strategies for mainland family support. Research in this area should increase mainland sensitivity to Pacific people and cultures and result in an identification of "best practices" of family involvement in rehabilitation.

Political and Government Perspective

All of the island entities have discrete, unique, political and governmental perspectives. There is a common theme in the Pacific Islander's interest and commitment to maintaining ties to the past, preserving the respective island culture, and maximizing an active and participatory role in self-determination. Through much of the developmental history of each of these islands, there has been a reliance on outside forces to provide expertise and governance.

The Pacific political and governmental systems are in a state of evolution with each entity in the process of examining or restructuring its current relationship to the United States. Table 2 provides an overview of the political status of each of the seven Pacific entities.

Table 2
Political Status of the Pacific Entities

Pacific Areas               Status/Type of Government

American Samoa              Unincorporated U.S. Territory (1900)
Northern Marianas Islands   American Commonwealth (1977)
Federated States of         Independent State in Free Association
Micronesia                    with the United States (Since 1986)
Guam                        Unincorporated U.S. Territory (1890)
Hawaii                      State of the United States
Republic of Palau           Independent State in Free Association
                              with the United States (since 1994)
Marshall Islands            Independent State in Free Association
                              with the United States (since 1986)

Source Ryen, 1993.

The intricacies and uniqueness of these island governments are described for two entities: American Samoa and the Federated States of Micronesia.

The political and governmental structure in American Samoa combines a traditional mode of operation (i.e., the Matai system) with a Western style of governance. The influence of religion and family play a key role in governmental decisions.

Micronesia is composed of four states--Pohnpei, Yap, Chuuk, and Kosrac each of which has its own state governance. The national government is located in the state of Pohnpei. From a political and governmental standpoint, each state is developing its own organizational and political culture and has established priorities and is operationalizing its constitution. Interrelationships and cooperation between the states and the national government is an ongoing debate.

Anderson (1992), in a recent assessment of the political environment in one of the Pacific freely associated national governments, found a very different environment than that found in Hawaii. U.S. legislation and funding, which once supported rehabilitation and special education services, were no longer applicable. Consumer and advocacy groups in the island entity were not organized and there was little evidence of adults demanding or supporting rehabilitation services; few groups were organized for political action; there was no formal organization of rehabilitation professionals; and there was no evidence of any professional organization attempting to influence political decisions regarding rehabilitation services for individuals with disabilities.

The political and governmental arena in each of the island entities needs to be more fully explored. In the island areas, the government agenda drives the implementation of services and allocation of resources (human and monetary) to sustain these services. In each of the island areas addressed, the political and governmental arena is untapped. Individuals with disabilities have had limited involvement in programs and services afforded them. Island governments may not fully be aware of how decisions made for allotment of resources impact the very essence of life and quality of life for individuals with disabilities. For example, a parent from Palau wrote ". . . we have established a parent network to work with special education . . . we have little influence in how the system operates. . . at the local level. . . we have no leverage." A young man in a support group in American Samoa said: ". . . we really don't have a voice in our community." He then expressed a need for transportation services, wheelchair ramps, and special transportation for people with disabilities (e.g., handivans). A service provider from Micronesia stated ". . . we are currently negotiating with the U.S. Government to reinstate VR services in our constitution. We have many disabled people but limited funds and no resources . . . Most of our services for adults with disabilities are over."

The demand for basic infrastructure and services, such as sewer, water, power, and health services, are critical in these government entities. Burdened with limited resources and infrastructure, and lacking the labor pool necessary for full-scale development, the islands struggle to bring their economies in line with the material wealth of the industrialized West. New roads, interisland ferries, airports, power plants, and communication networks rank high on the wish lists of the emerging Pacific states (Ryen, 1993).

The political systems in each of the island entities are distinct and delicate and need to be treated as such. Their involvement in the process of rehabilitation needs to be encouraged and solidified.

Employment/Economy Perspectives

Employment figures are affected by the cultural mores and socioeconomic factors of each Pacific entity. The traditional concept of employability of individuals with disabilities is viewed differently in the Pacific Islands. In the State of Hawaii--particularly the Island of Oahu--and in the Territory of Guam, employment opportunities for individuals with disabilities seem to be more readily available than in the remaining island entities. These two developed areas have a more defined economic base than the other Pacific islands.

Government is one of the greatest sources of employment everywhere in the Pacific. The government of Palau employs nearly half of the Republic's total labor force (40 percent work for federal and local governments). One out of six persons in Guam's labor force works for local government. In Micronesia and the Marshall Islands, the government employs up to two-thirds of the available local labor force. Since World War II, government has been the major provider of jobs and incomes in the islands (Eastly, 1994). Throughout the Pacific, government employment is the norm (ASG Economic Development Planning Office 1990 Census Release). In view of these facts, it would be interesting to know what percentage of the government labor force are persons with disabilities.

Most of the Pacific entities rely heavily on U.S. dollars to maintain their economies. In 1991, U.S. aid totaled $84.8 million to Guam, $55.5 million to the Northern Marianas, and $56.6 million to American Samoa. Palau, the Marshalls, and Micronesia get 80 percent of their income from U.S. subsidies (Ryen, 1993).

The tourist industry is a principal economic influence in Hawaii, Northern Marianas Islands, and Guam. Although tourism exists in the other entities, it is less developed. Hawaii, with one of the lowest unemployment rates in the nation, seems to have reached its natural rate of unemployment. The gains in employment can be equated to an increased standard of living. Micronesia, the Marshall Islands, and the Republic of Palau are attempting to develop new and ongoing revenue sources through economic growth based primarily on investments in fisheries, tourism, and agriculture. In these areas, new business revenues have come primarily from fishery development. Tourism has not developed as rapidly as expected and agriculture-based products (pepper and citrus fruits) have reached limited Japanese and U.S. markets (Eastly, 1994). Job opportunities for individuals with disabilities are limited in the entities beyond Hawaii.

There are no common minimum wage laws in the Pacific entities. For instance, the minimum wage on Guam is $4.25. The government minimum for Palau is $2.00 per hour. American Samoa's minimum wage ranges from $2.10 to $3.35, depending on the type of employment. The Northern Marianas Islands' commonwealth agreement negotiated an exclusion from minimum wage laws (Ryen, 1993). The minimum wage on the Marshall Islands is $1.50 per hour. There is no established minimum wage in Micronesia. On the mainland and in Hawaii job opportunities at the entry level (i.e., food service work at McDonalds, Pizza Hut) are common practice. However, in the Pacific, these are considered careers and usually are family operated businesses.

Another growing trend impacting the economy and availability of jobs within the islands is the migration of skilled and unskilled workers. Most service jobs (i.e., maids, cooks, hotel jobs) are taken up by an influx of immigrant, unskilled workers from the Philippines and other Pacific Rim nations. Employment opportunities for persons with disabilities are limited or non-existent, especially for individuals with limited English and work skills.

Cultural practices influence economic and employment practices, which in turn impede the availability of employment options for individuals with disabilities, who may not have the ability to do jobs other than those being done by nonlocal workers. There is a stigma attached to a native Pacific Islander doing the menial work that is now done by immigrants. Galea'i (1994) said, "In the Pacific we address our work from a different perspective. It is not a separate life from our domestic life as it is in the Western culture. Work is integrated into our living environment. As a greeting, Pacific Islanders like the Tongans, say `Malo Galue,' or `good work.' At the close of the working day, Samoans frequently say `e mua mua,' I go first to do other chores." Galea'i (1994) further stated "We mix our work, play, and living as part of our community. We are bound by a fellowship of endeavor often towards the goals of this broad community to which we contribute the best of our abilities, in which each contribution is recognized and credited. In our traditional mores all voices are heard and our individual success contributes to the success of the common enterprise and to the success of others. We can disagree and often do, holding different viewpoints without withdrawing from the community."

Orientation to employment for all individuals must, in most cases, involve the individual's family. Successful employment outcomes are usually the result of full family support and acceptance of the individual's contributions to the family and community. The integration of and reliance on local cultural practices is necessary for successful placement and employment outcomes for individuals with disabilities. The economic climate and limited opportunities for employment impact services for individuals with disabilities, their families, and the community at large.

The Challenge for Rehabilitation

A growing concern throughout the Pacific is that westernization is causing the deterioration of the culture, family, and social systems. There is concern that the homogeneity of the culture within each entity is being lost due to outside influences. Throughout the Pacific Islands, and among its people, there remains a strong adherence to traditional beliefs, customs, and culture. In many instances, the predominant, indigenous culture has embraced westernization and adopted or adapted cultural practices. This is seen in changes to local diet, increased health/rehabilitation concerns, Western-style homes, cultural stigmas, and the general adoption of Western behaviors. The island cultures are adapting to the demands of an industrial age, cash-based economies, and the consequences of population growth. Except for Hawaii and possibly Guam, the current lack of developed economic infrastructure continues to hinder growth and development at all levels in the Pacific.

Critical issues for individuals with disabilities include limited human and medical services, community inaccessibility, cultural beliefs and practices, isolation, external economic influences and limited resources. In many cases, medical services are provided by the government, and the availability and range of services may be limited. The needs of persons with disabilities living in the Pacific compete against needed infrastructure services such as road construction, community development, communications systems, and general health service delivery (Heath, 1987). In most cases, human services, including vocational rehabilitation and mental health, are considered fringe benefits.

There has been limited technical assistance and/or research into the most feasible ways to accommodate the cultural and environmental needs of Pacific residents. Rehabilitation research has focused on medical research in the area of tropical and infectious diseases, treatments, and mental health. Although rehabilitation services are available to individuals with disabilities through special education, vocational rehabilitation (in selected entities), and public health, much of the service provision has been offered without prior evaluation or research to identify the needs and expected outcomes. Rehabilitation service has been developed based on mainland legislative mandates, requirements, and expectations, as well as mainland needs and assumptions.

The local service needs of each entity have been virtually ignored in the attempt to fulfill dictated standards and criteria for service provision. This situation is further compounded by requiring Pacific governments to develop new programs in response to U.S. Congressional mandates without benefit of the technical assistance needed to implement these programs. The significant challenge is to ensure that basic services keep pace with the growing needs and future changes in the Pacific.

The rehabilitation needs of individuals with disabilities in the Pacific are unique, diverse, and specialized; issues critical to quality of life in this area need to be addressed and much more must be done here in rehabilitation service provision, research, education, and training.

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[18.] Sanchez, J. (1979). Rehabilitation in paradise: An opinion; from Cultural Factors in the Rehabilitation Process. Proceedings of a short-term training conference, sponsored by RSA at the Navajo Community College, April 3-5, 1979.

[19.] Seekins, T., Clay, J. & Rauesloot, C. (1994). A descriptive study of secondary conditions reported by a population of adults with physical disabilities served by three independent living centers in a rural state. The Journal of Rehabilitation, 60, 2, 47-51.

[20.] Seekins, T., Smith H., McCleary, T., Clay, J., & Walsh, J. (1991). Secondary disability prevention: Involving consumers in the development of a public health surveillance instrument. Journal of Disability Policy Studies, 1, 21-38.

[21.] Vash, C. (1994). The influence of metaphysical assumptions on disability perspectives: A cross-cultural comparison. A proposed study to IEEIR-Institute on Disability, University of New Hampshire.

Dr. McFarlane, Director of the Rehabilitation Research and Training Center of the Pacific (RRTCP), San Diego State University, has been a professor in rehabilitation counseling at the university since 1972. He has been involved in preservice and continuing education efforts in rehabilitation as a planner, instructor, researcher, and administrator. He presently conducts training in rehabilitation administration throughout RSA Region IX and serves as principal investigator on various grants, contracts, and services. In these capacities, he has worked with all the vocational rehabilitation administrators in the Pacific Basin and conducted training for more than 20 years with rehabilitation professionals there.

Ms. Farley, coordinator of Training, RRTCP, has served as the RCEP IX Human Resources Specialist to the Pacific Programs since 1990. Prior to working with RRTCP, she developed and implemented two specialized training projects addressing specific learning disabilities and Client Assistance Program personnel training through the RCEP IX.

Ms. Guerrero, research analyst, RRTCP, has been working with faculty and staff at the Interwork Institute on rehabilitation research.

Dr. Galea'i, co-director and coordinator of Research, RRTCP, is the only American Samoan with formal doctoral training in rehabilitation. He has been actively involved in rehabilitation for more than 15 years, served as the assistant director and director of the American Samoan Department of Vocational Rehabilitation, and is the former director of the Region VIII RCEP at the University of Colorado.