Improved Health Status for Native Hawaiians: Not Just What the Doctor Ordered

The health status of native Hawaiians is considered the poorest of all ethnic groups in Hawai'i (Office of Hawaiian Affairs 1998) and among the poorest in the entire United States. This poor health status holds despite increased federal efforts over the last two decades to improve conditions. As we move into a new millennium, it is natural to inquire whether this poor status will continue or whether we can expect improvements, and, if so, how these improvements will come about. This paper will first set the historical context for the current health status of native Hawaiians and then present the major current medical issues. The final section will lay out some of the key ways in which native Hawaiian communities are working to improve their health status.

It is appropriate here to present some basic data on the ethnic breakdown of the state's population as well as a short commentary on the use of the various descriptors used to define the Hawaiians. Figure 1 breaks out the state's population on an ethnic basis and shows that native Hawaiians make up about 21% of the state's population.

In this paper the term "native Hawaiian" will be used to include all those who have some claim to Hawaiian blood. Within the state, however, there are a wide variety of descriptors used for those regarded as native Hawaiian. The Office of Hawaiian Affairs Data Book (1998) lists no fewer than 19 ways to define "Hawaiians" based on blood quantum, legal opinions, and regulations of bureaucratic and political agencies. None of these definitions include the term "native Hawaiian," which is coming to be the more accepted term, especially among native Hawaiians. Nor do they include the term kanaka maoli, which literally means the original people of the islands and is the preferred term for some Hawaiian groups (Blaisdell 1993). Descriptors used by the state in a variety of studies can even include individuals who have no actual genetic link with the inhabitants of the islands prior to the first recorded contact with Europeans in 1778. Thus, when viewing data dealing with native Hawaiians, the reader is cautioned that in many cases the data may be a compilation using differing definitions. The terms could include those who are full-blooded Hawaiians, currently numbering about 11,000, as well as those who have no Hawaiian blood at all. In some instances the terms "native Hawaiian" or "Hawaiian" include those who simply regard themselves as native Hawaiian or are self-defined native Hawaiians. In such circumstances, decisions and correlations based on the link between ethnicity and health status are fraught with difficulty. However, the researcher can still make informed assessments if these caveats are taken into account.

To better understand the problems of working on native Hawaiian health issues, the reader should be aware of the main geographical features of the state, which have a direct impact on the health status of all the inhabitants of the state including the native Hawaiians.

Figure 2 shows the main islands of the state, seven of which are permanently inhabited.

The state's population (1999) is approximately 1,200,000. Roughly 860,000 reside on the island of O'ahu, about 57,000 on Kauai, 116,000 on Maui, 7,000 on Moloka'i, and 140,000 on the "Big Island"--more properly called the island of Hawai'i. (The island of Hawai'i is almost 1,000 square miles in area, about 80% the size of Rhode Island.) The island of O'ahu has most of the state's population and is also the seat of the state government. Because of the island makeup of the state and the distances between the islands--ranging from around 30 to 200 miles--access between the neighboring islands and Honolulu is essentially possible...