Native Hawaiian Health: A Review

Introduction

After almost two thousand years of independence in the Hawaiian islands, and two centuries after the arrival of Captain James Cook and foreigners, the original pure-blooded native population has gone from about 400,000 (possibly 1,000,000) to about 5,000-7,000 (1-3). This signifies a greater than 98% decrease in the pure blooded Hawaiian population over the last two centuries. The current part-Hawaiian population exceeds 400,000 in the United States (4). Tragically, a 1987 document stated that the pure blooded Native Hawaiians are predicted to become extinct by the year 2044 if current (1980's) mortality trends persist (5). It is already established that Native Hawaiians or kanaka maoli have remarkable morbidity and mortality (6). However, the relative lack of a current easily accessible comprehensive article on the topic of Hawaiian health and documented authors' recommendations was noted by the author of this paper. Hence, this paper provides an epidemiological and high-risk health review of Hawaiians until the year 2003. It also addresses the practical question "What can clinicians, patients, and researchers do about it?"

Methodology

A literature review was done in search of information applicable to Hawaiian health published until the year of 2003. Appropriate journals, books, and magazine articles were utilized. Hawaiian words and diacritical marks were checked using a reliable internet Hawaiian dictionary resource (7).

The term "Native Hawaiian" in this article implies that one can link their genealogy or heritage to Hawaiians or Kanaka Maoli in the Hawaiian Islands before Western contact.

Results

High morbidity of Hawaiians compared to non-Hawaiians in Hawai'i

In 2000, Native Hawaiians had higher prevalence rates compared to non-Hawaiians for asthma and diabetes (8). The asthma prevalence rate was 139.5/1,000 and state total rate was 86.5 per 1,000 in Hawaii. The diabetes prevalence rate was 49.0 per 1,000 for Hawaiians and 45.9 per 1,000 for the state total (8). The Japanese ethnic group had the highest diabetes prevalence at 67.7 per 1,000. Hawaiian rates for arthritis (38.3 vs. 71.7), high lipids (85.6 vs. 133.1), and hypertension (116.7 vs. 144.2) were lower than some state totals.

High mortality of Hawaiians

Low life expectancy

Since the early 1900's, Hawaiians and part-Hawaiians have reported the lowest life expectancy at birth for both genders combined, compared to Caucasians, Chinese, Filipinos, and Japanese. In 1990, the Native Hawaiian life expectancy was 74.27 years old with the Hawai'i state total at 78.85 years of age (9).

Elevated total and specific causes of death

Native Hawaiians have the highest reported rates of all cause mortality. From 1980 to 1990, the full and part-Native Hawaiian all cause standardized mortality rate increased from 642 to 755 per 100,000 (10). Compared to non-Hawaiians in Hawai'i, Native Hawaiians have greater than twice their total mortality rate. All ages' standardized mortality in 1990 was highest in Native Hawaiians for heart disease, malignant neoplasms (cancer), stroke, all accidents, diabetes (10) and asthma (11-12). Full-blooded Native Hawaiians' mortality rates are worse than part-Hawaiians (10).

Cancers
Cancer is another major health problem for Native Hawaiians. From 1995 to 2000, the Native Hawaiian male and female total cancer mortality rates per 100,000 were higher compared to Hawaii's state total cancer mortality rates (13).

Breast cancer

Over the last few decades, the incidence of Native Hawaiian female breast cancer has increased, while the mortality rate has decreased. Still, breast cancer incidence in Hawai`i was the highest in Native Hawaiian women (162.4/100,000) from 1995 to 2000 compared to the state total which was 128.3/100,000 (13) . Even after adjustment for breast cancer risk factors, one cohort of Native Hawaiian women had a relative risk 65% higher than Caucasians (14). Native Hawaiian women also reported the highest breast cancer mortality rate at 31.0/100,000 (58% higher) versus the total state rate of 18.1 per 100,000 (13). Another study suggests that Native Hawaiian females have significantly lower breast cancer survival rates and the worst stage status and metastases status compared to all other groups (15). In the Hawai`i 2001 Behavioral Risk Factor Surveillance System (BRFSS), Native Hawaiian females were reported to have the same prevalence rates for mammography screening compared to other ethnicities (16).

Cervical cancer

Native Hawaiian female cervical cancer incidence rates have decreased over the last three decades, but from 1995 to 2000 they still reported the highest incidence rates compared to state total, 13.5/100,000 and 10.1/100,000 (13), respectfully. For all ethnic groups in Hawai'i, cervical cancer mortality rates have declined. However, over the last three decades, Hawaiians, Chinese, and Filipinos appeared more likely to have an invasive cancer stage at time of diagnosis (13). In 2001, the BRFSS showed that Native Hawaiian women had the lowest prevalence rates (based on the previous 3 years) in Hawai`i for having had a Pap smear test (16).

Colorectal cancer

Over the last three decades, the Native Hawaiian female colorectal cancer incidence rates increased,
while there was no significant change for Hawaiian male incidence or mortality rates (13). From 1995 to 2000, colorectal cancer mortality was highest in Native Hawaiians for both males and females (13). Native Hawaiians may have the lowest colorectal cancer survival rates, even though they received more chemotherapy and radiation treatments compared to other ethnic groups (17). In 2001, Native Hawaiians 50 years and older reported the lowest percent of ever having had a fecal occult blood test, ever having had a sigmoidoscopy or colonoscopy, and having had a sigmoidoscopy or colonoscopy within 5 years. However, in the previous year (2000) Native Hawaiians reported the highest fecal occult blood testing percentage compared to all other ethnicities in Hawai'i (16).

Lung cancer

From 1995 to 2000, Native Hawaiian males and females reported the highest lung and bronchus cancer incidence and mortality rates compared to the total state rates. Native Hawaiian females have lung cancer mortality rates about twice the state total, 48.2/100,000 and 24.8/100,000 respectfully. And Hawaiian males have a 50% higher lung cancer mortality rate compared to the total state, 75.9 and 50.6 respectfully (13). In one small study (Hinds et al) of 132 Native Hawaiian female lung cancer patients, smoking by Hawaiian females was significantly more contributory toward getting lung cancer compared to other groups in Hawai`i (18). Another small pilot study of 45 Native Hawaiian cancer survivors showed that improved access to care and utilization of cultural values with education and services may improve quality of life and survival status (19).

High-risk behaviors and cancer

About 68% of all cancers are thought to be due to the maladaptive habits of tobacco use, drinking excessive alcohol, and a poor diet (20). Being overweight or obese are proven to be linked to cancer deaths. A study of over 900,000 adults followed for ten years showed the overweight cohort to have increased risk of death from cancer of the esophagus, colon, rectum, liver, gallbladder, pancreas, kidneys, non-Hodgkin's lymphoma, and multiple myeloma. The obese cohort had higher mortality from cancer of the stomach, and prostate. The postmenopausal obese group had higher cancer rates of the breast, cervix, ovaries, and uterus (21).

Behavior Risk Factors among Native Hawaiians

A search of the literature reveals a high prevalence of behavioral risk factors among Native Hawaiians. Curb and colleagues found one group of Native Hawaiians on a rural island to have frequent risk factors for cardiovascular disease with poor control and awareness about them (22). BRFSS has reported on the prevalence of behavioral risk factors in Hawai`i among the 5 major ethnic groups, including Native Hawaiians. From 1986 to 1993, 56% of Native Hawaiians had a sedentary lifestyle. This was similar to the Hawai'i state total of 55.5% (23). Out of 576 Hawaiians profiled in 1991, 63.4% had chronic alcohol use and binge drinking that was twice the state total (n=1,984). Hawaiians also had a 10% higher prevalence of marijuana use and smoking tobacco compared to the Hawaii state total in 1991 (24). Native Hawaiian behavioral risk data in 1993 reported 46% to be overweight, 20% had acute and chronic alcohol intake, and 27% were smokers (25). This was from a relatively small sample size of 341 (12%) Hawaiians out of a total of 2,155 (25). In a 1990 publication, Native Hawaiians also reported having the lowest use of seatbelts compared to other ethnicities in Hawai'i. (26).

BRFSS data in Hawai'i reports that these high risk cardiovascular and cancer trends continue in 2002 (n=approximately 750 surveyed for Native Hawaiians). In the 2002 BRFSS report, Native Hawaiians 18 years and older reported higher (compared to Hawai'i state total) percentages for current smoking status, overweight/obese body mass index greater than 25, never to nearly always using seatbelts, not having healthcare coverage, sub optimal physical activity, and heavy drinking (16).

In regard to obesity, genetics possibly play a role for one rural male and female (30 years old and older) Native Hawaiian population (n=567, cross-sectional), as seen in the dependant relationship of increased percentage of body mass index, and increased waist to hip ratio with the increased percentage of Hawaiian blood quantum. This conclusion was made even after adjustment for calorie intake, activity level, and age (27).

Hawaiian youth

In regard to Native Hawaiian adolescents, recent mental heath and high-risk behavior statistics are disturbing. Data from 2000 shows a progressive increase in drug use and the highest rates of substance abuse among Native Hawaiians youth, grades 6 to 12. This includes use of tobacco, alcohol, marijuana, cocaine and methamphetamines (28).

One study found that Native Hawaiian adolescents have a high rate of suicide attempts, which appears dependently related to a higher Hawaiian cultural affiliation (29). Hawaiian adolescents who are more culturally Hawaiian attempt suicide more than those with less cultural affiliation. In 1990, Native Hawaiians aged 15 to 29 years old reported the highest suicide rates (30) In one study, Hawaiian adolescents were found to have significantly elevated psychiatric symptomatology (especially females), family adversity problems, and less family support (31-32). Furthermore, the 2000 Hawai`i Student Alcohol, Tobacco, and Other Drug Use Study reported that Native Hawaiian high school seniors had the highest percentage for suspension from school, being drunk at school, and violence (28).

Crime and violence

Native Hawaiians are over represented in prison. Of the prison inmate population in Hawai'i in 2000, 39% were Native Hawaiians. This is disturbing as Native Hawaiians make up approximately 20% of the total state population (33). Also in 2000, Native Hawaiians reported higher rates of aggravated assault, burglary, motor theft, arson, property fraud, and forgery, and were over represented as murder victims and known offenders (34).

Remarkable Hawaiian subgroups

Mahus (may mean transgender, a very feminine male, homosexual, and/or bisexual) appear to be a critically high-risk subgroup of Native Hawaiians in regard to drug abuse and violence. One study of over 100 Native Hawaiian mahus reported that 74% were smokers, 31% admitted to illegal drug use (excluding marijuana), and 50% were involved with violence (35).

Availability of health insurance

After identifying high-risk Native Hawaiian behavior and subgroups, access to care also needs to be addressed. Now let us look at availability of healthcare coverage. In Hawai'i, Native Hawaiians (ages 18-65 years) reported the highest percentage of non-health insured status at 10.3 percent, versus Caucasian 8.6%, Filipino 6.4%, Japanese 3.3% in 2001 (36). According to Hawai'i's BRFSS report in 2002, the percentage of non-insured Native Hawaiian adults increased to 15.2% (16).

Summary

It is established that Hawaiians have remarkable morbidity, mortality, and high prevalence of risk factors for cancer and cardiovascular disease. But what can clinicians and researchers consider or support in order to improve the health status of the Native Hawaiian community?

This next section summarizes many recommendations from various authors, which specifically relate to Native Hawaiian health. Many recommendations are cross-cultural and deal with health disparity issues of Native Hawaiians. However, they may also be applicable to other groups as many are universal. Utilizing these recommendations, clinicians and healthcare providers are encouraged to be aware of cultural influences that are unique to this population or traditionally oriented individuals and groups.

1. Kekuni Blaisdell M.D. suggests revitalizing the culture, language, and spirituality of Hawaiians. He also recommends regaining "inherent sovereignty and self determination," and arresting factors that exploit and undermine Hawaiians. This recommendation includes denying materialism and returning to more traditional ways (37).

2. Access and kuleana to 'aina and sovereignty are cited by many as essential to wellness of the Hawaiian people (37-42).

3. Healthcare providers need to appreciate that 'olelo (the word) is very important and influential to Hawaiians (43), and that they need optimism and honesty in their medical discussions. Communicating with proper and familiar layman's terminology is required. In one study of Native Hawaiian women, only about 50% knew the definition of a "PAP test" (44). The teaching of medical concepts using analogies of things from Hawaiian culture seems to be a practical idea. Taro or kalo was the staple food of Hawaiians of old and symbolically represents the family or relatives. The taro fields need a group effort in order to allow proper nutrients and irrigation (or circulation) for an optimial harvest. Likewise, people and their families need to optimize nutrients and their circulation in order to attain wellness. And like taro cultivation, if a habit of holistic care is initiated and maintained, any hard and tedious productive work can reap great rewards.

4. Hawaiians can enhance their health and mana (divine power) by reinstating the culturally relevant idealistic ways of eating natural foods, maintaining daily physical activity, meditating, and not abusing substances or committing offenses. A program called Uli'eo Koa is a pilot program that uses culturally appropriate methods to improve diet, as well as physical and spiritual wellness (45-46). Specific culturally appropriate physical activity recommendations for Native Hawaiians might include the hula (traditional and contemporary Hawaiian dancing), lua (Hawaiian martial arts), working in the taro lo'i (taro or kalo field), surfing, hiking, and swimming in the ocean, among many others.

5. Native Hawaiians need to be recruited into medicine in order to address their under representation in the health care field. There is a discrepancy of the current 5% Native Hawaiian physician population to the 20% Hawaiian state total population (47). Native Hawaiian rural communities are areas in dire need of culturally competent providers.

6. Cultural competence needs to be taught in health professions schools (48-50). Analogous to mnemonics taught to medical students as a memory tool, remembering the Hawaiian na piko 'ekolu and na'au concepts could ensure a culturally sensitive, thorough, and systematic awareness in clinical interactions with traditional patients.

The na piko 'ekolu (three navels or centers) and na'au ("gut emotions,intuition) concepts can be organized by location, symbolism, and it's representation in time (43,45-48).

The head/crown or Manawa/Po'o PIKO (fontanelle) relates to one's spirituality or 'aumakua/ancestors and the past. Our navel or Waena PIKO signifies the family, earth, and current "umbilical ties". The navel or waena piko involves the present.
The lower abdomen or NA'AU signifies our "Gut emotions", intellect, and intuition and involves the present time.
Our genital area or Ma'i PIKO signifies our offspring and the future. A healer would be reminded of holism if they could visualize the location of these cultural concepts when with the patient. Applying these Hawaiian cultural concepts would incorporate the importance of the body, mind (psychology and parapsychology), spirit, nature or environment, , intellect, culture, community, and family relationships.

Also, it may be appropriate to use cultural terms, like mana (divine power) and pono (correct and true nature), etc., when having clinical discussions with Hawaiian patients. It is well known that spirituality is an essential part of Hawaiian culture and daily life (51). The integration of mutually respectful spirituality and religious beliefs can be complimentary. If appropriate to the individual patient and their beliefs and needs, clinicians might even consider saying a prayer with the patient and family, or recommend praying when patient takes their medication. Furthermore, providers and patients might benefit from incorporating dream-work and respecting other spiritual or cultural forms of communication and beliefs (52-53). These alternative resources are not only essential, but also affordable and may be culturally appropriate. Ho'oponopono (traditional conflict resolution method) is also a resource for the Native Hawaiian community that may even help them with academic difficulties and addictive behaviors. Psychological counseling in a university setting is found to correlate with better academic outcomes (54). Like ho'oponopono, the alcoholics anonymous twelve step group support program acknowledges a higher power, involves group support, and then emphasizes forgiveness and appropriate behavior (55). Identifying or incorporating this similarity to ho'oponopono may increase acceptance of this established rehabilitation program by Native Hawaiians. In order to exhibit respect and support for the Native Hawaiian community, clinicians may consider inquiring about and referring patients to traditional Kahuna healer training and practices (53), like la'au lapa'au, lomilomi, and ho'oponopono, when deemed appropriate.

7. The association with Hawaiian cultural affiliation and adolescent Native Hawaiian suicide attempt rates (29) needs to be intensively studied and addressed.

8. In order to optimize outcomes, the family, community and cultural peers of Hawaiian patients need to be involved with clinical endeavors. The use of lay facilitators may help the Native Hawaiian population, as seen in the breast and cervical cancer program done in Waianae (56). For example, clinicians or researchers may encourage or emphasize family or peer participation with clinic visits, treatment plans, and research activities.

9. A special effort to help and understand special subgroups of Hawaiians, based on gender (57), age (58), sexual orientation (35) and HIV status (59) is indicated. Another special subgroup are the Hawaiians who live outside of Hawaii (60).

10. The participation, research, and behavior of Native Hawaiians in clinical trials for cancer and other disorders could be better understood (61-64). Appropriate outreach, access, and professional support may help Native Hawaiian women with breast cancer health practices, as found in a ten year study (65).

11.Health care providers can spend extra time with Native Hawaiian patients, make house calls if needed, and frequent phone calls to facilitate respect, bonding, rapport, and trust (66).

12. Clinicians and researchers may recognize and address socioeconomic issues, access to care problems (19, 67), and the distrust of Western medicine (68-69).

13. In order to facilitate a connection and communication with native ancestors or 'Aumakua, themselves (or higher self), others (people and other living creatures) and nature, a meditative state can be of value to both the healer and patient. Hawaiians need to learn how to meditate daily (70). Rest and relaxation were also part of traditional Hawaiian healing instructions (44). Also, in order to be prepared for patient interactions, healers need to be relaxed, free of personal negative or judgmental thinking, and biased expectations (71-73).

14. We need to reinstate the federal census quantification of pure Hawaiians and standardize ethnic definitions for prevalence, mortality, and populational data. It does not make sense that the federal government would stop quantifying how many pure Native Hawaiians currently exist. Furthermore, the recent grouping of "Pacific Islanders" with statistical data is very ambiguous, and will not allow comparison with past data nor allow more specific statistics on Hawaiians or other Polynesians. Any definition of "Native Hawaiian" should allow or imply an objective genealogical connection to Hawaiians living before Western contact in the Hawaiian Islands.

15. And finally, Native Hawaiian healthcare providers can be role models and encourage indigenous youth to pursue medicine and other health related fields.

Limitations

Limitations to this paper includes: limited or minimal data, some studies were with small sample sizes and that may underestimate or exaggerate rates, and lack of consistency and confusion on the definition of a "Hawaiian" over time and with different organizations.

Hawaiian language experts were not consulted for this paper and diacritical marks were not available due to font limitations. Please see section on methodology.

Conclusion

In short, Hawaiians and non-Hawaiians are challenged to have koa (courage) and work together to get the goal of wellness accomplished. For both the patient and healer, understanding and enhancing mana (divine power), pono (true nature), and lokahi (unity) are required to succeed. One traditional Hawaiian healing secret is to have lokahi of the body, mind, nature, and spirit (71). Many Native Hawaiian healing ways are timeless, universal, and relevant in modern times. Following the advice of the Native Hawaiian Biennial Healing Conference in 2002, we need to know that "We are Hawai'i", and "We need to perpetuate the breath, the knowledge, and the life". Furthermore, "We need to stand proper, stand connected, and stand in harmony" (74).

Acknowledgements

The supportive encouragement and advice provided by Kim Ku'ulei Bernie of Papa Ola Lokahi, and Douglas Massey MD on this paper was greatly appreciated.

The anonymous critique by a few Hawaiian health specialists was also extremely helpful and informative.

The authors' accept full responsibility for any errors.

There was not financial support for this paper.

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By Bradley E. Hope MD (last revised 07/03/2006)