In the 216 years since Captain Cook wrote in his journal about a people who "walk gracefully and run nimbly," the natives of Hawaii have experienced near total destruction of their culture. Introduced diseases, foods, and habits, combined with the loss of their land and the colonialists’ forced denial of their traditions have had devastating effects on a people that had thrived on these islands since 600 AD. Today, the 200,000 native Hawaiians are the least healthy ethnic group in the state, with death rates 44 percent higher than average for heart disease, 39 percent higher for cancer, 31 percent higher for strokes, and an alarming 196 percent higher for diabetes.
In response to these grim statistics, native Hawaiian health providers around the state are helping Hawaiians regain their health by reclaiming their lost cultural heritage.
Of all the Hawaiian islands, Moloka’i is home to the largest percentage of native Hawaiians. Communities occupy the island’s 261 square miles in a slow-paced, rural lifestyle. The traditional values of the extended family provide the native people a firm foundation for a return to their ancestors’ spiritual beliefs, native foods, and sacred relationship with the land, all of which are helping them regain their individual and community health.
"Our main emphasis is to try to alleviate some of the health problems that are caused by and actually exacerbated by social and environmental problems. We try to look at the families’ lifestyle and support their relationship to the land," said William "Billy" Akutagawa, founding member and current director of Na Pu’uwai.
Molokai’s native Hawaiian health system, Na Pu’uwai, was established in 1988 by the Federal Native Hawaiian Health Act to serve the people of Moloka’i and Lana’i, an island of 2,000 located south of Moloka’i. Na Pu’uwai staff do not provide clinical services, but instead focus on educational outreach into the native Hawaiian community and prevention screenings for high-risk diseases such as diabetes and breast cancer. Because they have no clinic of their own, health workers have developed close relationships with service providers available on the island, such as Queens Medical Center.
Na Pu’uwai defines health holistically, so health care includes helping a father find a job, helping a family get a home loan, or supporting local farmers to increase the availability of native foods. "People are beginning to understand that healthy eating makes them healthier. We’re trying to get them to rely on the food we produce on this island rather than on canned goods," says Akutagawa.
With the support of Na Pu’uwai, social workers have helped start cooperative farming operations that reclaim land for traditional food production. Working with the families and landowners of one valley, they fought for the right to hunt and gather on a piece of land stretching from the ocean to the mountains, customary places for gathering herbs and flowers, hunting and fishing. Gathering or hunting for your dinner has the added physical benefit of regular exercise.
"We say if you want to know your culture you have to ‘broke your back’ [a pidgin phrase for hard work]. You have to sweat, you got to learn how to do it. You just can’t be a Hawaiian in the books," says Dr. Emmett Aluli, a Moloka’i physician, environmental activist, and founding partner of Na Pu’uwai. Sweat and hard work were key to the success of the "Back to the Taro" movement of the late ’70s, which helped Hawaiians reclaim traditional taro patches. A symbol of being truly Hawaiian, poi – made from pounded taro – is an essential food. "Today we have a lot of people who are growing taro and reviving the old taro patches in most valleys," Aluli says.
The return to a traditional diet does more for the Hawaiian people than put them in touch with their cultural roots. In the 1987 Moloka’i Diet Study under Aluli’s direction, volunteers turned in their SPAM, mayonnaise, and candy for traditional Hawaiian foods like poi, fish, and sweet potatoes. Within three days many reported feeling more energetic, and their lower blood fat levels proved the physical benefits of the traditional foods. People on the diet began to feel so good, the word spread and before long the island was running low on taro!
Today, Dr. Aluli continues to recommend his patients infuse their western diets with Hawaiian foods. "Instead of reaching for a soda, they start to go for a Hawaiian tea; instead of potato chips, why not sweet potatoes?" asks Aluli who has poi in his kitchen and likes to keep his diet at least 50 percent traditional.
"Rural people have stayed healthy because they have a sustenance lifestyle," says Aluli. "Today part of our battle is to protect our resources and use them sustainably so the next generations will also have the benefit of living off the healthy foods of the land and ocean. I find it hard to separate healing and fighting for the land. If you’re ill then the whole family suffers, and if the family suffers, it extends into the community. It’s the same with the land. The land is alive – a source of strength, inspiration, and of healing. When the land suffers, we become ill."
Over the past 20 years Aluli has devoted his time after office hours to working on Hawaiian land and environmental issues. One of the largest and most recent land victories happened in May 1994 when the sacred island of Kaho’olawe (located off the southwest coast of Maui) was returned to the native people of Hawaii after its use as a US Navy bombing site. Since 1976, Aluli and members of the activist group Protect Kaho’olawe ‘Ohana had demonstrated, occupied the island, served jail time, and (two members) had even died, in the fight to regain sovereignty over the sacred land and surrounding ocean.
"The island is a sacred sanctuary for spiritual cleansing and healing," said Aluli. "It is one of the few places that has allowed our generation to blossom as Hawaiians … in our own way, without criticism. In our work to heal the island, we work to heal the soul of our Hawaiian people. Each time we pick up a stone to restore a cultural site, we pick up ourselves as Hawaiians."
Aluli sees the connection between stewardship of the land – restoring sacred sites, building trails, and beginning revegetation and soil conservation efforts – and the increasing numbers of college students pursuing environmental issues, biology, medicine, and Hawaiian studies. He believes these choices are a result of an increased pride and awareness among his people due in large part to a reconnection with their land and heritage.
As a child, Aluli began learning herbal and prayer healing from his grandfather, a practiitoner of the healing traditions. Aluli explains that if a developer bulldozes a temple or shrine, the family with connections to that place is impacted spiritually and psychologically. "We’re suffering because people have destroyed the sacred places where our ancestors worked and worshipped, and we have to live with the pain of that disconnection," he says.
The native Hawaiian health workers of Na Pu’uwai are helping to heal this disconnection. Created by Hawaiians, for Hawaiians, Na Pu’uwai supports the belief in the importance of wellness of the whole – whole person, family, and community. By building on the existing social support network of the extended family (see second story that follows), Na Pu’awai has brought health services to people who have not seen a doctor in years – many of whom refuse to come into a clinic for care.
They target high-risk patients through community outreach efforts, then coordinate with clinics on the island for the use of their medical services. One joint effort involved a clinical screening at the Women’s Health Center at Moloka’i General Hospital. Na Pu’uwai workers found the patients, arranged their appointment times and transportation, and provided moral support during the screening. Women’s center health practitioners performed pap, pelvic, and breast exams for the native Hawaiian women who have the highest rate of breast cancer in the world.
In tune with the culturally focused efforts of Na Pu’uwai, the Women’s Health Center has created a relaxed atmosphere with a waiting room that looks and feels more like a family room. "Clients get to mingle and talk with the other women," says Phoebe Starkey, a native Hawaiian and receptionist at the center, who believes the casual, friendly clinic environment makes for repeat patients and healthier people.
Na Pu’uwai health workers have also drawn on expertise found in their own communities. "We are starting to rely on the beliefs and customs of our older people, the kupuna," said Na Pu’uwai’s director, Akutagawa. "Part of the key to good health is going back and reviving the culture, and you can do it through the older people. We’re not going to cut ourselves off completely and go back to the past. We need to use what we know now to help us care for future generations."
The social, cultural, and small land victories have helped people gain self-esteem and power. "Ten to twenty years ago we were looking for an identity, and now we have one. We are starting to feel really good about being Hawaiian and believing in the cultural and spiritual practices of our elders," Aluli said. "Within the whole movement to regain sovereignty over the land and protect our oceans, people begin to see that they too are an endangered species. People feel good about getting together and taking care of the land and of each other."
by Karen Farias, RN, MPH
To the early native Hawaiians all in the cosmos were products of the mating of Wakea, sky father, with Papa, earth mother – and all were living, conscious, and communicating. This inherent oneness required continuous individual personal effort to maintain harmonious relationships, which involved sharing and respect for others.
Kapu (sacred restrictions) were enforced by all. This was society’s way of preserving pono for the common good. The kapu fostered self-discipline and responsibility in personal hygiene, health promotion, illness prevention, public sanitation, and respect for the sacredness of nature. The traditional native diet was high in fiber and starch, low in saturated fat and sugar, and ample in protein, minerals, and vitamins. The early Hawaiians maintained strict public sanitation and environmental protection which accounted for control of potentially harmful microorganisms. Also contributing to their health was the rigorous physical exercise of work and recreational activities like surfing.
Wellness represented adequate personal mana (spirit). Illness resulted from loss of mana due to lack of pono (balance, harmony) with oneself or another person, violation of the sacred restrictions, or a curse or ill will from another.
Once illness had occurred, diagnosis was a matter of determining what caused the loss of mana and pono. Treatment was directed at restoring the lost mana and pono. The patient first assessed himself and attempted to manage his illness, having been trained since childhood in self-reliance. If he did not recover, he would likely seek the care of an experienced elder healer. If this failed, he would give the appropriate offering – such as a hog – in exchange for the care of a physician priest at the healing temple.
The Hawaiians were the most advanced of all Polynesians in: 1) experimentation with systematic observation of biomedical phenomena, detailed nomenclature and classification, empirical clinical trials with medicinal, human autopsy, and animal research; 2) health education with each child trained in self care, experienced healer and physician priest training of carefully selected students with a rigorous l0 to 15 year curriculum; and 3) establishing specialized temples for training of healers, research, preparation of treatment materials, and communication with the spiritual realm.
Excerpted from Health Care Reform and Native Hawaiian Health written for the School of Public Health, University of Hawaii.
by Jane Lee
For especially complicated family medical and social problems, Na Pu’uwai uses case management teams that center on supporting the cultural practices of the family. Each member of the Hawaiian ‘ohana (extended family) has his or her own responsibilities, which include the well-being of the whole. The ‘ohana provides a natural support system for the members, and is an important element in the case management work of Na Pu’uwai. Outside support systems, such as social service agencies, are used to supplement the family’s efforts.
Jane Lee, social worker for Queen Lili’uokalani Children’s Center and co-founder of Na Pu’uwai, describes the case management approach for an elderly woman (a kupuna) with failing kidneys and diabetes who is taking care of an ill husband at home:
What the case management team would look at first is what the physician is saying the kupuna must do to maintain her own health. We never take the responsibility of the person’s health away from the individual or the family – that would be disrespectful. We sit down with the kupuna and significant members of the family – of her support system – and create a plan together.
In this case, the doctor is saying that the kupuna has to go for dialysis. We don’t have it on the island, so she must go to Oahu, taking a round-trip plane trip three times a week at $100 a trip. Her husband is too weak to help her, so she needs someone to go with her to the dialysis appointments. She also needs someone to make sure she takes insulin and eats regularly.
We would sit with the family to find out who would be available to do what on a daily basis, including who has the resources to provide for plane fare and accompany her to Oahu. If the family says they don’t have the money for airfare, we look for other resources.
This is simple to say, but hard to do in a cultural context. The kupuna would likely protest imposing her needs on the family, because in the Hawaiian culture, it is inappropriate to consider individual needs first. Believing her own health to be a last priority, the kupuna would not want to take away resources from the family.
A person has to be open to receive treatment. It might be a state of mind, but it’s important. If they are worrying or thinking about something else, they’re not in a good place to receive treatment.
The process we use is a traditional Hawaiian practice used to resolve conflicts called ho’oponopono, meaning to clear the way. There might be conflicts within families or inside the patient themselves – problems they need to forgive and be forgiven for to open them up. When they receive treatment they should not have other concerns or worries, so they can concentrate with the physician on the treatment of their body. It’s like taking care of the spirit first so they will be ready to deal with the physical treatment.
So, if the kupuna has to go to Oahu, and Grandpa is home, who’s going to take care of him while she’s gone? You have to adjust the patient’s priorities and find a way to break the barriers to successful treatment. The kupuna would choose death over leaving Grandpa alone.
In order to trust you, a Hawaiian likes to be able to talk-story. This means a conversation that involves a soul connection: "I know you, you know me – we’ve made a connection. I know you will honor me and take care of me – I’m not just a number or another face."
Doctors today say, "Hello, nice to see you today," give an exam and leave. The fact that you have an ill child and your husband is out of work, is not taken into consideration, but these things have bearing on health. If you’re going to talk holistically, you must take all of the things in that person’s life into consideration and deal with them so the patient can focus on the treatment they are going to receive and take care of their own health program.
It’s a slow process, it’s not the most efficient or fast, it cannot be. We will take the time we need to make a decision the client is comfortable with and is willing to put 100 percent into. It’s probably very costly, but I don’t think there’s any other way. We know these people by name, we know their families, and we are held accountable.