Richard Kekuni Akana Blaisdell is a professor of medicine at the University of Hawai'i, in Honolulu and is a co-founder of E Ola Mau, an organization of Hawaiian health professionals. His research interests include the history of medicine, Polynesian medicine and Hawaiian health. He is also on the board of Ke Ola Mamo, convenor of the Pro-Hawaiian Sovereignty Working Group and coordinator of Ka Pakaukau, a group of twelve organizations seeking independence. The following article was presented at the Asian American and Pacific Islander Health summit, San Francisco, June 21-24, 1995. Footnote references are linked to a new window which can be left open for reading convenience.

Introduction. In modern times, only since the 1980s has serious public attention been given to the health plight of the Kanaka Maoli (indigenous Hawaiians) as the worst of all ethnic groups in their homeland, Ka Pae'aina (Hawaiian Archipelago)(1). Kanaka Maoli activism in the early 1980s resulted in the 1988 U.S. Congress Native Hawaiian Health Initiative which began to address these health needs. Special interest, therefore, is currently directed at trends as Kanaka Maoli health statistics for the 1990s are revealed .

Methods. The available data and not readily accessible unpublished information on the major health indicators by ethnicity. for the 1990s in Ka Pae'aina were reviewed and compared to earlier decades. Numerator figures were derived from the Hawai'i State Department of Health and other resources as described. Population denominators were mainly U.S. Census and Hawai'i State Health Surveillance based (2,3).

Results. The 1990 U.S. Census reported 211,014 Kanaka Maoli, an increase of 18.3% over the previous decade, with 138,742 in Ka Pae'aina and 72,272 in continental U. S. (2) In Ka Pae'aina, Kanaka Maoli were the fourth largest ethnicity. comprising 12.5% of the islands' multi-ethnic population which totalled 1,108,229. U.S. Census undercounting was revealed by the 1990 HSHS report of 205,078 self-identified Kanaka Maoli in Ka Pae'aina, the third largest ethnicity. comprising 18.8% of the islands' total population.(3) Circa 96% of Kanaka Maoli were of mixed ancestry with only 5,000 to 9,019 estimated remaining piha ("full-blooded") Kanaka Maoli. The 1990 HSHS proportions of the major ethnic groups in descending order were White 24.1%, Japanese 20.4%, Kanaka Maoli 18.8%, Filipino 11.4%, Chinese 4.7% , Black 1.5%, Korean 1.1%, American Indian 0.9%, Samoan 0.3%, Puerto Rican 0.3%, and others 16.5% .

Life expectancy at birth in 1990 continued to be shortest (67.5 (5) and 73.6(6) years) for Kanaka Maoli and was even shorter than in 1980 (74.1 (7) years). This was unlike life expentancies for the other main ethnicities which were longer and continued to converge since 1930 (6,7).

In 1990, Kanaka Maoli age-adjusted mortality rates for all causes of death continued to be highest for piha Kanaka Maoli (1,062.7 / 100,000) and then for hapa (mixed) Kanaka Maoli (449.6) compared to all other major ethnicities (281.4) (8,9). These 1990 mortality rates were greater for Kanaka Maoli than in 1980, whereas they continued downward for all other ethnicities.

1990 age-adjusted mortality rates for the 5 top leading causes of death -- heart disease, cancer, stroke, accidents and diabetes -- were greater for piha Kanaka Maoli then hapa Kanaka Maoli compared to other ethnicities (9). Except for accidents, these death rates were higher for Kanaka Maoli in 1990 than in 1980.

Infant mortality rates for 1990 remained highest for Kanaka Maoli babies (l0 deaths / 1000 live births) compared to all ethnicities, although they were lower than in 1980 (12 death / 1000) (10).

For the first time in 1995, the U.S. National Center for Health Statistics reported data on a total of 108,195 births in 1992 of Asian and Pacific Islander (API ) subgroups from 7 states with the largest populations of API's (11) . Kanaka Maoli had the highest rates, 18.8%, of births from mothers under 20 years of age and unmarried mothers, 46.5%. For low birth weights, the Kanaka Maoli rate, 6.9% was intermediate between the highest Asian Indian figure of 9.6% and the lowest Samoan 4.5% and Korean, 4.2% rates.

By March 1995, a total of 1,617 AIDS patients were reported in Ka Pae'aina since 1982 (12). Asian and Pacific Islanders comprised 405, or 25%, of the total. Of these, Kanaka Maoli ranked first with 170 patients, or 42% of all APIs with AIDS.

In 1992, behavioral risk factors in 1,944 telephone interviews were highest in Kanaka Maoli for obesity (43%), cigarette-smoking (22.3%), alcohol-drinking (32.3%) and non-use of seat belts (6.6%) (13) For obesity and alcohol consumption, these rates were higher than in 1987.

Persistent under-representation of Kanaka Maoli in health professions was evident in 1994, as in previous decades. Of the 5,633 licensed M.D.s in Ka Pae'aina, only 144 or 2.6% were identified as Kanaka Maoli (14). In spite of recruiting efforts by the University of Hawai'i's school of Medicine from 1975 to 1994, only 109 or 9.1% of the school's total of 1,200 graduates were Kanaka Maoli.

In 1988, two programs enacted by the U.S. Congress became known as the Native Hawaiian Health Initiative (19). By 1993, the Native Hawaiian Health Professional Scholarship Program (16) had granted educational awards to 61 recipients: 25 in medicine, 12 in nursing, 9 in social work, 6 in dental hygiene, 4 in public health, 3 in clinical psychology and 2 in dentistry(15). The first M.D.s in this program, numbering 5, were graduated in 1994, and are currently in residency training.

Also in 1988, the Native Hawaiian Health Care Act authorized 5 Ka Pae'aina-wide Native Hawaiian Health Care Systems (17). By 1991, these 5 systems had begun outreach health promotion, disease prevention and some case management and primary care to Kanaka Maoli (18) In 1993-1994, 13,315 (6.5%) clients out of 205,078 eligible Ka Pae'aina Kanaka Maoli were seen in 33,459 encounters (19). Thus, little or no impact could be expected of the meager numbers of Kanaka Maoli health professionals and the 5 health care systems on health data collected and or reported beginning in 1990.

The 1994 North Kohala Cardiovascular Risk Survey (CVRS) of 305 adult Kanaka Maoli revealed prevalence of obesity to be 76%, hypertension 42%, tobacco-use 55%, hyperlipidimia 34% and diabetes 23% (20). These rates were higher than in the 1985 Moloka'i CVRS of 257 Kanaka Maoli homestead adults(21).

In the 1987 Moloka'i Diet Study, 10 Kanaka Maoli adults with hyperlipidemia consumed individualized isocaloric diets of pre-Western Kanaka Maoli foods containing 10% total fat, cholesterol 114 mg, carbohydrate 80%, protein 11%, fiber 16 g and sodium 2 g/d (22). After 3 weeks, mean blood cholesterol declined from 227 to 206 mg/d and triglyceride 331 to 174 mg/d. When the participants returned to their previous, Western, high-saturated fat, high cholesterol, high-sodium, low-fiber, but isocaloric diets, their blood lipid values rose to pre-Kanaka Maoli diet levels. The study included group support with dining together and cultural, social, and health education sessions with sharing of personal experiences. This was the first demonstration that Kanaka Maoli could reverse their hyperlipidemia by returning to their traditional pre-Western foods.

In 1991, the Wai'anae Diet Program's first group of 20 corpulent Kanaka Maoli participants revealed the following changes after 3 weeks of ad libitum feeding to satiety of traditional Kanaka Maoli foods, as in the Moloka'i Diet, and inexpensive modern equivalents: a decrease from 1594 to 1569 mean kcal consumed /d and mean body weight loss of 7.8 kg (23). Mean blood cholesterol declined from 222.3 to 191 mg/dl, triglyceride from 236.2 to 163.4 mg/dl and mean blood glucose decreased from 161.9 to 123.4 mg/dl. Arterial pressure fell an average of 11.5 mmHg systolic and 8.9 mmHg/dl. One of 2 diabetic patients taking insulin no longer required this drug. One of 4 participants was able to discontinue anti-hypertensive medications.

By 1995, the Wai'anae Diet Program had engaged 260 participants on 4 of the main islands. Follow-up to date of 46 of the 61 initial 1991 participants revealed that 39% had maintained body weight reduction of 10-19 lb, 30% had maintained body weight decline of 20-39 lb and 20% had maintained body weight decrease of 40 lb or more (24) Thus the Wai'anae Diet demonstrated that ad libitum feeding to satiety of traditional Kanaka Maoli foods and or their traditional equivalents could control obesity, hypertension, hyperlipidimia and diabetes mellitus. Long-term evaluation of the Wai'anae Diet in control of these risk factors and maladies is still under investigation.

In 1990, Kanaka Maoli also continued to have the worst social, educational and economic indicators (5). Home ownership was lowest for Kanaka Maoli 49.9% vs. White 75.7%, Japanese 63.6% and Filipino 60.5%. Education completed was lowest for Kanaka Maoli: 45.1% completed high school and 7.2% completed college. Household mean income and family mean income were lowest for Kanaka Maoli. In 1990, the Kanaka Maoli juvenile arrest rate of 159 / 1,000 population was highest and greater than in 1980, 102 / 1,000 (10) In 1994, Kanaka Maoli comprised the largest proportion, 40.9% of prison inmates compared to other ethnicities (25).

Conclusions.

1. In the 1990s, most Kanaka Maoli health indicators have not improved significantly. In some instances, such as life expectancy, overall mortality and death rates for heart disease, cancer, stroke and diabetes, and risk factors, such as obesity, hypertension and alcohol-use, the rates are worse than in the 1980s.

2. The 1988 federal-mandated Native Hawaiian Health Professional Scholarship Program and the 5 islands-wide Native Hawaiian Health Care Systems, operational only since 1991, have not been established long enough to reach significant numbers of Kanaka Maoli and to have a measurable impact on Kanaka Maoli health indicators.

3. One favorable outcome has been the Wai'anae traditional Kanaka Maoli and adapted diet which demonstrated short-term control of body weight, hypertension and diabetes. However, this program has affected less than 300 participants and long-term results have yet to be reported.

4. Persistent, grim Kanaka Maoli social, educational and economic indices extending into the 1990s support the hypothesis that societal, as well as lifestyle, factors are major determinants in Kanaka Maoli ill health (26) These factors appear to include Kanaka Maoli depopulation and minority status from continuing foreign transmigration, colonial exploitation with Kanaka Maoli landlessness and economic dependency, coercive assimilation, cultural conflict and despair, adoption of harmful foreign ways and institutional racism (1, 27, 28)

Recommendations

1. Kanaka Maoli continue to test the hypothesis of causal societal factors in their ill health by revitalizing their traditional culture; and resisting further coercive assimilation, cultural conflict, despair and self-destructive foreign lifestyle ways (1, 28).

2. Kanaka Maoli engage non-Kanaka Maoli support in liberation from colonialism and institutional racism; and regain control over their lands and other natural resources, their lives, their future and thus, their health in their homeland (1, 27, 28). The Kanaka Maoli People's International Tribunal of August 12-21, 1993, and the U.S. Congress Apology Resolution of November 23, 1993, provide the historical and legal bases for a process of Kanaka Maoli re-empowerment (30).

3. Kanaka Maoli and non-Kanaka Maoli in Ka Pae'aina restrict unlimited foreign population ingress with resulting social illnesses, such as excessive crowding, crime, substance abuse, automobile dependency and recklessness, consumerism, waste, depletion of natural resources, excessive commercial development, environmental degradation, soaring housing costs and homelessness (1,28).

4. Kanaka Maoli increase and broaden community taro-roots, self-supporting, cooperative management and eventual ownership of the 5 Native Hawaiian Health Care Systems (1); enhance coordination and support of Kanaka Maoli health services with private organizations, including Kanaka Maoli trusts and government agencies and facilities(1).

• a. Emphasize Kanaka Maoli culturally-competent health services, such as, traditional, holistic, preventive and 'ohana (family)-oriented healing practices, protecting and nurturing ahupua'a (local, integrated, land-sea-food-production) in self-reliant livelihood (1, 28, 29)
• b. Augment education and training of Kanaka Maoli in providing community-based health services, management and health care research at all levels (1).
• c. Broaden outreach health services to under-served Kanaka Maoli communities with scheduled dates for attaining realizable client-encounter goals(1).
• d. Target programs to Kanaka Maoli at high risk and with special needs, such as illicit substance-abusing and pregnant school youngsters, tobacco and alcohol consumers, and morbidly obese, hypertensive and diabetic patients (1)

5. Kanaka Maoli coordinate and share resources, education, training, research and health services with also in-need other Pacific Islanders (31).

Acknowledgements

Mahalo (thanks) to Puaalaokalani Aiu, Dr. Emmett Aluli, Dr. Richard Arakaki, Prof. Herbert Barringer, Prof. Kathryn Braun, 'Iwalani Else, Brian Horiuchi, Claire Hughes, Mele Look, Dr. Joyce Martin, Dr. Marjorie Mau, Prof. Noreen Mokuau, Faye Newfield, Dr. Sita Nissanka, Dr. Alvin Onaka, Dr. Neal Palafox, Dr. Terry Shintani, Hardy Spoehr, Carrie Takenaka, Jo Ann Tsark, Prof. Michael Haas, Dr. Robert worth and Dr. Haio Yang for providing critical information and advice. Special gratitude to Prof. Elena S. H. Yu for reviewing an early draft of the manuscript and to Editor Prof. Moon Chen for his guidance and patience. The author alone, however, bears full responsibility for this paper.

Published in In Motion Magazine November 16, 1997