One hundred fifty years ago my kupuna (ancestor) wrote about maʻi pālahalaha (infectious diseases) as a journalist and editor of Hawaiian language newspapers. In Ka Leo o ka Lahui, Kahikina Kelekona discusses the spreading sickness of Hansen’s Disease, or as it was called at that time, Leprosy. He refers to it in his writings as Maʻi Hoʻokaʻawale ʻOhana, the sickness that separates families, due to the quarantine mandates set-up in Hawai‘i. Faced now with COVID-19 and need for racially just health policy in 2020, the testimonies of our ancestors beg a question of us as their descendants: what are we going to do today in order to survive, and thrive for our family, another 150 years?
I recently presented on a 10-year effort that answers this question and will result in billions of dollars of government investment in programs that connect cultural values to social determinants of health in Hawai‘i. This work was voted best Snapshot of Innovation at the Robert Wood Johnson Foundation Sharing Knowledge convening in Jackson, Mississippi earlier this year.
Titled “Ulu Kukui o Kaulike,” meaning the growth of a grove of equity, my Snapshot uses the traditional metaphor of a kukui grove to illustrate a Native Hawaiian Culture of Health that thrives with equity, justice, and self-determination in all policies. The kukui, or the candlenut tree, is of deep cultural, functional, and spiritual importance to Kānaka Maoli (Native Hawaiians) and referenced here to facilitate policy as a healing agent. This blog post will focus on the power of a cultural foundation and the diverse perspectives needed to harvest solutions within one generation.
Understanding of the Problem to Find the Right Solution
Native Hawaiians are experiencing our seventh decade of a public health crisis, marked by numerous chronic conditions oppressing our overall well-being. In Hawai‘i, Native Hawaiians have the shortest life expectancy and exhibit higher mortality rates than the general population due to heart disease, cancer, stroke, and diabetes. Similar to the disparities laid bare by the COVID-19 pandemic, the disparate health outcomes of Native Hawaiians underscore the need to build a Culture of Health that centers equity and addresses long-standing and ongoing racial injustices.
In 2010, health leaders in the Native Hawaiian community created a joint initiative to eliminate disparities among Native Hawaiians. Rather than focusing on the inequalities alone, we elevated culturally and linguistically responsive strategies, outlining a pathway toward health equity beginning with understanding our culture and history at the intersection of public health and public policy. As Nā Limahana o Lonopūhā, the Native Hawaiian Health Consortium, we planned for policy change within the communities we live and work. A robust variety of experts—including traditional practitioners and artists—could see that planning goals in the State of Hawai‘i were not meeting our needs and hadn’t been for decades. Consequently, we set to modernize and update state planning to benefit Native Hawaiians and our health through our holistic worldview. Our efforts resulted in the introduction of Hawai‘i Revised Statute (HRS) §226-20, or the Social Determinants of Health (SDOH) Act, which requires state departments and agencies to eliminate health disparities by identifying and addressing social determinants of health through their respective roles. Passed in 2014, and enforced through 2019, we hope our efforts can serve as an example for others to start these kinds of conversations in their own communities, for their communities.
The Power of a Cultural Lens
We started our community-based conversations ten years ago seeking to understand how the power of our living culture can help improve health systems through the Indigenous lens which is all encompassing and passed through transgenerational wisdom. In our worldview, individual health and resilience is linked to family and community well-being; the health of the natural and built environment reflects the population health of our people. Thus, if the kukui trees are sick and unable to grow, then our long-term health as a people is in jeopardy.
Applying this cultural lens to the policy landscape, we focused our efforts on Hawai‘i’s health and human service programs through Medicaid and CHIP, which provide coverage to one in four residents in Hawai‘i. Specifically, we worked with AlohaCare, a non-profit Medicaid health plan in Hawai‘i, with 70-86 percent of their members self-identifying as Native Hawaiian, Pacific Islander, Filipinx, and/or Asian, making the demographics of the plan highly diverse and primed for health equity programming. We saw this focus as a perfect opportunity to awaken a Native Hawaiian Culture of Health at Hawai‘i’s managed care organizations and health plans for years to come.
In response to the growth of SDOH programs across Hawai‘i’s communities, AlohaCare took action to lead what health plans can do to apply these goals into local operations. To eliminate health disparities among Native Hawaiians, AlohaCare has established a permanent commitment to their Native Hawaiian members and created my Native Hawaiian Cultural Liaison position to lead it. They are the first insurer in Hawai‘i—or anywhere in the United States—to do so. AlohaCare understands that health disparities for Native Hawaiians are maintained by a complex interaction of SDOH, cultural and historical trauma, and a disconnect between culture and effective health and medical services. By utilizing both traditional and contemporary wisdom, this new focus will influence the Medicaid environment by contributing to increased understanding of Native Hawaiian health and medical needs. AlohaCare’s new focus implements the SDOH Act through a cultural foundation which honors the values Indigenous to Hawai‘i and is planning culturally-responsive member services as a major target by 2025.
Bringing Diverse Perspectives to Solve Complex Problems
Native Hawaiian well-being is relational from the self to others and from the land to the people. A Culture of Health in our population refers to achieving and sustaining the well-being of all, including our natural resources, across every generation. Our work acknowledged and honored Indigenous insight while also drawing on the experience and knowledge of policy experts.
We conducted a comprehensive policy analysis cross referencing international human rights declarations and state objectives with federal policies – within the context of the special legal and political relationships between Native Hawaiians and various governing entities. Policy analyses informed our viable health strategy options and documentation to support our effort.
A robust team with expertise from both a health disparities and policy lens strengthened our efforts. Regardless of our differing training or experience, we shared a core bond and personal passion to our professional work together: at the core of social justice for Native Hawaiians is racial equity and healing.
As the PI or Program Lead or Executive Director, you don’t have to have all the answers yourself. You have to promote value-based leadership where everyone in your team has vision and expertise to share for the good of the long-term goals ahead. We are proof of the power of shared community decision-making, trust building, and collective strengthening, which is very typical to how Indigenous communities approach problem solving through opportunity. For us, that’s how you build a community of health based from a cultural foundation as a core practice inherited from our ancestors like my kupuna.
Within ten years, cross-sectoral research and community planning successfully shaped legislation to codify a state commitment to addressing health disparities among Native Hawaiians across State of Hawai‘i agencies. In 2021, $17 billion will be invested in Medicaid programs across all islands through 2030.
Ulu Kukui o Kaulike is a snapshot of innovation to advance equity for Native Hawaiians—and eliminate health disparities—within one generation. The growth of this kukui grove will represent the advancement of racial justice for Kānaka Maoli. The seeds have been planted. Though we have persisted, we have far to go. May these kukui light the way ahead for all of us and the important changes we seek.
Ka ipu kukui pio ʻole.
We are the light of justice that will not be extinguished.