NHSC Health And Social Services

Health And Social Services

A. INTRODUCTION

Since a wide variety of health statistics for native Hawaiians and for the State of Hawaii were presented in the previous chapter, they will not be repeated here. Instead, this chapter will focus on the historical and cultural background of native Hawaiian health; and the State and federal programs that exist to address the health needs of all residents of the State, as well as programs specifically for native Hawaiians.

The Hawaii State Health Department administers a wide range of programs emphasizing health maintenance and promotion, risk reduction, and preventive services. 1/ Total expenditures by the Department for the fiscal year ending June 30, 1980, were $116,368,576. The Federal Government provided 12.1 percent of this amount, or $14,055,526. The various programs available to address health needs are described below. Descriptions include the services provided, the community served, and the problems encountered.

B. HISTORICAL AND CULTURAL BACKGROUND

Critical historical events and unique cultural features influencing the health and illness of native Hawaiians are conveniently considered in three periods: before contact with the non-Polynesian world; contact, beginning with Captain James Cook in 1778 to the overthrow of the monarchy in 1893; and the end of the kinqdom to the present.

Pre-contact (Ancient to 1778)

Health and Illness

Prior to and at the same time of the arrival of Captain Cook in January 1778, the Hawaiians of old were generally healthy because they had adapted effectively to island ecosystems about them, and they had lived in isolation from the rest of the planet for over 500 years. 2/ Gene strength was evident in a flourishing population of an estimated 300,000 at the time of Captain Cook. 3/ These were descendants of perhaps one hundred hardy, first settlers who had arrived more than 1,000 years previously from the South Pacific, after braving over 2,000 miles of open sea in double-hulled canoes. Some gene weakness was possible because of

*/ The following section on historical and cultural background is a complete reproduction of a section of the paper prepared by Richard Kekuni Blaisdell, M.D., entitled: "Health Section of Native Hawaiians Study Commission Report" (pages 1 through 18, February , 1983), written at the direction of and funded by the Office of Hawaiian Affairs. Dr. Blaisdell is a Professor in the University of Hawaii's Medical School. Minor editorial changes have been made to conform to the Final Report's format, and the footnotes have been redesignated for the convenience of the reader. Except for these changes, the section of Dr. Blaisdell's paper appears as submitted by OHA and is otherwise unchanged. The second part of Dr. Blaisdell's paper, "Health Profile," is not included here--it is consistent with the health data presented in the "Demographics" chapter of this Report which incorporates previous comments submitted to the Commission by Dr. Blaisdell. Dr. Blaisdell's entire paper is reproduced in the Appendix of this Report and are marked with "[1]" in the "List of References."

-p99-

the small gene pool, inbreeding, and opportunities for genetic drift. 4/ These genetic factors could accoutn for gcongenital-hereditary deformities described below, and for the impaired immunity and peculiar hypersusceptibility to disseminated infections that characterized the later contact period.

The natives' food was mainly taro, sweet potato, yam, bread-fruit and banana, with fish, and for the maka'ainana (commoners), only infrequently pig and dog. This high-fibre, low-fat, unrefined and limited sugar diet ample in vitamins and abundant in minerals, is now considered superior to the usual fare of modern westeren societies, with one important common fault--excessive sodium. 5/ This is a basis for inferring that the natives of old probably also had some arterial hypertension and related disorders, as shall be discussed later.

Personal, household, and public cleanliness of the early Hawaiians are well documented 6/ and were strictly controlled by kapu (sacred law) of the kahuna (priests). 7/ Physical activity in work and play was vigorous and enjoyable, and yet with adequate time for sleep and rest. 8/

There were no crowding, no public latrines, no garbage heaps or litter, and no use of human or animal exreta as fertilizer. Because of clean air, pure water, and unpolluted land and sea, promoted by the kapu, natives unknowingly maintained control of potentially harmful pathogenic microorganisms. 9

The natives were free of the epidemic, contagious pestilences that scourged the continents in recurring waves for thousands of years. However, islanders did have some focal infections as evidenced in pre-contact skeletons recovered from burial sand dunes. 10/ Dental caries, which result from acid-producing mouth bacteria acting on carbohydrate-containing foods, occurred in less than 7 percent of those under age 40, to 51.5 percent in persons over the age of 60--frequencies much lower than those observed today. 11/ Some bones abscesses were also evident, such as in the maxilla or mandible, as extensions from dental pulp infections. 12 "Boils" were also described in Cook's journals. 13/ Thus, the early Hawaiians were not entirely free of pathogenic organisms, as some have claimed. 14/

Metabolic maladies, so prominent in native Hawaiians today, were probably also present in their ancient ancestors. However, the evidence is largely indirect and their frequencies remain uncertain. The direct evidence is also to be found in unearthed bones, which show examples of gouty arthritis, degenerative arthritis, and rheumatoid arthritis. 15/ Common soft tissue disorders, such as coronary atherosclerotic heart disease, arterial hypertension, stroke, chronic obstructive lung disease, diabetes mellitus, and end-stage renal disease, are presumed to have occurred in pre-Cook Hawaiians because heredity appears to play some role in these dieases so prevalent in native Hawaiians today. 16/ However, since th elife-style factors of the maka'ainana did not include a high-fat diet, cigarette somking, physical inactivity, and appressine stress, the frequencies of these "diseases of civilization" in the early Hawaiians were probably less than today. No

-p100-

signs of nutritional deficiencies, such as rickets and scurvy, are apparent in the osseous materials. 17/

Evidence of metastatic cancer to the bony spine has been seen in one pre-contact specimen, 18/ but no obvious cases of neoplasm were described in Cook's journals.

Trauma from accidents or intentional violence was probably the most common class of ailments, as recorded in writings, 19/ and as observed in skeletal remains. 20/ "Poisoning" may have been due more to psychic effects 21/ than to direct pharmaceutical toxicity, because the pre-contact islands apparently had no lethally poisonous plants. 22/ The only type of chemical self-abuse known in old Hawaii was "kava debauchery," described among some ali'i in Cook's journals. 23/

Mental illness was described in the form of two natives who were "wrong in their senses" in Cook's journals. 24/ This single passage contrasts with frequent other references to the islanders being "social, friendly, hospitable, humane," "blessed with frank and cheerful disposition," and "mild and agreeable, not easily excitable," 25/ which support the views of subsequent foreigners that the natives were adept at coping with stress. 26/

Congenital-hereditary disorders were apparent to Cook's men in a young man "born with neither feet nor hands," another "born blind," and two dwarfs. 27/ Four cases of club foot were found among the 1,117 precontact persons buried at Mokapu. 28/ The described defects were probably related to inbreeding. The survival of these malformed natives beyond infancy counters the later claims by missionaries that infanticide was traditional and widely practiced. 29/ Cook's journals record the Hawaiians as being "totally unacquainted with [Tahitians'] horrid custom of destroying their newborn infants." 30/ The natives prized physical beauty and practiced body molding of the infant and child. 31/ Some degree of infanticide of the severely deformed newborn may have been practiced, but there were no illegitimate births in the modern sense, and generally every child was he pua (a flower) to be cherished, assuring continuity of the heritage and race. 32/

Medical Beliefs and Practices

Health and illness were another example of the all-pervading dualism of the early Hawaiians' belief system, like sky and earth, sun and moon, male and female, mind and body, and life and death. 33/

Wellness was maintaining mana, quantifiable energy, which was both inherited and acquired. Proper balance of mana was promoted by harmony with oneself, with others, and with the gods and nature, through continuous communication with the spiritual realm and correct thought and action. 34/ The kapu (taboo), established by the kahuna (priests), sanctioned by the ali'i, and enforced by all, fostered self-discipline and responsibility in personal hygiene, health-promotion, illness-prevention, public sanitation, and respect for nature, which was the domain of the gods. 35/ Illness was loss of mana from dysharmony, such as from violation of a kapu, offending a god, or ill-thinking. 36/

The elderly were esteemed. Death after a meaningful life was welcomed as a reuniting with one's ancestors in the eternal spiritual realm and completion of a recurring cycle of rebirth and transfiguration into kinolau (non-human forms) or reincarnation into other human forms. 37/

-p101-

Diagnosis was determining the mechanism of loss of mana through psycho-spiritual communication, interviewing of the patient and his 'ohana (family), and physical examination, 38/ Treatment was restoring deficient mana through ritualistic communication with the psycho-spiritual realm of the gods, supplemented by special foods, secretly formulated herbals, physical therapy and limited surgery. 39/

Medical care for the commoner was the responsibility of the patient himself, and, if necessary, an experienced 'ohana elder. Only if the illness were serious, and expensive professional fees in hogs could be paid, did a maka'ainana engage the fastidious kahuna lapa'au (priest physician), rigorously trained at the heiau ho'ola (healing temple). 40/ The ali'i had regular access to varieties of specialty kahuna lapa'au whose rituals and practices were elaborate and extensive. 41/

The Hawaiians' autopsy observations, 42/ use of the clyster-enema, 43/ and emetics and cathartics 44/ provide evidence of beginning experimentation and scientific reasoning not found elsewhere in Polynesia. 45/

This highly-refined, holistic and preventive health system, harmoniously integrated in their social fabric, with nature about them, and their spiritual realm beyond, was never to recover from the impact of western ways.

Contact (1778 to 1893)

Depopulation

Infections: in January 1778, the arrival of the first foreigners, Captain Cook and his seamen, brought medical disaster in the form of the veneral diseases, mainly gonorrhea and syphilis, tuberculosis, other common contagious bacterial viral illnesses, as well as alcohol, gunfire, and otner forms of disrespect for the kapu, the gods, and nature. One year later, in March 1779, when these first, visitors departed, the natives could see from the sick and dead about them, that "the sliding way of death" had begun. 46/

In 1804, the diarrheal epidemic of ma'i 'oku'u (probably cholera or typhoid) killed perhaps 15,000, 47/ and convinced Kamehameha the Great that the gods did not favor his military invasion of the island of Kauai. 48/

Subsequent sporadic "catarrhs and fevers" took other lives, so that by 1820, when the first missionaries landed, the population estimate of 150,000 was half that at the time of Cook, about 40 years previously. 49/ Other outbreaks of disease occurred as follows:

• In 1824, Kamehameha II and his sister-wife Queen Kamamalu died of measles in London. 50/

• In 1824-1826 and again in 1832, epidemics of cough (whooping?)and measles killed thousands of

natives. 51/

• In 1839, mumps killed "great numbers" including Kina'u, kuhina nui (regent), daughter of Kamehameha the Great, and mother of Kamehameha IV and V. 52/

• In 1845-1849, epidemics of measles and pertussis and then diarrhea and influenza left over 12,000 dead. 53/

• In 1840, the first case of leprosy in a Hawaiian was detected. 54/ In 1865, because

of the alarming spread of this fearsome malady, a new

-p102-

segregation law established a receiving leprosy hospital in Honolulu and isolation of lepers on the Kalaupapa peninsula of the island of Molokai. 55/ One out of every 39 (2.6 percent) of native Hawaiians was affected, whereas the occurrence in non-Hawaiians was one in 1,847. 56/ A peak of 1,310 active cases was reached at the end of the century, and over the 40 years since the start of segregation, an estimated 4,000 natives died of this affliction. 57/

• In 1853, 1861, 1873, and again in 1882, smallpox took over 7,000 lives, in spite of compulsory smallpox vaccination in 1854. 58/

• In 1857, an epidemic of colds, headache, sore throat, and deafness (influenza?) raged. 59/

• In 1866, cough, chills, fever, vomiting, nose bleeding, and disability (dengue?) affected

hundreds.

• In 1878-1880, whooping cough brought death to 68 in Honolulu. 60/

• In 1888, whooping cough struck again with 104 lives, and in 1890 diphtheria. 61/

• In 1889-1890, measles and dysentery killed 26. 62/

• By the time of the overthrow of the monarchy in 1893, the native Hawaiian population was

reduced by 87 percent to about 40,000. 63/

Lack of Immunity, Genetic and Other Factors: Multiple factors probably accounted for the steep logarithmic decline in the population of the pure Hawaiian. 64/ Introduced infections, as cited above, in a people who lacked immunity because of their long isolation, not only explained high and irregular direct mortality, but could also explain the decreased birth rate. Local, genital, venereal, and other infections, and general, systemic infections probably impaired fertility in both men and women, increased early and late fetal deaths in utero, and contributed to neonatal and infant mortality, through indirect general debility and malnutrition. 65/

Latent genetic defects could have predisposed to reduced birth rates, 66/ and probably account for the natives' hypersusceptibility to chronic infections, aside from impaired immune mechanisms, such as in leprosy and tuberculosis. 67/

Other chronic metabolic illnesses, not readily or specifically diagnosable, especially among the maka'ainana, but related largely to conflicting life-styles, were probably also taking their toll. These disorders include arterial hypertension, atherosclerosis, heart, kidney, and lung failure, stroke, and diabetes, so prevalent among modern Hawaiians. 68/

Among the ali' i, these terminal illnesses were identified as follows: in 1854 Kamehameha III died at age 42 of convulsions and delirium that could have been a stroke; in 1863 Kamehameha IV died with asthma at the age of 29; in 1872, at the age of 42, Kamehameha V succumbed of "buttock abscess, dropsy and asphyxia;" in 1883, Princess Ke'elikolani died at age 57 of heart failure; in 1884, Queen Emma died of stroke at the age of 49; and in 1891, King Kalakaua died at the age of 54 of "Bright1s disease" (kidney failure). 69/

-p103-

Despair: Cultural conflict resulted in disintegration of the old social order. In 1819, despairing because the kapu were no longer effective, the Hawaiians themselves, under the leadership of Kamehameha II, Queen Kaahumanu, and High Priest Hewahewa, formally abolished these strict sacred laws that governed personal hygiene and public sanitation. 70/ Gross pollution of person, home, the land, and water followed, as described and decried by the missionaries and other foreigners. 71/ There was decline of ali'i leadership and stewardship as the chiefs sought material luxury by exploitation of the maka'ainana in sandalwood and other trade with foreigners. 72/

With alienation from the land came disruption of the 'ohana and replacement of their traditional self-reliant, ahupua'a subsistence economy by an urban market economy. The kahuna and 'ohana educational systems disintegrated. New social ills emerged, such as alcoholism, tobaccoism, vagrancy, prostitution, and the malnutrition of processed foods. Finally, there was the perception by the native Hawaiians, preached by the missionaries, of the "superiority" of certain western ways and material culture, compared to native "primitive" beliefs and practices. The stress was too overwhelming for many islanders. Some fled, like an estimated 5,000 out-migrating Hawaiians in 1850. Others despaired inwardly, lost their will to live in a haole-dominated new order that made them strangers in their homeland, as they sought the comfort of death. 73/

Inadequacy of Traditional Native Medicine for Haole Illnesses

In this period of culture shock, there evolved a makeshift, loose health care system for native Hawaiians with the following characteristics.

Although the major gods had been toppled, and the kahuna hierarchy abolished, the kanuna lapa'au remaine underground. These officially disenfranchised kahuna, plus experienced 'ohana elders, and the patient himself, continued to care for "Hawaiian illnesses" as of yore, but with some modifications. 74/

Newly-introduced plants, such as the guava and eucalyptus, were incorporated into the native materia medica. Some western notions of disease and the pharmaceutical action of herbals on body functions were adopted, therapeutic effects that were not mediated by the traditional native concept of restoration of mana. However, there was still some reliance on aumakua, or family guardians, although the senior gods had departed. 75/ As the heiau ho'ola, as well as the other heiau, were destroyed, formal training of kahuna ceased. They were replaced by more self-styled, poorly-trained or untrained "kahuna," many of whom incurred the denunciation of missionaries, other foreigners, and even some native Hawaiians. 76/

"Hawaiian medicine for Hawaiian disease" probably survived because at that time, non-Hawaiian medicine was no more effective. Psycho-spiritual aspects of native medical care merged with new beliefs, such as Christianity, sometimes confusingly so, or were abandoned so that little of the old liturgy found its way into print when the natives learned how to write. 77/

Haole illnesses, such as gonorrhea, syphilis, cholera, diphtheria, measles, mumps, smallpox, and tuberculosis, did not respond to Hawaiian medicine, and since there were too few haole physicians initially to demonstrate that haole medicine was no better, some natives tried whatever was called haole medicine. 78/

-p104-

Ascent of Haole Medicine

Haole surgery, however, was perceived as generally superior, with metal instruments, instead of bamboo or adzes, for resections, incision, and drainage of abscesses, and the techniques of suturinq and ligature to arrest bleeding and promote wound healing. 79/

Western public health measures replaced the old kapu system, but initially they, too, did not seem any more effective against the devastating contagious epidemics. Key events in this area include:

• In 1836, kuhma nui Kina'u was advised to issue the first public health proclamation — the Honolulu harbor pilot was instructed to screen all foreign-arriving vessels for smallpox and other pestilences. 80/
• In 1850, Kamehameha III created a board of Health, and the first public water pipeline carried fresh water from Nu'uanu Valley to Honolulu harbor to fill water casks. 81/
• In 1854, smallpox vaccination was made compulsory, but three smallpox epidemics followed, the iatest in 1882 82/
• In 1865, a drug law for western medications was passed and the "Hawaiian Medical Society" for haole physicians was chartered. 83/
• In 1859, the queen's Hospital, providing western medical care, was founded by King Kamehameha IV and Queen Emma. It was the first hospital for native Hawaiians, 22 years after the first of seven hospitals had been opened for foreigners. 84/
• In 1862, the first Sanitation Commission was appointed. 85/
• In 1864, burial of the dead was regulated by law. 86/
• In 1865, the first receiving hospital for lepers opened in Kalihi, in Honolulu, with the kingdom's new segregation laws. The following year, the first lepers were exiled to Kalawao on the Kalaupapa peninsula on the island of Molokai. 87/ In 1890, the population of the settlement reached a peak of more than 1,200. There was no satisfactory therapy and the annual death rate varied from 12 percent to 20 percent. 88/
• In 1866, the first insane asylum opened in Palama, Honolulu, with six patients. 89/
• In 1868, durinq the reign of Kamehameha V, a "Hawaiian Board of Health" licensed practitioners of native medicine, but certain rituals of old were proscribed, and no formal training was authorized. 90/
• In 1870, ex-missionary and ex-Prime Minister Dr. Gerrit P. Judd was authorized by the Board of Education to establish the first medical school of western medicine. Two years later, ten young native graduates were licensed to practice haole medicine, but shortly thereafter Dr. Judd had a stroke and the school was closed. 91/
• In 1873, collection of garbage and street-cleaning began in Honolulu. 92/
• In L874, King Lunalilo died of "pulmonary consumption"

-p105-

(tuberculosis) and alcoholism. His will provided for "a home for elderly infirm and destitute Hawaiians," which opened in Makiki in 1885. 93/

• In 1876, the legislature authorized drainage of taro wetlands that were declared "insanitary." 94/

• In 1879, the first artesian well for drinking, washing, and irritgation was drilled at Honouliuli, Oahu by James Campbell, foudner of the large, land-holding Campbell Estate. 95/

• In 1882, the first water filtration plant was constructed at Nu'uanu, in Honolulu. 96/ Inspection of food and licensing of dairies began in Honolulu. 97/

• In 1884, the first local government hospital, Malulani, was opened at Wailuku, Maui. 98/

• In 1886, the first plantation hospital at Makaweli, Kauai was built by the Hawaiian Sugar Co. By 1890, there were 18,900 plantation employees and four plantation hospitals. 99/

• In 1880, the government of King Kalakaua was so alarmed at the decline of the native Hawaiian population and the prevalence of squalor, insanitation, and morbidity, that the Board of Health issued a book in the Hawaiian language on Sanitary Instructions for Hawaiians, written by Walter Murray Gibson. 100/

• About the same time, the Ho'oulu a Ho'ola Lahui Society was founded by the king and Queen Kapiolani t"to propagate and perpetuate the race." A home for destitute Hawaiians was established in Kaka'ako and the first Kapiolani Home for non0leprous children of leprous parents on Molokai opened next to the Kaka'ako Receiving Hospital. 101/

• In 1890, the Kapiolani maternity Home for birthing of infants of native Hawaiian women opened in the renovated house of the queen's recently-deceased sister, Princess Kakaulike, in Makiki in Honolulu. 102/ This private hopsital was supported by contributions. Native women were not required to pay for their medical care until 1917, when non-Hawaiians were first admitted. 103

Overthrow of the Monarchy to the Present (1893-1983)

Population Changes

In 1893, with the dethronment of Queen Liliuokalani and the establishment of a non-elected Provisional Government by the haole business oligarchy, the native Hawaiins were already a minority in their homeland, although the pure Hawaiians still outnumbered the part-Hawaiians (see table in footnote). 104/ The controlling whites were the smallest minority, exceeded by the imported, non-voting Oriental laborers.

The contrast 90 years later, in 1983, is striking. Native Hawaiians are relatively an even smaller minority, with the part-Hawaiians far outnumbering the almost vanished pure Hawaiians. The white population has greatly increased, although still exceeded by all Orientals combined. 105/

-p106-

Major Illnesses

Serious infections continued in the early post-kingdom period, as is evident in the following chronology, but with no reliable, readily available data on the numbers or proportions of pure and part- Hawaiians involved. The population figures cited above provide only rough guidelines for such speculative inferences.

• In 1895, with the oligarchical Provisional Government succeeded by the oligarchical Republic of Hawaii, cholera swept through Honolulu and killed 64. 106/

• In 1899, the bubonic plague took 61 lives. With the turn of the year, fire to control the plague-carrying rodents destroyed Chinatown in Honolulu, awakening public concern for the residual "filth, squalor...homeless, destitute and incurables," including more victims with tuberculosis that for the first time became reportable. 107/

• In 1901, when the Honolulu Home for the Incurables (forerunner of Leahi Hospital) opened, 32 of the first 72 patients had tuberculosis. 108/

• In 1903, when 900 known cases of tuberculosis were identified, about 32 percent were native Hawaiians. 109/ From 1900 to 1923, tuberculosis remained the number one reported "cause of death," with mortality as high as 200 per 1,000 population. The corresponding U.S. mainland tuberculosis mortality rate was declining from 152 to 92 per 1,000. By 1937, although TB mortality rates for all races in Hawaii had fallen to 88 per 1,000, the rates for pure Hawaiians remained high at 265 and for part-Hawaiians at 126, while the rate for whites was 23 per 1,000. 110/

• In 1918-1920, the post-World War I influenza pandemic accounted for 1,700 deaths in Hawaii. 111/ During the war years, venereal disease became reportable. 112/

• In 1919, typhoid killed 42. 113/ In this year, the leading reported "causes of death" were influenza-pneumonia, tuberculosis, and diarrheas. 114/

• In 1920, leprosy still claimed 662 active hospital cases at Kalaupapa, with 114 new cases for the year, the majority native Hawaiians. 115/ Not until sulfone chemotherapy in 1946 did the mortality rate drop from 10 percent to 2.5 percent per year. 116/ By 1974, there were only 13 active cases of leprosy, but over 100 deformed and disabled mainly Hawaiians, with the kidney, nerve, skin, nasal, oral, facial, and limb complications of this dreaded disorder. 117/ The 29 new leprosy cases for that year were chiefly in immigrant non-Hawaiians. 118/

• In 1928-1929, acute meningitis accounted for 68 deaths. 119/

• In 1930, for the first time, heart diseases displaced infections as the leading reported "cause of death." 120/

• In 1936-1937, measles deaths numbered 205. 121/

-p107-

• In 1940, the highest-ranking recorded "causes of death" in the Territory were heart diseases, cancer, and kidney failure. 122/

• In 1942, during the second World War, diphtheria involved 90. The following year, mosquito-borne dengue affected scores. 123/

• In 1950, the top reported "causes of death" were heart diseases, cancer, and stroke. 124/

• In 1958, acute poliomyelitis struck 77. 125/

Health Measures

The following anti-disease actions parallel similar developments on the U.S. mainland, but with some features distinctive of Hawaii and the native Hawaiian people.

• In 1899, after the annexation of Hawaii to the United States as a territory, the first sewers were laid in Honolulu, then a city of 40,000. 126/

• In 1902, what is now Leahi Hospital opened on the mauka slope of Diamond Head in Kaimuki, Honolulu, as the Home for the Incurables, with four wards. It was a private institution created with contributions from nine wealthy businessmen of the haole oligarchy and $750 from the Board of Health. 127/ The proportion of tuberculous patients rose from 50 percent initially, to 100 percent in 1950, when the Territorial Government built a new hospital wing and assumed operating expenses for the hospital, with free medical care for TB patients. 128/ In 1968, the hospital became a State institution of the University of Hawaii School of Medicine. In 1976, it was transferred to the Staff Department of Health. 129/

• In 1908, the U.S. Congress generously provided $300,000 for the ambitious U.S. Leprosy Investigation Station on the Kalaupapa peninsula, Molokai. Only 9 of the 700 patients at the settlement agreed to participate in the Station's investigations, and then only for a few days, so the elaborate facility was compelled to shut down after only two years. 130/ In l980, the U.S. Ccnqress approved the recommendations of a commission that Kalaupapa be preserved indefinitely for the remaining leprosy patients there, and then become an historical and cultural reserve under the U.S. National Park Service. 131/ Active cases of leprosy are now treated at Leahi Hospital in Honolulu, but some patients are still championing the right to remain in the non-hospital, rural cottage setting of Hale Mohalu in Pearl City on Oahu. 132/

• In 1911, the first resident intern was appointed in Hawaii at the Queen's Hospital, a haole medical graduate from California. 133/

• In 1914, the first public health nurse was appointed by the Board of Health. 134/

• In 1916, the first school of nursing in Hawaii started at the Queen's Hospital. 135/

-p108-

• In 1918, during World War I, venereal diseases became reportable. 136/
• In 1921, the Territorial Government established Waimano Home for the mentally-retarded and severely deformed. Statistics on the number of native Hawaiian patients institutionalized there are scheduled to be available in March 1983. 137/
• In 1925, the first maternal and child care programs were started by the Board of Health. 138/
• In 1930, the new Territorial mental health hospital opened at Kaneohe, Oahu with 541 patients. 139/
• In 1936, a Crippled Children's Bureau and Office of Health Education were created in the Board of Health. 140/
• In 1937, a separate Bureau of Vital Statistics was established. 141/
• In 1938, the Hawaii Medical Service Association (HMSA), a private health insurance firm, was founded by the Territory's school teachers and social workers. HMSA is now open to all and by 1975 it had over 400,000 members. 142/
• In 1967, the University of Hawaii School of Medicine accepted its first class of 25 students. None was a native Hawaiian. 143/

C. MENTAL HEALTH PROGRAMS

Mental Health Status of Native Hawaiians 144/

Native Hawaiians generally present the same variety and pattern of mental health problems as other groups in the State, according to a service and research project in Hawaii called Hale Ola o Ho'opakolea. 145/ (The efforts of this group will be described below.) One main difference, however, is that the native Hawaiians have "that unique set of problems associated with indigenous peoples living under a non-indigenous government." 146/ For instance, immigrants who are non-English speakers have a choice, usually, of returning to their respective countries to maintain their linguistic, cultural, and other ties, while native Hawaiians have no choice but to remain in Hawaii. Some native Hawaiians "perceive themselves as citizens of an unfairly defeated nation [and] some see themselves as an oppressed people." 147/

Native Hawaiians are a unique cultural group with long-standing traditional patterns of personal, family, and social behavior that still contribute to the identity and security of individuals in their daily lives. As a result, the causes of mental health problems, their perceptions by native Hawaiians, and the appropriate means by which they are resolved differ markedly from non-Hawaiians. 148/ The Hale Ola Project summarizes the situation as follows:

Pressures to successfully provide adequate income levels for families and stable jobs produce stresses among native Hawaiians and generate role and value

-p109-

conflicts, and present competing incentives to maintain cooperative, Hawaiian collective lifeways or to adopt more contemporary, competitive and individualistic lifeways associated with modern American lifeways. A significant part of the problem is perhaps that there are no real alternatives that one can freely turn to aside from the dominant Western lifestyle. A great deal of evidence has been accumulated in particular on how a native Hawaiian child who wants to retain the Hawaiian lifestyle is heavily penalized in the state educational system.

Such conficts and stresses foster mental and emotional disorders among native Hawaiian families in particular. In addition, lower levels of formal education attainment and higher levels of unemployment and underemployment contribute to stresses and disorders . . . 149/

Hawaii State Department of Health Programs

According to the Hawaii State Department of Health, the community's needs for mental health services exceed the available public and private resources, although the State is attempting to decrease the gap and make its services available to more people. The Mental Health Division of the Health Department now operates eight community mental health centers—five on Oahu, and one in each of the other counties (Hawaii, Maui, and Kauai). 150/ Many of these centers also operate satellite facilities to reach more people. The first ethnic-oriented mental health clinic, which is for Chinese-speaking persons, was opened in June 1980. A new program has also been funded to set up a network of community residential facilities.

The centers on the neighboring islands report some problems, mainly with manpower. The island of Hawaii has only one community residential facility for mentally-ill adults--with only four beds. The county hopes to expand the facility to twelve beds. Maui County reports that outpatient services are adequate in the Central Maui area, but are limited in West Maui, the South Shore and "up-country" areas, and on Molokai and Lanai.

In addition to its community mental health centers, the Mental health Division also operates four specialized programs:

• Courts and Corrections, which provides mental health consultation to the State's court and correctional programs;
• Children's Mental Health Services;
• Hawaii State Hospital; and
• Alcohol and Drug Abuse.

The first three of these programs report problems of manpower availability that may restrict services.

The Alcohol and Drug Abuse program does not provide direct services itself. Through contracts with private agencies, the program allocates State and Federal funds to twenty-one drug abuse and alcohol programs statewide. The State program does provide technical assistance, research, and training to these local programs.

The Alcohol and Drug Abuse branch completed a statewide population survey of the incidence and prevalence of substance abase in Hawaii. Preliminary data from the survey indicate that:

• Hawaii has a significantly higher percentage of people

-p110-

using cocaine (4.7 percent) than the U.S. mainland (two percent);

• Marijuana is used by a slightly higher percentage of people in Hawaii (14.4 percent) than on the U.S. mainland (13 percent); and
• The current non-medical use of sedatives is also slightly higher in Hawaii (1.2 percent) compared to the U.S. mainland (0.7 percent). 151/

Federally-Funded Programs

The Hale Ola Project is a service and research effort supported by federal funds from the National Institute of Mental Health and the Administration for Native Americans (under the U.S. Department of Health and Human Services). 152/ The Project is administered in Hawaii by Alu Like, Inc., and was initiated because it was found that "Western approaches to therapy and mental health care are not entirely suitable or appropriate for non-Western, including native Hawaiian, individuals with mental or emotional problems." 153/

Hale Ola o Ho'opakolea is a recent effort to test and demonstrate the effectiveness of an alternate and culturally-sensitive approach to meeting the mental health care needs of native Hawaiians. The three-year project (entering its third and final year at the beginning of 1983) is located on the Wai'anae Coast.

According to the Project Director, the Hale Ola Project is a unique effort in several respects. It represents the first time that a service center has been established to utilize a culturally-sensitive approach to service delivery targeted for native Hawaiians with mental, emotional, and related problems. It is a center that employe qualified service staff drawn from the Wai'anae Coast communities to provide counseling, referral, follow-up, training, and information gathering in a manner appropriate to native Hawaiians. Informal approaches to care-giving assistance are emphasized and flexibility is maintained with regard to setting the time and frequency with which care is provided. Hale Ola also represents a unique effort to identify, recruit , and coordinate the variety of informal care-givers and natural healers who are present in every community and offer a wide range of services generally uncatalogued and unacknowledged by professional service agencies. Hale Ola is working to link formal and informal sources of assistance in order to create a network of care for individuals with various kinds of problems and service needs. Finally, Hale Ola is unique in its organizational character; it was initiated by Wai'anae Coast community groups and it continues to be directly guided by and responsible to a community-based administrative committee consisting of residents and service agency staff.

The Hale Ola Project has also been, responsible for sponsoring cultural research efforts that seek to elicit specific kinds of information directly applicable to culturally-sensitive service delivery. In particular, Hale Ola has formulated a community research program that consists of three main research efforts:

• A community survey of native Hawaiian perception and communication styles with regard to personal problems;
• A survey of informal care-givers and natural healers on the Wai'anae Coast; and

-p111-

• A survey of the knowledge, attitudes, and practices of formal agency-based service providers on the Coast with regard to their sensitivity to native Hawaiian service needs.

By the beginning of 1983, the first research effort had been completed and documentation of this effort was being produced. The second effort was almost completed, and the third was being initiated.

Another program involving federal funds transferred from the National Institute of Mental Health to the Administration for Native Americans is the "Most-In-Need" (MIN) project. 154/ This program, also administered by Alu Like, addresses the needs of native Hawaiian youth through service system change, as well as improved relations among community, private, county, and state agencies. The need for this program was founded in the experience that native Hawaiian youth were particularly affected by disjointed care from traditional service delivery systems.

On the island of Molokai, the most-in-need group was identified by island human service providers as native Hawaiian youngsters between the ages of 12 and 14 years, residing in the Hawaiian Homestead areas of Hoolehua, Kalamaula, Kapaakea, Kamiloloa and One Alii. Puu Huoli, a subsidized housing project in Kaunakakai, and the Mana'e (east) end of the island, were also targeted. An estimated 2 50 youth fall into the target group.

Since 1979, the MIN Project has contacted and established positive relationships with over 150 native Hawaiian youngsters. The Project operated a demonstration summer program for two years and implemented a special after-school program in 1981 in the Hoolehua, Kaunakakai, and Mana'e areas. In addition, MIN conducted studies in juvenile delinquency and recreation to further clarify problems and concerns on Molokai.

D. MEDICAL HEALTH SERVICES

Among the programs operated by the State of Hawaii in this area are: public health nursing, chronic diseases, and nutrition.

The public health nursing program focuses on "wellness"—health promotion and maintenance, and disease prevention. The program provided services to 33,268 individuals during 1979-80, through visits to homes, private and parochial schools, day care centers, care homes, neighborhood centers, and nursing offices. The program also provides ongoing home health services to eligible people on Molokai and Lanai.

The objective of the Chronic Disease Branch is to reduce the complications and severity of chronic diseases by providing prevention, detection, and educational services. Major activities include:

• Screening for diabetes, hypertension, and cervical cancer;
• Provision of financial assistance to those with end-stage kidney disease; and
• Consultations to medical facilities about the rehabilitation care of chronically-ill patients.

The Nutrition Branch seeks to promote "wellness" in the State through good nutrition and the reduction of the risk of nutritionrelated diseases. Direct nutrition services, consultation to other public and private agencies, and educational services are provided. Recently, the Branch developed and distributed a new publication that is entitled, "You Can Reduce Your Risk of Disease Through

-p112-

Diet—Follow these Dietary Guidelines."

The Federal Government currently funds several programs in the priority medical health problem areas for native Hawaiians. 155/ The National Heart, Lung, and Blood Institute currently funds two large-scale programs in Hawaii concerning heart disease. The first is an epidemiologic study of heart disease conducted by the Geographic Diseases Section of the Honolulu Heart Study. The second is a high blood pressure education program directed at communication problems among ethnic groups.

There is also a great deal of activity in relation to cancer in the State of Hawaii. The National Cancer Institute, Public Health Service currently supports almost $2.5 million in grants and contracts in Hawaii specifically directed at cancer. Among the subjects under study are alcohol and cancer, diet and prostate cancer, lung cancer and dietary vitamin A, and clinical cancer education programs.

E. FAMILY HEALTH SERVICES

The Family Health Services Division of the Hawaii State Department of Health offers several programs. Among them are: maternal and child health, school health, crippled children services, and community services for the developmentally disabled. The goal of the Maternal and Child Health Branch is to "interrupt the cycle of medical and psychosocial problems which tend to be passed from one generation to another, particularly in the more disadvantaged families." 156/ In order to reach this goal, programs are offered in the areas of family planning, perinatal care, and growth and development from infancy through adolescence. The combined programs serve approximately 45,000 individual clients annually. Specific programs include:

• Maternity and infant care project clinics for low-income families in Hilo, Waimanalo, and Nanakuli;
• Attempts to prevent child/spouse abuse and neglect through identification of families at high risk and an integrated system of community support;
• Screening and referral for vision, hearing, and development delays of children attending preschools; and
• Children and youth project for low-income families in Waimanalo. 157/

Special mention should be made of a project in Waimanalo, where the population consists of a high proportion of native Hawaiians. The Waimanalo Health Clinic is a combined Maternity and Infant Care/Children and Youth project. The Clinic offers a full range of services for mothers and children, and is staffed by a multidisciplinary team that includes specialists in speech and hearing, nutrition, public health nursing, social services, and medical services. The Clinic has developed unique projects in the areas of community public health nursing, adolescent health care, nutrition, and dental health programs. The Waimanalo Health Clinic is the only one of its kind in the State of Hawaii and "serves as a model to demonstrate the ideal in delivery of maternal and child health services in the community setting." 158/

Under the School Health Program, health aides, supervised by school nurses, provide preventive and

-p113-

emergency care in every public school in the State. The program also offers diagnostic evaluations for three- to ten-year-olds with learning disabilities.

The services provided by the Crippled Children Services Branch include: diagnosis, medical and surgical treatment, general counseling, occupational and physical therapy, speech therapy, social work, and nursing services. Diagnostic evaluations are provided without charge to all medically-eligible children. Treatment services are also free to families in financial need. The Federal Government also provides funds for specific programs in the family health area. 159/ The U.S. Department of Health and Human Services supports:

• A program at the State Department of Health to support services to children with special needs;
• A special State project for mentally-retarded children; and
• A medical genetics screening program at the State Department of Health.

In addition, the School of Public Health at the University of Hawaii is the recipient of $301,000 in Federal funding to support a maternal and child health program directed to help young mothers during the pre- and postnatal periods.

F. COMMUNICABLE DISEASES

The Epidemiology Branch of the Hawaii State Department of Health operates the one venereal disease clinic in the State. Other programs include school immunization programs, an influenza vaccine program, and research on fish poisoning, salmonellosis, and leptospirosis. It is feared that the latter may be an occupational hazard of the growing aquaculture industry, and surveillanc activities to monitor the situation are to be intensified.

The Tuberculosis Program offers detection services and preventive treatment. Tuberculosis remains a problem in Hawaii because of immigration, particularly of Indo- Chinese refugees.

The other major program in the communicable diseases category is the Leprosy Program. At the end of December 1979, there were 458 cases of leprosy on the state register. Of these cases, 328 were outpatients, 12' were residents of Kalaupapa on Molokai, 160/ and six resided at the South Trotter Wing at Leahi Hospital on Oahu. The Communicable Disease Division reports that, over the past ten years, there have been an average of 40 new leprosy cases each year. Of these cases, about 80 percent involve people who were born in Samoa or the Philippines. The Leprosy Program does not collect ethnic data on patients, but has informed the Commission that the distribution of the small numbers of locally-born cases appear to be indicative of the ethnic population distribution in Hawaii. 161/

Since 1974, the policy of the State has been to place all new leprosy cases under outpatient treatment, unless there are severe reactions or complications. Only three percent of the leprosy program budget was allocated to outpatient care in 1979-1980, while inpatient care accounted for the balance. The majority of the inpatients, as noted above, live in Kalaupapa, and their care is made more expensive by their advancing age (their average age in 1979 was 61). By law, the residents of Kalaupapa may live out the rest of their natural lives there.

In December 1980 (in the same public law that created the Native Hawaiians Study Commission), the U.S. Congress established the Kalaupapa National Historic Park. However, the

-p114-

State of Hawaii continues to provide for the care of the patients.

G. COUNTY AND STATE HOSPITALS

The Hawaii State Department of Health administers four hospital systems that include twelve hospitals and one medical center. These facilities provide and coordinate high-quality acute and long-term health care to all citizens of the State, where such care is not routinely available from the private sector.

The locations of the facilities are as follows:

Hawaii County: Five hospitals in Hilo, Kona, Honokaa, Kau and Kohala; Maui County: Two hospitals on Maui (Maui Memorial and Kula Hospital) and one medical center (at Hana); one hospital on Lanai; Honolulu County: Two hospitals (Leahi and Maluhia); and Kauai County: Two hospitals (Kauai Veterans and Samuel Mehelona Memorial).

H. OTHER PROGRAMS

The Hawaii State Department of Health also conducts the following programs:

• Dental health, with programs in dental hygiene, hospital dentistry, and community services;
• Waimano Training School and Hospital, which is the State's only residential institution for the mentally retarded;
• Health Promotion and Education, which promotes healthful lifestyles and health maintenance; and The State Health Planning and Development Agency, whose activities are statewide planning for health services, manpower and facilities, and the development of resources to support its plans.

-p115-

HEALTH AND SOCIAL SERVICES

NOTES

1/ All of the information on the Hawaii State Department of Health programs in this section is taken from the Hawaii State Department of Health, Narrative Annual Report, Fiscal Year Ended June 30, 1980; hereinafter referred to as "Dept. of Health, Annual Report, 1980."

2/ 0. A. Bushnell, A History of Infectious Diseases in Hawaii (unpublished manuscript, 1970). Dr. Bushnell is Professor Emeritus at the Medical School of the University of Hawaii.

3/ J. C. Beaglehole, editor, The Journals of Captain James Cook on His Voyages of Discovery, Vol. 3, The Voyage of the Resolution and the Discovery, 1776-1780 (London: Cambridge University Press, 1967).

4/ Bushnell, A History of Infectious Diseases in Hawaii.

5/ C. D. Miller, "The Influence of Foods and Food Habits upon the Stature of Teeth of the Ancient Hawaiians," Appendix E, in C. E. Snow, Early Hawaiians: An Initial Study of Skeletal Remains from Mokapu, Oahu (Lexington: University of Kentucky Press, 1974); and also, Personal Communication to Dr. Blaisdell from J. Hankin, University of Hawaii professor of nutrition, 1979.

6/ See Beaglehole; and O. A. Bushnell, "Hygiene and Sanitation among the Ancient Hawaiians," Hawaii Historical Review, Vol. 2, No. 5 (1966):13.

7/ Bushnell, "Hygiene and Sanitation among the Ancient Hawaiians."

8/ See Beaglehole.

9/ Bushnell, "Hygiene and Sanitation among the Ancient Hawaiians."

10/ See C. E. Snow, Early Hawaiians: An Initial Study of Skeletal Remains from Mokapu, Oahu; and I. J. Larsen, Ancient Hawaiian Medicine, Thesis for the American Orthopedic Academy, 1966.

11/ H. G. Chappel, "Jaws and Teeth of Ancient Hawaiians," Vol. 9 (Honolulu: Bernice P. Bishop Museum, 1927):249.

12,/ See I. J. Larsen.

13/ See Beaglehole.

14/ F. J. Halford, Nine Doctors and God (Honolulu: University of Hawaii Press, 1954).

15/ See Snow; and I. J. Larsen.

16/ R. K. Blaisdell, "Hawaiian Health Needs," The Native Hawaiian, Vol. 5 (December, 1980):1.

17/ See Snow; and I. J. Larsen.

18/ See Snow.

19/ See Bushnell, A History of Infectious Diseases in Hawaii; I. J. Larsen; and Halford.

20/ See Snow; and I. J. Larsen.

21/ S. M. Kamakau, Ka Po'e Kahiko, Special Publication No. 51 (Honolulu: Bernice P. Bishop Museum, 1964).

22/ Personal Communication to Dr. Blaisdell, from K. Nagata, University of Hawaii botanist, March, 1982.

-p116-

23/ See Beaglehole.

24/ Ibid.

25/ Ibid.

26/ See Bushnell, A History of Infectious Diseases in Hawaii; and, Mary Kawena Pukui, E. W. Haertig, and Catherine A. Lee, Nana I Ke Kumu, Volumes I and II (Honolulu: Hui Hanai, 1972 and 1979).

27/ See Beaglehole.

28/ See Snow.

22/ Robert C. Schmitt, The Missionary Censuses of Hawaii, Pacific Anthropology Record No. 20 (Honolulu: Bernice P. Bishop Museum, 1973).

30/ See Beaglehole.

31/ See Pukui, Haertig, and Lee.

32/ Ibid.

33/ Rubellite K. Johnson, Kumulipo, Hawaiian Hymn of Creation (Honolulu: Topgallant Publishing Co., Ltd., 1981).

34/ Pukui, Haertig, and Lee. [See, also, chapter in this Report entitled, "Native Hawaiian Religion."]

35/ See Bushnell, "Hygiene and Sanitation among the Ancient Hawaiians;" and, Pukui, Haertig, and Lee.

36/ See Pukui, Haertig, and Lee; and, E. S. C. Handy, Mary Kawena Pukui, and K. Livermore, Outline of Hawaiian Physical Therapeutics, Bulletin 126 (Honolulu: Bernice P. Bishop Museum, 1934).

37/ See Kamakau; and, Pukui, Haertig, and Lee. [See, also, chapter in this Report entitled , "Native Hawaiian Religion."]

38/ See Bushnell, A History of Infectious Diseases in Hawaii; Pukui, Haertig, and Lee; and Handy, Pukui, and Livermore.

39/ Ibid.

40/ See Kamakau; and, John P. li, Fragments of Hawaiian History (Honolulu: Bernice P. Bishop Museum, 1959).

41/ See Kamakau; li; and, David Malo, Hawaiian Antiquities (Moolelo Hawaii), Special Publication 2, Second Edition (Honolulu: Bernice P. Bishop Museum, 1951).

42/ See Kamakau.

43/ See Kamakau; and, Handy, Pukui, and Livermore.

44/ See, Ibid.; and, li.

45/ P. Buck, "Remarks on Hawaiian Medical Lore," in N. P. Larsen, Rededication of the Healing Heiau Keaiwa, Hawaiian Historical Society Annual Report (1951).

46/ See Bushnell, A History of Infectious Diseases in Hawaii; Kamakau; li; and, Malo.

47/ Robert C. Schmitt, "The "oku'u—Hawaii's Greatest Epidemic," Hawaii Medical Journal, Vol. 29 (1970):359.

48/ Bushnell, A History of Infectious Diseases in Hawaii.

49/ See Schmitt, The Missionary Censuses of Hawaii; and, Robert C. Schmitt, Demographic Statistics of Hawaii, 1778-1965 (Honolulu: University of Hawaii Press, 1968).

-p117-

50/ Bushnell, A History of Infectious Diseases in Hawaii.

51/ Ibid.

52/ Ibid.

53/ Ibid.

54/ See Halford.

55/ A. V. Skinsnes, Evolution of Hawaii's Leprosy Control Program, 1865- 1981, Master of Science Thesis, University of Hawaii (April, 1981); and, o. K. Skinsnes, "Notes on Leprosy in Hawaii" (unpublished, 1983). [O. K. Skinsnes is a Professor in the Dept. of Pathology, University of Hawaii Medical School.]

56/ A. A. S. M. Mouritz, "The Path of the Destroyer," Honolulu Star-Bulletin (1916).

57/ Skinsnes, "Notes on Leprosy in Hawaii."

58/ Bushnell, A History of Infectious Diseases in Hawaii.

59/ Ibid.

60/ Ibid.

61/ Ibid.

62/ Ibid.

63/ Schmitt, Demographic Statistics of Hawaii.

64/ See Bushnell, A History of Infectious Diseases in Hawaii; and, R. K. Blaisdell, "Hawaiian Medical Practices" (Lecture and Manuscript, Kamehameha Schools, 1979).

65/ See Blaisdell, "Hawaiian Medical Practices;" and, E. C. Nordyke, The Peopling of Hawaii (Honolulu: University of Hawaii Press, 1977).

66/ N. Morton, C. S. Chung, and M. P. Mi, Genetics of Interracial Crosse; in Hawaii (New York: Karger, 1967).

67/ O. K. Skinsnes, "Infectious Granulomas: Exposit from the Leprosy Model," Annual Review of Medicine, Vol. 33 (1982):47.

68/ See Blaisdell, "Hawaiian Health Needs;" and, R. K. Blaisdell, "He Mau Ninau Ola," Ka Wai Ola O OHA (February, 1983).

69/ R. K. Blaisdell, "History of Medicine in Hawaii" (unpublished, 1983).

70/ Blaisdell, "Hawaiian Medical Practices."

71/ See Halford.

72/ See Bushnell, A History of Infectious Diseases in Hawaii; and Lawrence Fuchs, Hawaii Pono: A Social History (New York: Harcourt, Brace & World, 1961).

73/ See Bushnell, A History of Infectious Diseases in Hawaii; Blaisdell, "Hawaiian Medical Practices;" and, Fuchs.

74/ Blaisdell, "Hawaiian Medical Practices."

75/ See chapter on "Native Hawaiian Religion," below, by Rubellite K. Johnson.

76/ See Halford.

77/ See chapter on "Native Hawaiian Religion," below, by Rubellite K. Johnson.

78/ Blaisdell, "Hawaiian Medical Practices."

-p118-

79/ See C. S. Judd, Medical History of Hawaii (unpublished manuscript, University of Hawaii Medical School, 1978); and, Halford.

80/ Bushnell, A History of Infectious Diseases in Hawaii.

81/ See Bushnell, A History of Infectious Diseases in Hawaii; Blaisdell, "History of Medicine in Hawaii;" and, J. Liberman, "Our 125-Year Health Heritage," Hawaii Health Messenger, Vol. 38, No. 4 (1975):1.

82/ See Bushnell, A History of Infectious Diseases in Hawaii; and, Blaisdell, "History of Medicine in Hawaii."

83/ See Ibid.; and, Judd.

84/ R. Greer,"The Founding of the Queen's Hospital," Hawaiian Journal of History, Vol. 3 (1969):110.

85/ Bushnell, A History of Infectious Diseases in Hawaii.

86/ Ibid.

87/ See Mouritz; and, Skinsnes, Evolution of Hawaii's Leprosy Control Program.

88/ See Mouritz; and, Skinsnes, "Notes on Leprosy in Hawaii."

89/ Blaisdell, "History of Medicine in Hawaii."

90/ Ibid.

91/ O. A. Bushnell, "Hawaii's First Medical School," Hawaiian Historical Review, Vol. 2 (October, 1967):396.

92/ See Bushnell, </u>A History of Infectious Diseases in Hawaii</u>; and, Blaisdell, "History of Medicine in Hawaii."

93/ Blaisdell, "History of Medicine in Hawaii."

94/ See Bushnell, A History of Infectious Diseases in Hawaii; Judd; and, Blaisdell, "History of Medicine in Hawaii."

95/ Blaisdell, "History of Medicine in Hawaii."

96/ See Judd; and, Blaisdell, "History of Medicine in Hawaii."

97/ See Ibid.; and, Bushnell, A History of Infectious Diseases in Hawaii.

98/ See Judd.

99/ Ibid.

100/ See Bushnell, A History of Infectious Diseases in Hawaii; and, Blaisdell, "History of Medicine in Hawaii."

101/ M. L. Hanley and 0. A. Bushnell, "A Song of Pilgrimage and Exile: The Life and Spirit of Mother Marianne of Molokai," Franciscan Herald (Chicago, 1980).

102/ M. Yardley and M. c. Rogers, "A History of Kapiolani Hospital" (unpublished, 1983).

103/ Ibid.

-p119-

104/ Schmitt, Demographic Statistics of Hawaii. See table below.

105/ Ibid.

106/ See Bushnell, A History of Infectious Diseases in Hawaii; Judd; and, Blaisdell, "History of Medicine in Hawaii."

107/ See Bushnell, A History of Infectious Diseases in Hawaii; and, Leahi Hospital, Annual Reports, 1902- 1980.

108/ Leahi Hospital, Annual Reports.

109/ Ibid.

110/ B. H. Douglas, "Tuberculosis in the Territory of Hawaii," Public Health Committee, Chamber of Commerce of Honolulu (1938).

111/ See Bushnell, A History of Infectious Diseases in Hawaii; and, Blaisdell, "History of Medicine in Hawaii."

112/ See Ibid.; and, Judd.

113/ Bushnell, A History of Infectious Diseases in Hawaii.

114/ Ibid.

115/ See Skinsnes, "Notes on Leprosy in Hawaii;" and, R. K. C. Lee and A. Russell, Public Health and Medical Sciences in the Pacific: A 55-Year Review, 1920-1975, U.S.-Hawaii, Pacific Science Association (1983).

116/ Ibid.

117/ Lee and Russell.

118/ See Skinsnes, "Notes on Leprosy in Hawaii;" and, Lee and Russell. [See also, below, page 114.]

119/ Lee and Russell.

120/ Ibid.

121/ See Liberman; and, Lee and Russell.

122/ Lee and Russell.

123/ See Liberman; and, Lee and Russell.

124/ Lee and Russell.

125/ See Liberman; and, Lee and Russell.

126/ See Bushnell, A History of Infectious Diseases in Hawaii; Judd; and, Blaisdell, "History of Medicine in Hawaii."

127/ Leahi Hospital, Annual Reports, 1902-1980.

128/ Ibid.

129/ See Ibid.; and, Lee and Russell.

-p120-

130/ See Skinsnes, Evolution of Hawaii's Leprosy Control Program; and, Hanley and Bushnell.

131/ Kalaupapa National Park Advisory Commission Report (1980).

132/ Skinsnes, Evolution of Hawaii's Leprosy Control Program.

133/ See Judd.

134/ Ibid.

135/ Ibid.

136/ See Bushnell, A History of Infectious Diseases in Hawaii; Judd; and, Blaisdell, "History of Medicine in Hawaii."

137/ Personal Communication to Dr. Blaisdell from W. Sakai, Waimano Training School and Hospital Administrator (February, 1983).

138/ Lee and Russell.

139/ Ibid.

140/ Ibid.

141/ See Liberman; and, Lee and Russell.

142/ See Judd.

143/ Personal Communication to Dr. Blaisdell from B. B. C. Young, University of Hawaii Medical School, Dean of Students (February 1983).

144/ The Commission also received two other papers that deal, in whole or in part, with the mental health of native Hawaiians; both were written at the direction of and funded by the Office of Hawaiian Affairs. They are: (1) Richard Kekuni Blaisdell, M.D., "Health Section of Native Hawaiians Study Commission Report" (see, particularly, pages 34-37); and (2) Ramon Lopez-Reyes, "The Demise of the Hawaiian Kingdom: Its Psycho-Cultural Impact and Moral Legacy." Both papers appear in their entirety, in the Appendix of this Report.

145/ See Appendix for comment received from Hale Ola o Ho'opakolea, p. 2.

146/ Ibid.

147/ Ibid.

148/ Ibid.

149/ Ibid.

150/ According to comments received from the Hale Ola Project/ the clinic operated on the Wai'anae Coast of Oahu "was noted for its inability to adequately meet the mental health care needs of native Hawaiians on the Coast. This problem was largely due to the insensitivity of clinic staff to the unique manner in which native Hawaiian clients identified, communicated and sought to resolve their problems" (p. 3).

151/ Dept. of Health, Annual Report, 1980, p. 9. For a detailed discussion of this survey, see preceding chapter, "Demographics," pages 57 to 59.

152/ The information on this program is drawn from comments received by the Commission from the Hale Ola Project staff, pp. 3-5.

153/ Ibid., p. 3.

154/ Information on this program supplied by Commissioner Carl Anderson, U.S. Department of Health and Human Services; and in written testimony submitted to the Commission on January 10, 1982, by George Osakoda,

-p121-

Project Director for the Most-In-Need Project on Molokai.

155/ Information supplied by Commissioner Carl Anderson, U.S. Department of Health and Human Services. The Commission also received a comment from the Director of Indian Health Services (a part of the U.S. Department of Health and Human Services) stating that: "Native Hawaiians are not within the scope of the [Indian Health Service (IHS)] program and there are no IHS programs specifically targeted to serve them. The regulations governing eligibility for IHS services at 42 CFR Part 36.2 (b) states in pertinent part: (b) Indian includes Indians in the continental United States, and Indians, Aleuts and Eskimos in Alaska" (p. 1).

156/ Dept. of Health, Annual Report, 1980, p. 19.

157/ Ibid.

158/ Ibid., p. 20.

159/ Information supplied by Commissioner Carl Anderson, U.S. Department of Health and Human Services.

160/ In January 1983, the number of patients who were residents of Kalaupapa was 114. (Communication from Hawaii Department of Health, Communicable Disease Division.)

161/ This information on the national and ethnic origin of new leprosy cases was obtained by the Commission from the Communicable Disease Division of the Hawaii State Department of Health in January 1983, in response to a comment received from Bill Kama who states that the Draft Report did not mention the lepers' plight and that "the majority are Hawaiians, and they have been treated like third class citizens."

-p122-