Historical Trauma, Health Disparities, and Native Hawaiian Representation in Nursing

Background

He hawai’i au. Keiki hanau o ka ‘aina hawai’i.

The above phrase pays homage to The Kumulipo, the Hawaiian creation chant. It is not directly taken from the chant but rather is an example of how the Native Hawaiian people view themselves and the land when introducing themselves to another. He Hawai’i au. I am Hawai’i. The Hawaiian people view themselves and the land to be one because the creation of the Hawaiian Islands and people are birthed from the same deities, earth mother (Papa) and sky father (Wakea). Keiki hanau o ka ‘aina hawai’i. I am a child born from the land of Hawai’i.

According to Native Hawaiian activist and scholar Haunani-Kay Trask, “The (Hawaiian) people cannot exist without the land and the land cannot exist without the (Hawaiian) people.” The existence of the Hawaiian people is one that has been fought for, with profound pain, loss, and trauma, since the arrival of Captain Cook to Hawai’i in 1778. Captain Cook’s arrival marked the beginning of the decimation of the Native Hawaiian people by foreign disease and the proliferation of Western influence. This colonization process continued when Western missionaries came in 1820; they furthered the degradation process of Hawaiian cultural and spiritual practices, replacing them with the Christian doctrine. The ascendence of colonization and oppression was marked on January 16, 1896, when the sovereign Kingdom of Hawai’i was violently and illegally overthrown by a group of American businessmen and U.S. armed soldiers, resulting in an occupation of a colonizing majority that has persisted to today.

The colonization of Hawai’i has created three major losses for the Native Hawaiian people: (1) loss of health, (2) loss of cultural and spiritual practices, and (3) loss of self-governance. Such losses resulted in the long-term subjugation of the Hawaiian people, which has had devastating and multigenerational effects. Today, current systems perpetuate the impacts of colonization, such as the cheapening of the Hawaiian culture via Western depictions of paradise and tourism; restrictive land policies; urbanization that has led to the loss of traditional aquacultural and agricultural practices (2011); and replacing the Hawaiian language with English in nearly all facets of daily life. All of these have carried losses that have “limited the ability” of Native Hawaiians “to actualize optimal health.”

Historical Trauma

Historical trauma is defined as “. . . intergenerational trauma experienced by a specific cultural group that has a history of being systematically oppressed.” For Hawai’i, it is particularly important to understand the history of colonization to understand health disparities today.

Since the arrival of Captain Cook, Western people have brought diseases like syphilis, leprosy, measles, polio, tuberculosis, and so forth that destroyed the native population and, from a health context, also led to a mistrust of Westerners and Western medicine. According to David Swanson from the University of California Riverside, it is estimated that within two years after Captain Cook’s arrival, 1 in 17 Native Hawaiians had died. The population continued to decline, so much so that, by 1840, the Native Hawaiian population had declined by 84 percent. Today, Native Hawaiians remain a minority in their own homeland, making up 21 percent of the Hawai’i population, including those who identify as part Hawaiian.

As the influx of Western people continued in the 1820s with the protestant missionaries, the breakdown of the traditional Hawaiian Kapu system, which governed nearly all aspects of daily and spiritual life for Native Hawaiians, left a huge gap that was replaced by Christianity. Christian missionaries set up schools that removed Hawaiian children from their homes and enforced strict Western and English-only practices. The cultural stripping of the Hawaiian identity through the replacement of traditional systems, practices, and language illustrates one of the three major losses felt by Hawaiians. To speak Hawaiian or practice Hawaiian culture was looked down upon with “disdain as primitive and pagan.”

Then in 1848, to further the Hawaiian Kingdom’s position with Western powers, King Kamehameha III created “The Great Mahele,” which redistributed land based on the foreign and Western practice of ownership, something that was unknown to many Hawaiians, who never saw themselves as owners of land but rather stewards. The Great Mahele did not favor Hawaiians, and the overall effect for Hawaiians was the overwhelming loss of land and claim to the resources and wealth associated with that land. It is important to note that in addition to the economic loss, Native Hawaiians also view the loss of land as a loss of self because the Native Hawaiians view themselves and the land to be one. Such loss of resources is reflected in the socioeconomic status of Native Hawaiians today and the loss of power in economic, political, and social status.

Modern Implications to Health Care

Today, Native Hawaiians in Hawai’i have the shortest life expectancy of 62.2 years compared to other ethnic groups: Caucasians, 72.1 years; Chinese, 75.9 years; Japanese, 74.8 years; and Filipino Hawai’i residents, 73.3 years. Native Hawaiians also exhibit higher mortality rates than the total population due to heart disease, cancer, stroke, and diabetes. In terms of socioeconomic factors, Native Hawaiians are more likely to live below the poverty level, experience higher rates of unemployment, and experience imprisonment. In an interview with Dr. Kealohaku‘ualohaku‘upoki‘i Balaz, she states,

Native Hawaiians are at the bottom of the totem pole in our own homeland. We have the highest rates of incarceration, drug use, COVID-19 numbers, those needing help with government assistance, etc. So, it is no surprise that our (Native Hawaiian) people have the highest rate of diabetes, hypertension, high cholesterol, etc. When you cut off the access to food and to the land, our people don’t have the economic status or means to stand on, so they will make do with what they can.

There are several health disparities that have been studied extensively, such as coronary heart disease (CHD) and stroke prevalence in the Native Hawaiian community. CHD is the first leading cause of death for Native Hawaiians, and the prevalence of CHD has increased in the last four years for Native Hawaiians (currently at 4.2 percent), which is twice that of European Americans and three times that of Japanese Americans. Stroke is the third leading cause of death for Native Hawaiians, with Native Hawaiians afflicted by stroke an average of 10 years younger than others. Hypertension and obesity are also disproportionately higher in the Native Hawaiian population and are risk factors for stroke and CHD. A study by Dr. Joseph Keawe’aimoku Kaholokula and other researchers from the University of Hawai’i School of Medicine found that a high prevalence of hypertension and obesity was linked to perceptions of racism in Native Hawaiians.

An Indigenous Worldview, Representation, and the Nursing Metaparadigm: Person, Wellness, and Health

By applying the metaparadigm of person and health to the problem of Native Hawaiian disparities, we can position our understanding of a Native Hawaiian patient and the Hawaiian worldview so that nursing interventions can be applied early on in care and allow collaboration with the patient. Wellness is a multidimensional and dynamic process that holistically examines the physical, social, psychological, and spiritual aspects of a patient’s life to move toward a positive and affirming successful existence. For Native Hawaiians, in order to truly achieve health equity and wellness, it is important that providers delivering care to Native Hawaiian communities understand the Hawaiian worldview through Hawaiian values of l¯okahi (harmony) and pono (equity/righteousness) and the relationship between k¯anaka (man, people), aina (land), and na akua (spirits/god).

Nursing

The nursing component in the nursing metaparadigm acknowledges the nurses’ skills, training, and experience in caring for and with patients. Nurses play a critical role in establishing effective partnerships with patients to motivate, facilitate, and promote overall wellness. The unique and irreplaceable perspective that Native Hawaiian nurses bring to the integration of community and Indigenous cultural practices can transform health care settings into culturally competent environments for Indigenous communities to heal. Increasing diversity within the nursing workforce is not a new concept, and such increases have demonstrated reductions in health disparities.

When it comes to the nursing profession in Hawai’i, although 21 percent of the total state population identifies as Native Hawaiian, only about 12 percent of the nursing workforce identifies as such. Hawai’i County, where I grew up, has one of the highest concentrations of Native Hawaiians in the state, yet it is medically underserved and is designated as a health care provider shortage area. When you combine the depressed Native Hawaiian nurse workforce with the fact that the counties with the highest need for medical providers also have the highest concentration of Native Hawaiians, the probability of a Native Hawaiian being able to access a Native Hawaiian nurse is nearly impossible. If one looks further into nurse disciplines, for counties such as Kaua’i and Hawai’i, there are no Advanced Practice Registered Nurses or Licensed Practical Nurses that identify as Native Hawaiian. It is no surprise that there is a lack of representation of Native Hawaiians in nursing, given the systemic suppression and subjugation, which extend to the educational outcomes. Native Hawaiians have lower proficiencies in math and reading and the lowest rate of on-time high school graduation and postsecondary enrollment.

Conclusion

During my time working for the Queens Medical Center in Honolulu, I was able to work with the Ke Ku ‘una Na ‘au program, which provides culturally adapted patient navigation behavioral health services for patients who identify as Native Hawaiian. The navigation team was multidisciplinary, made up of nurses, social workers, and community health workers, all of whom understood their patients from a cultural perspective. From their personal knowledge of the community, cultural awareness, and competency, team members of Ke Ku ‘una Na ‘au are able to build strong trusting partnerships with their Native Hawaiian patients in order to provide key pathways to clinical resources and support for safe transition after discharge. The foundation of the Ke Ku ‘una Na ‘au program is rooted in Hawaiian values and practices. These values included kˉokua, to help, and pilina, unity/connection. The success of the program in reducing readmission rates at the hospital for patients who were navigated is just one example of the effectiveness of such programs that provide health interventions that are aligned with cultural values and perspectives. In a place like Hawai’i, which holds so much cultural and ancestral knowledge, to achieve health equity for the Hawaiian people, in addition to greater representation of Native Hawaiians in the nursing workforce, the Hawaiian worldview should be central in the creation, establishment, and implementation of health intervention programs.