Native Hawaiian Health in Hawaii : Historical Highlights

The Hawaiians still have evidence of remarkable spiritual, mental, and physical illness since western contact over two centuries ago. Their pure blooded population has decreased by more than 98% but the mixed Hawaiians are approximately near pre-contact pure blooded levels, at 400,000. 60,000 (15%) people with Hawaiian ancestry now live in California. This paper attempts to provide a detailed but concise historical summary of health in Hawaii and of Native Hawaiians. Also, an attempt is made to educate health providers, and to help them take better care of their Native Hawaiian and traditional patients. © 2003 Californian Journal of Health Promotion. All rights reserved.


Introduction
Native Hawaiian health is a very fascinating and critical topic.Since pre-1778 western contact, Native Hawaiians have changed from a population of about 400,000 (literature ranges from 100,000 to one million) to a current population of around 7,000, signifying more than a 98% decline (Schmitt, 1977;Stannard, 1988).In contrast, Part-Hawaiian or mixed blooded Hawaiian populations increased from zero to 401,162 (with only 1.7% pure blooded) in the United States (US Census, 2000).Currently, 15% of people with Hawaiian ancestry live in California totaling 60, 048.Many Hawaiians have moved from Hawaii to California.And rightly so, where else can you get a beautiful ocean and mountains right next to each other with a very gracious climate reminding one of home?This author has also recently relocated to Santa Barbara, California.
It is well established that those of Hawaiian ancestry still have alarming physical morbidity and mortality, mental health, socioeconomic status, education level, welfare use, incarceration representation, drug abuse, high risk behavior, obesity, etc., in Hawaii.(Blaisdell, 1989(Blaisdell, , 1990(Blaisdell, , 1996;;Hawaii State Department of Health, 1997, 2001).In response to this overwhelming situation, many organizations have been organized and fundings obtained to address the challenged health status of Native Hawaiians and to change it for the better.
Western contact literally resulted in the virtual obliteration of the Hawaiian cosmology, customs, beliefs, land occupation, spirituality, medicine, population, values, social infrastructure, language, and lifestyle (Bushnell, 1993;Halford, 1954;Mills, 1981).No blaming is in order however, since a true kanaka makua or mature Hawaiian would accept responsibility for their own existence, forgive, and remain respectful to themselves, others, and the environment (Bray, Low, 1990;Ka'anoi, 1992;Pukui, Haertig, & Lee, 1979).Still, certain facts remain.Now the challenge remains whether Hawaiians will reverse these trends and take personal, positive and active steps.We are a people in need of help and support during this critical time of transition.This journal's special Hawaii issue is a step in the right direction.This paper attempts to present a basic historical overview of Native Hawaiian and Hawaii's health in order to help the reader gain an appreciation and understanding of the past and present.This is an effort to educate health care providers outside and inside Hawaii to better address and help these sacred and precious people called the Hawaiians.The timeline was constructed from the remaining references cited below.
<1778: Papa (earth mother) and Wakea (sky father) produce the cosmos and Haloa who is the first kanaka and ancestor of all kanaka maoli or Native Hawaiians (Beckwith, 1970;Malo, 1951).
Diseases are more related to trauma and degenerative diseases.One out of about 1,100 fossil skeletons showed evidence of cancer metastases to bone.Low incidence of dental caries was also noted (Chappell, 1927;Snow, 1974).
Due to lack of documentation, pre-contact 1778 Kahuna ways are not entirely known.Population pre-contact estimates have ranged from 100,000 to 1 million, with academic consensus at about 400,000 pure blooded Native Hawaiians (Schmitt, 1977;Stannard, 1988).

Post-Western Contact
Ancient Hawaiians live in harmony and balance with spirits, nature, and each other.They pass knowledge on by oral tradition, and have rules in the form of kapus (that promote cleanliness and order), resolve psychological and interpersonal conflicts with ho'oponopono (a type of family group therapy), eat natural healthy foods (78% complex carbohydrates, 12% protein, and 10% fat, high fiber) and are physically active (Shintani, Hughes, 1993;Shook, 1985).Hawaiians live in communal segments, called ahupua'a, from the mountains to the sea, and inhabitants share goods and services (not barter system).The chief or ali'i helps to supervise and organize their ahupua'a or land area.Health was defined as possession of a powerful sacred living force called mana which must be kept in pono or harmony and lokahi or unity with the universe.
Native Hawaiian health always involved mana, pono, and lokahi.Illness could also be associated with negative thoughts or words from another or oneself, and kahunas used this to their advantage to facilitate healing.There are a few anecdotal stories of Hawaiians dying once they truly believe a Kahuna 'ana'ana is intending to kill them.Likewise, positive words and thoughts can heal.The natives greet by honi (a "kiss") or sharing of breath via nares.Ha, or the breath of life, is shared and sacred (Dudley, 1990;Blaisdell, 1989Blaisdell, , 1990Blaisdell, , 1996;;Handy & Pukui, 1972;Malo, 1951;Kamakau, 1964).
Kahunas have a holistic approach (incorporate body, mind, and spirit), learn and practice at healing temples, called heiaus, require years of training, and made house or hale calls.There is one famous story of a Kahuna performing an autopsy to find out why his father died.There are many Kahuna (specialized experts) specialties in medicine, but the other experts included geneology, chanting, and canoe building.An example of a Kahuna visit includes prayer, help from the gods (Ku, Lono, Kane, Kanaloa, Hina, Ma'iola, etc.), dream work, a specific diet, and "family counseling" called ho'oponopono.A history and physical could be done.This may be followed by collection and distribution of an herbal preparation and or lomilomi massage.The whole process from beginning to end involved spirituality and prayer.
Kahunas reserved the right to refuse certain cases.Many traditional healers learned to send "western diseases" to western physicians.Kahunas passed their knowledge down mainly by oral tradition which was considered a secret and sacred.A kahuna's mana (powerful and sacred life force) could be passed to their apprentice via ha (the breath of life) over the crown of the head or by spitting into their mouth.

1778: Captain James Cook discovers the
Hawaiian islands and some say he was thought to be a God named Lono by natives.Cook failed in his honest attempt to prevent the transmission of sexually transmitted diseases such as syphilis and gonorrhea.A history and physical is not enough to triage these diseases.Morbidity, mortality, and infertility ensue (Bushnell, 1993).Captain Cook was killed by Native Hawaiians in 1779.
1800's: Subsequent visitors from ships and immigrants throughout the 1800's introduce tuberculosis, Hansen's disease-in 1840 first Native Hawaiian with leprosy is detected by Dr. Dwight Baldwin in Maui (Blaisdell, 1989, Ka 'Uhane Lokahi, 1998), measles, influenza, cholera, gastroenteritis, mumps, scarlet fever, dengue, bubonic plague, scabies, sylvatic plague, etc., that literally killed thousands over the next century (Bushnell, 1993;Blaisdell, 1989Blaisdell, , 1990Blaisdell, , 1996)).Many of the infectious diseases introduced to Hawaii came from Asian immigrants, mostly from China.As a result of labor shortages in the fields, and Hawaiians in 1834 refusing to work for low wages, the agricultural corporations began importing cheap labor from Asia under contracts.The native custom of honi ("kiss") or sharing the ha or breath of life via touching nares may have facilitated upper respiratory transmission of microbes.
1819: King Kamehameha I, who united the Hawaiian Islands aided by western weapons, dies of a stroke at around 69 years of age.His death results in the eventual dissolution of the kapu system and social and religious infrastructure.It was never reinstated by successor King Kamehameha II, who was thought to be influenced by Chiefess Ka'ahumanu and western ideas.In essence, the Hawaiians no longer had their traditional rules, order, and spirituality.They were exposed.1820: Missionaries arrive from New England with first physician Dr. Thomas Holman during an opportunistic and vulnerable time in Hawaii's history.Dr. Holman becomes a physician to royalty (Halford, 1954).They introduce Christianity and a written language, but many westerners condemn traditional native Hawaiian cosmology, beliefs, customs, values, and spirituality.In all fairness, many Hawaiians (royalty and commoners) "buy into newer and better ways".

1822:
The first water filtration plant on Oahu is established.

1827: Mosquitos arrive in Hawaii.
1828: Dr. J. P. Judd, a missionary physician, arrives and starts Hawaii's first medical school in 1870 to train natives, and to publish an anatomy textbook in Hawaiian language (Judd, 2003).Ten Hawaiian students graduate and are licensed in 1872.The medical school dissolves shortly after death of Dr. Judd (Bushnell, 1967).Dr. Judd was also active with vaccination campaigns.

1836:
Screening of all visiting vessels for small pox ordered by Kuhina Nui Kina'u.
1839: Kamehameha III signs quarantine law, and first Vital Statistics Act initiated.

1848:
The Great Mahele results in only 0.8% of lands going to 30% of Hawaiians.Hawaiians did not have a concept of land ownership in their culture.The Gods owned everything, and their role was a kuleana or right to cultivate and live on the land and share resources.1899: First sewers in Hawaii.First bubonic plague case reported in Territory of Hawaii (Hawaii Department of Health, 2001)."The Great Fire" in Downtown Honolulu to fight "bubonic" plague in Hawaiian/Asian living quarters.Native Hawaiians displaced from their apartments (Mills, 1881, Ka 'Uhane Lokahi, 1998).

1900:
About half or more of Hawaiian population provided petition signatures in opposition of annexation with United States.Hawaii becomes the Territory of Hawaii under the U.S. Organic Act.The timeline continues....

Discussion
The journey is not finished.Like the Hokule'a voyages, traditional ways are achievable and possibly hold the secret for progressive improvement in the health of Native Hawaiians.In the way that the Hokule'a voyage showed how Hawaiians and others can learn, work together and confidently accomplishing their goals by utilizing traditional ways, Hawaiians need support and need to work together to reach their destination of wellness.What I learned myself while writing this article is that I could not keep a very narrow scope in timeline summary of events due to obvious impact other issues have on Hawaiians psychological and therefore physical health.Imagine if a country came to the United States and told you that your language, beliefs, lifestyle, values, spirituality, was wrong and you were forced to change.Imagine your land being taken away and suddenly living in a society that spoke a different language.It would be devastating, spiritually, mentally and physically.Therefore, healing the native Hawaiians will obviously involve incorporating their spirituality, cosmology, Kahunaism, ho'oponopono ("to make things right", type of family therapy that promotes forgiveness and closure of conflicts), giving back the kuleana (right to cultivate and live) of the land or 'aina, sovereignty, and ancient habits of eating natural foods and being physically active.

Recommendations
The following are recommendations by this author to health care providers to help them take better care of patients with Hawaiian ancestry or who have traditional belief systems: 1. Spend more time with them (longer visits, more frequent visits, follow-up phone calls, make home visits, "talk story" and share appropriate personal things about yourself).
Traditional ways require more time to gain confidence and bonding.Kahunas or Curanderismos (traditional Mexican healer) might even spend hours or days with patients.You are following their lead.
2. Incorporate the respected family member, who may be an elder, sibling, or even younger family member, to approve of the treatment plan and help.

1846- 47 :
Native Hawaiians leave Hawaii for San Francisco to join California gold rush.1850: First cases of the cholera epidemic diagnosed in San Francisco were Kanakas.
Le'ahi Hospital mainly started for tuberculosis.Kahunas legalized to practice per State of Hawaii Penal Code, Title 37, Chapter 773.State Office of Family Planning Services established.
Don't interpret lack of Native Hawaiian eye contact or different body language to apathy or lack of intelligence.It may be their way of showing you respect.10.Always remember the impact words or 'olelo can have on the psychology of a Hawaiian.Never present their health situation as hopeless.They may believe you.Be honest and optimistic.Use familiar terminology.Use cultural topics or objects as analogies to teach.11.Incorporate spirituality in treatments.For example, suggest a prayer when taking medications.Encourage and explore meditation and relaxation via reiki (healing touch) which utilizes concepts similar to mana.Many hospitals have these volunteer practitioners.Refer patients to them.12. Learn what "ALOHA" really means, and make it part of your personal daily life and work.