The Health of Native Hawaiians: A Legacy and a Challenge

1. Informational Briefing Committee on Hawaiian Affairs Committee on Commerce, Consumer Protection and Health February 3, 2016 Conference Room 016 Hawai`i State Capitol

2. A Healthy PeoplePrior to Colonization • Epidemic FREE • NO contagious pestilence • Low incidence of disease • Traditional healing mostly used for injuries • Skeletal remains reveal focal infections (dental caries) • Society was orderly, organized and highly sophisticated

3. A Legacy of Excellence • Navigation and Canoe making • Fishing and Agriculture • Feather work • Plaited Mats • Wooden bowls, gourds and bottles, • Musical instruments, dance, chant • Sports and games • Religious practices

4. Engineers, Ecologist and Masons Fishponds and breeding systems were comparable to today’s aquaculture. Auwai (canals), lo`i (ponds) allowed cool water to circulate and not stagnate or overheat. The flow of water was controlled to prevent erosion. Native Hawaiians were conservationists, taking from nature only what was needed. They allowed time for replenishment in order to maintain a constant balance and resource.

5. Traditional Healing Kahuna La`au Lapa`au (Practitioners) practiced as a distinct profession or part of a priesthood, since the process of healing incorporated prayer, introspection and mental conditioning Kahuna La`au Lapa`au (Practitioners) practiced as a distinct profession or part of a priesthood, since the process of healing incorporated prayer, introspection and mental conditioning • Lā‘auLapa‘au – healing spiritually with plants, herbs and prayer • Lomilomi– healing spiritually with massage, prayerful work • Ho‘oponopono - healing spiritually a broken relationship and/or conflict within the ‘ohana

6. Changes That Impact Health Arrival of Capt. James Cook brought profound changes to Hawaiian society. Hawaiian language, religion, ruling system and system of economy were changed, challenged and eventually suppressed.

7. Native Hawaiian Decimation • Foreigners brought disease for which Hawaiians had no antibodies resulting in their rapid demise. • The inability to fight disease challenged Hawaiians belief in their traditional healing methods. • Pure Hawaiian population went from 300,000 (later studies by Stannard were 1 million) when Cook arrived in 1778 to about 30,000 in 1900. In just over 100 years, 90% of the pure Hawaiians were GONE.

8. Legacy of our Ali`i • Health • Kamehameha IV/Queen Emma • Queen Kapi`olani • Education • Bernice Pauahi Bishop • Kamehameha IV/Queen Emma • Children and Families • Queen Liliu`okalani • Kupuna • Prince William Lunalilo • Housing • Prince Jonah Kuhio Kalaniana`ole

9. E Ola Mau Study • 1980s --21 researchers and agencies for 2 years, with funding from ALU LIKE, Inc., created the E Ola Mau: The Native Hawaiian Health Needs Study. • The EOM 6 volumes identified Native Hawaiians’ physical, mental and spiritual health status and their needs and concerns, and placed them in a historical and cultural framework.

10. Leading Causes of DeathNative Hawaiians (1980 – 1985) Compared with the overall US population at the time: • The overall death rate for all Hawaiians was 34% higher than US average. • Cardiovascular disease 44% higher • Cancer 39% higher • Cerebrovascular disease 31% higher • Diabetes mellitus 222% higher

11. Three Critical Findings • Native Hawaiians did not access health care in a timely fashion, go to health screenings or other prevention activities; • Native Hawaiians accessed health care at a later stage of the disease and so treatments were more expensive and outcomes poorer than they could have been with early detection and treatment – giving rise to the belief that hospitals were places to go to die; and • There were very few Native Hawaiians in the health profession. Study identified the importance to link Native culture overall

12. The Concept of Lōkahi “Traditional Hawaiian conceptions emphasize the unity of body, mind, and spirit….for many Native Hawaiians, detachment from traditional beliefs and lifestyles ,,,has created a sense of marginality, helplessness, and alienation.” Excerpt from E Ola Mau, Mental Health Task Force Executive Summary, December 1985

13. Native Hawaiian Health Care Act (1988)Public Law 100-579 The Congress hereby declares that it is the policy of the United States in fulfillment of its special responsibilities and legal obligations to the Indigenous People of Hawai`i resulting from the unique and historical relationship between the United States and the government of the Indigenous People of Hawai`i: • To raise the health status of Native Hawaiians to the highest health level; • To provide existing Native Hawaiian health programs with all resources necessary to effectuate this policy.” Reauthorized as Native Hawaiian Health Care Improvement Act (NHHCIA) (1992), (P.L. 102-396) and in 2010 as part of the Affordable Care Act. Authorized until 2019.

14. Components of NHHCIA • Papa Ola Lōkahi • Native Hawaiian Health Scholarship Program • Native Hawaiian Health Care Systems

15. NāKānaka are increasing! Source: Selected Population Profile in the US, 2013 ACS 1-year, US Census

16. Native Hawaiian PopulationsContinental US vs Hawaii Counties Source: Selected Population Profile in the US, 2013 ACS 1-year, US Census

17. Population PyramidNative Hawaiians in the State of Hawai`i ACS 2013 data reports 35% or 107,419 are under age 18 (10% = 0-4, 25% = 5-17) Source: Selected Population Profile in the US, 2013 ACS 1-year, US Census

19. Access to Healthcare Life expectancy for Native Hawaiians 6.2 year lower than the state average. Dental • 42% have not seen a dentist • 50.7% have had one or more teeth extracted in a lifetime Health • 13.4% without health care coverage • 13.5% did not get health care services because of cost • 44%-64.1% adolescents had a physical exam (covered services) Source: HBRFSS, HDOH, 2011-2012HYRBS, HDOH, 2011-2014Panapasa, S.V., Mau, M.K., Williams, D.R., & McNally, J.W. (2010). Mortality patterns of Native Hawaiians across their lifespan: 1990-2000. American Journal of Public Health, 100(11): 2304-10.Ka‘opua, L.S., Braun, K.L., Browne, C., Mokuau, N., Park, C.B. (2011). Why are Native Hawaiians underrepresented in Hawai‘i’s older adult population? Exploring social and behavioral factors of longevity. Journal of Aging Research. Look M.A., Trask-Batti M.K., Agres R., Mau M.L., & Kaholokula J.K. (2013). Assessment and Priorities for Health & Well-being in Native Hawaiians & other Pacific Peoples. Honolulu, HI: Center for Native

20. Access to Care 2012 Physician Shortage by Island

21. Traditional Healing´A´ohe pau ke ´ikei ka halauho´okahiAll knowledge is not taught in the same school(One can learn from many sources) • To support, perpetuate and facilitate the cultural integrity of Native Hawaiian traditional healing practices and its practitioners. • To encourage the education and presentations of these healing practices, lā‘aulapa‘au, lomilomi, ho‘oponopono, lā‘aukahea. • To liaise with indigenous practitioners of their respective traditional healing practices on the continental United States, in the Pacific, and around the world.

22. Traditional Healing Kupuna Councils To support the inclusion of Native Hawaiian traditional healing practices within the scope of health services provided to the general public for those desiring such services. Kupuna Councils of traditional Hawaiian healers are recognized at each of the five Native Hawaiian Health Care Systems throughout Hawai‘i.

23. Census Information Center (CIC) Designated in 2000 by US Census Bureau, only CIC in the nation and in the Pacific that focuses on data that represents Native Hawaiian. “Translates” Census data at the community and grassroots level and provides feedback and beta-testing for Census products, tools and issues. Protects and represents data needs, interests and “data identity” at the highest level POL CIC received national recognition from Dept. of Commerce for outstanding accomplishments in 2010 based on Census 2010 activities, instrumental in increasing Hawai`i’s response rate by over 11 points.

24. CIC National Partnerships • Provides Bureau with network of diverse organizations that disseminates census data to underserved, under-represented, and hard-to-count communities for planning and decision-making, providing training and workshops upon request. • Contributed to Hawai`i section and launched publication release of A Community of Contrasts, Western Edition, published by Asian Americans Advancing Justice (AAJC), as a data resource for AANHPI and decision makers in October 2015 • Sponsored “No Hea Mai `Oe?” Gathering in July 2015, with US Census Bureau, EPIC and AAJC members who both presented and gathered information from the audience to help with design of 2020 Census.

25. ‘Imi Hale Native Hawaiian Cancer Network:Community Based Participatory Research and Programming Promote cancer education and awareness Increase the number of indigenous researchers addressing cancer prevention and control Increase research in cancer health disparities Funded by the National Cancer Institute Center to Reduce Cancer Health Disparities

26. Graham Colditz Janis Campbell Siteman Cancer Center Beti Thompson Judith Kaur University of Oklahoma Health Services Fred Hutch Cancer Center Mayo Clinic ▲ ▲ Grace Ma Dedra Buchwald Temple University Terrance Albrecht University of Washington Karmanos Cancer Center Howard Koh Harvard School of Public Health ▲ ▲ ▲ Moon Chen, Jr. Mark Dignan ▲ University of Kentucky Lexington UC Davis Cancer Center ▲ ▲ Claudia Baquet ▲ ▲ University of Maryland Sora Tanjasiri ▲ ▲ ▲ California State Fullerton Elmer Huerta MedStar Research Institute ▲ ▲ Paul Godley ▲ ▲ Paula Espinoza ▲ ▲ Lineberger Cancer Center- Chapel Hill University of Colorado ▲ ▲ James Hebert University of South Carolina ▲ Kathryn Coe Margaret Hargreaves Inter Tribal Council of Arizona Meharry Medical College ▲ Ronda Henry-Tillman Daniel Blumenthal Amelie Ramirez Morehouse School of Medicine ▲ Victor Tofaeono University of Arkansas Cancer Research Center Cathy Meade UT Health Science Center, San Antonio LBJ Tropical Medical Center, Samoa H. Lee Moffitt Cancer Center Edward Partridge Papa Ola Lokahi, HI University of Alabama Birmingham Cancer Center 1 of 23 Community Network Program Centers in the Nation, Funded by the National Cancer Institute

27.  Hawaiian researchers  cancer research projects with Hawaiian leadership  participation of communities in research  opportunities for research education and training  resources ($ and services) for cancer prevention & control  cancer education tools tailored for kanaka maoli  body of published literature by kanaka maoli Where ‘Imi Hale has made a difference 27

28. Increase in Native Hawaiian Researchers (cumulative total)

29. Research w/ Native Hawaiians – about 50 projects • BC survival • Nasal ciliary function • La`aulapa`au • Smoking cessation • HPV awareness • Colorectal cancer screening • Navigation • Church and family-based interventions • Biobanking • Health literacy • Survivorship • Worksite wellness • PILI@Work • More…

30. Hawai‘i’s only Cancer Patient Navigation Training Program 15 Completed 48 hr trainings 3 Community College trainings 50+ Continuing Education Sessions 7 Annual Cancer Navigation Conferences 5 Publications 112 8 39 14 • 211graduates • 19 Navigator positions established since 2006. • 8 Queen’s Medical Center • 3 Moloka`i General Hospital • 1 Hilo Medical Center • 1 Maui Memorial Medical Center • 1 Straub Clinic & Hospital • 1 Pali Momi Medical Center • 1 Wilcox Memorial Hospital • 3 Kapi`olani Medical Center for Women & Children Over 88% of graduates report using patient navigation skills in their current jobs as community outreach workers and health care providers. (Source: 2014 Annual CPN Survey) 38 Braun KL et al. Progress in Community Health Partnerships 2008; 4:329-40. Domingo J et al. Hawai‘i Medical Journal. 2011;70:257-61. Braun KL et al. Journal of Health Care for Poor and Underserved. 2012: Allison A et al. Hawai'i Journal of Medicine & Public Health. 2013; 72: 88-92.

31. Culturally Targeted Health Education Materials Avg100,000 education materials distributed annually

32. Native Hawaiian Health Scholarship Program (NHHSP) Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396

33. Mission and Components Mission: To increase the number of Native Hawaiian health care professionals trained in those disciplines and specialties most needed to deliver quality, culturally competent, health care to Native Hawaiians in the State of Hawai'i. • Three main components: • Federal Scholarships to pursue careers in designated health care professions, covering tuition, required fees and other educational and living expenses. Service obligations and payback requirements on acceptance of scholarship award. • Placement of NHHSP scholars in priority Native Hawaiian communities following the completion of their training, and • Training of NHHSP scholars in culturally appropriate ways to provide health care services in Hawaiian communities.

34. 24 Years of Awards • Federal allocations ~ $22 million • 245 scholarships • 70% to Primary Health Care professions • 30% to Behavioral Health & Social Service professions • 71% of awards went to the top three (3) professions : • Nursing – 82 • Physicians – 49 • Social Workers - 45

35. Awards Degree & Profession (n = 245)

36. Awards Degree & Profession (n = 245)

37. Native Hawaiian Health Care Systems NaPuuwai

38. HO`OLA LAHUI HAWAI`I Native Hawaiian Health Care System, Kaua`i

39. Scope of Services • Medical Services • Dental Services • Health Care & Preventive Programs • Fitness Programs • Pharmacy Services • Behavioral Health and Substance Abuse Programs

40. KE OLA MAMO Native Hawaiian Health Care System, O’ahu

41. Services Primary Care Behavioral Health Services Contracted Dental Services Nutritional Counseling Health Education Outreach Services Exercise Case Management Eligibility Traditional Native Hawaiian Healing Practices

42. NA PU`UWAI Native Hawaiian Health Care System Moloka`i, Lana`i and the Kalaupapa Settlement

43. Community-based Health Programs Chronic Disease Screening & Education Clinics Cardiovascular risk screening Diabetes complications screening Stroke health with peripheral arterial disease (PAD) testing Early kidney disease detection Cancer screening: breast, prostate, cervical, skin, oral, colo-rectal School-based Programs Heart Guardian: cardiovascular health to 3-6th graders Asthma: Open Airways for students with asthma Hearing screening for elementary schools Health Education Chronic kidney disease Cancer prevention/control Diabetes prevention/control Stroke health Cardiovascular disease risk factor control Lifestyle modification through wellness classes Programs Benefit Community CPR and FA to companies, organizations, individuals, schools Support groups: dialysis, diabetes, maintaining lifestyle changes Smoking cessation Task force to address domestic violence Hearing Screening for employees of companies Case management of referred patients with chronic disease

44. HUI NO KE OLA PONO Native Hawaiian Health Care System Maui

45. Programs & Services • Clinical Services • ‘Imi Ola Hou – “Seeking to restore Health” Primary Care • Behavioral Health – services related to chronic medical conditions through internal referral process • Women’s Health –Breast & Cervical Cancer Control Program (BCCCP) services for underinsured and uninsured women • Oral Health – dental services for clients including screenings at various elementary schools • Programs • Outreach • Simply Healthy Cafe • Lomilomi • Enabling • Transportation • Health Education • Case Management • Wellness Classes • Screenings

46. HUI MĀLAMA OLA NĀ `ŌIWI Native Hawaiian Health Care System Moku o Keawe

47. Programs & Services • Provides a wide variety of health enhancement services to Native Hawaiians, which include: • Facilitating access to health care • Referrals • Education • Transportation • Health screening • Networking with health care providers • Intake and outreach services

48. Population Census Data * Population only – no indication if category is alone and in any combination

49. Federal Funding of NHCIAA(millions of dollars) • 1988 $ 0.49 million • 2006 $14.4 million • 2015 $13.66 million