Mana'o from our healthcare experts.

Improving Kūpuna Health Through ʻAi Pono

Written by: Dr. Landon Opunui, ND & Miki Wong, RD on August 14th, 2020
There are multiple social and health disparities Native Hawaiian kūpuna face such as high rates of life-threatening diseases, financial hardship, disability, shorter life expectancies and underutilization of services. As a result, it should be no surprise that data suggests the health care needs of Native Hawaiian kūpuna far exceed that of their non-Hawaiian counterparts. This leads to health equity problems.

Hawaiian culture emphasizes care for kūpuna. However, many adult caregivers are less available to care for their aging loved ones because of competing work and ʻohana responsibilities.

Several studies have reported on the health benefits associated with a return to a precontact Hawaiian diet. Although this may be an ideal dietary approach for many Hawaiians, food access and cost limitations may not always allow this a practical option, especially for some of our kūpuna who rely on complimentary meal assistance. In addition, the high concentration of complex carbohydrates found in native starches along with high glycemic rich tropical fruits may still be problematic for kūpuna challenged with metabolic diseases such as diabetes.

One of Nā Puʻuwai’s flagship programs is our Kūpuna Program, the only adult day care offered on the island of Molokaʻi. The program provides kūpuna with a safe and structured environment to enjoy daily activities with other kūpuna and staff while ʻohana caregivers are at work. The program supports kūpuna to help them remain active and healthy, so they can remain at home as long as possible. With a previous capacity of 20 kūpuna, safety guidelines have reduced our capacity to 10 during the COVID-19 pandemic.

On July 1, we launched our kūpuna nutrition program, which redesigned meals with the goal of providing high-quality nutrition using flavorful, locally inspired recipes with locally sourced ingredients. The program was launched under the direction of cook Neil Gonzalez, registered dietitian/nutritionist Miki Wong, and volunteer chef coach consultant, Ikaika Molina.

Menus were designed to support the health and well-being of our kūpuna, many of whom have chronic health conditions. Gonzalez was inspired to change the menu after making improvements to his own diet. In addition, he developed daily themes to add creativity and fun to meal planning. “Mostly Molokaʻi Mondays,” for example, showcase locally sourced ingredients from the island—and the kūpuna enjoy their meals. Many of them already avoided rice, citing health concerns. Since introducing cauliflower rice, kūpuna are finishing their plates, with compliments to the cook. Recipe highlights include egg white frittatas, almond-flour waffles, venison stir fry and beef short ribs with cauliflower mash. Providing delicious and familiar meals also provides comfort to our kūpuna who have been isolated with limited access to socialization.

This helped Nā Puʻuwai forge partnerships with local organizations committed to ensuring the health of the community such as Sustainable Molokaʻi, which provides reduced pricing on produce.

We hope to inspire other organizations who have the resources and opportunities to feed our kūpuna to consider consulting with nutrition experts to curate ʻai pono meals that can be used to combat many of the chronic health challenges our kūpuna face today.

Don’t Forget About Our Keiki

Written by: Dr. Landon Opunui, ND on June 4th, 2020
The last official day of class for Molokaʻi public schools was March 13. Circumstances outside everyone’s control did not allow for students to return to school for the remainder of the academic year nor have traditional graduations.

With the exception of a very rare condition known as multisystem inflammatory syndrome in children (MIS-C), in which COVID-19 complications can lead to severe complications and death, most children respond to the virus with a healthy immune response that leads to mild symptoms that resolve quickly.

Like most residents on Molokaʻi, however, most downstream consequences of this pandemic come in the form of significant life adjustments, psychological stress and economic hardships.

The closure of schools and transition to remote learning has not been easy for both caregivers and students. Virtual education is not accessible for some, and not an effective teaching tool for others, which can lead to a loss in learning. Without friends and communities, mental health and socio-emotional development may also be affected.

With kids home early from school, child care now falls on households. Some parents are juggling telework and child care responsibilities, which is no easy feat.

Pediatric health care is also taking a back seat. Pediatric services have been reduced in some locations for safety and social distancing measures, resulting in a 46% reduction in childhood vaccinations across the state.

Along with reduced pediatric medical visits, one can see similar trends in dental care. Keiki oral health ranks highest in the nation for tooth decay, which will likely only get worse.

There is also a growing concern for the expanding waistlines of children. A recent publication uses health models that predict an increase of childhood obesity in the United States by 2.4% if school closures continue to December. This may be due to several reasons, which include shopping patterns influenced by economic hardship, higher consumption of shelf-stable foods, which are typically more processed, more snacking on unhealthy foods and a decline in physical activity because of the cancellation of sports and physical education.

On the other side of the spectrum, there is a concern for adequate child nourishment. Many school-aged children rely on the school system for breakfast and lunch on school days. Fortunately, Kilohana Elementary School, Maunaloa Elementary School and Molokai High School all offered grab-and-go meals through May 28. Although some schools across the state will continue to provide summer food services, Molokaʻi schools will not.

Child Welfare Services (CWS), which is comprised of child protection, foster care, adoption and family strengthening and support has also seen a reduced utilization. The primary referral sources come from medical providers, teachers and the judicial system, which have all been impacted by the pandemic. The result is a 33% reduction in CWS intakes across the state. There were 45 teacher referrals in February and zero in April.

This crisis we find ourselves in does not discriminate and it is important that we do not forget the impact it has on our most vulnerable population, our keiki.

A Future for Health Care

Written by: Dr. Landon Opunui, ND on May 29th, 2020

There needs to be a great redirection of energy toward reforming health care. The disease management and symptom suppression approach is costly and late to the game at addressing health. The COVID-19 pandemic has exposed the vulnerabilities of health care and the best time to change a system may be when it is unstable.

Integrative medicine (IM) may be a solution. IM is a healing-oriented approach to medicine that treats the whole person. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence and makes use of all appropriate treatment options.

IM is the future of health care and is a unique approach Nā Puʻuwai has adopted and will continue to expand to better serve the residents of Molokaʻi.

Health care consumers are becoming more empowered because of the free availability of health information online. Patients are expecting quality and requesting their own choices treatment options.

Patients across the health spectrum are consistently reporting higher-quality patient experiences and improved health outcomes through IM. This approach works and the field is growing. One can view IM as an approach that comprehensively addresses the right medicine, for the right person, at the right time.

IM is built on several principles that guide providers in better supporting their patients:

• Both the provider and patient are partners with shared goals.

• There are many contributing factors to diseases that need to be taken into consideration. These include the mind, body and spirit, along with other drivers of illnesses such as the social determinants of health.

• Appropriate, safe and effective use of both conventional and “alternative” medicines are taken into consideration.

• Effective nonsurgical and nonpharmaceutical interventions that are less invasive should be used whenever possible as appropriate.

• All treatment modalities need to be evaluated critically and should be guided by evidence.

• Good medicine is based on good science. However, research should not be generalized for every individual.

• Health promotion and prevention are just as important as managing diseases.

• IM practitioners should model healthy behaviors and practices.

• An individualized approach to care offers precision, which leads to better responses to treatment.

The future of health care has to transform in favor of a new direction. Instead of just treating diseases, we also need to promote health. Instead of generic care that follows algorithmic guidelines, providers need to personalize care. Instead of treatment approaches that only provide symptom relief and symptom suppression, we need to also start addressing the causes of illnesses. Instead of patients relying on providers, patients need to be empowered to take responsibility for their health. Instead of health care silos, we need fully integrated health care systems that ideally adopt IM philosophies.

IM is no longer “alternative medicine” and the phenomenon is fueled by growing patient demand. It provides more tools for providers and autonomy for patients. Hawaii has traditionally been slow at adopting types of reform, but the time to offer our residents a new perspective and approach to medicine that addresses the heart of healing is ripe.

Post-Pandemic Growth

Written by: Dr. Landon Opunui, ND on May 22nd, 2020

Molokaʻi has one of the state’s lowest measures of economic health, social stability and food security. These public health issues directly translate into islandwide health disparities and inequities. Unfortunately, the downstream consequences of the COVID-19 pandemic are likely going to make these challenges more pronounced.

Trauma occurs when our assumptions about the world, and our place in it, are shattered. Previous assumptions become unstable, uncontrollable and unpredictable. These assumptions can include a false sense of security, such as the belief that a tiny island in the middle of the Pacific could never see the impacts of a global pandemic.

The more one believes they are endangered, the more traumatized they will become. If a layoff, furlough or reduction in income occurs and results in the loss of ability to care and provide for oneself and one’s family, trauma has likely occurred.

Most may be familiar with the mental health diagnosis of post-traumatic stress disorder (PTSD), which occurs when someone has prolonged symptoms of anxiety, depression, hypervigilance or intrusive flashbacks that cause distress and impaired function following a traumatic event or events. Individuals can become “stuck” in a fear response and an overactivation of the fight-or-flee nervous system response may occur.

Conventional approaches to treating PTSD are primarily aimed at treating symptoms by blunting the effects of anxiety and mood through medication. This may relieve suffering, but does not address the cause of the trauma nor support a healthy coping response.

Regardless of the degree of trauma or stress, there is another approach. Post-traumatic growth (PTG) is the perceived positive changes that result from personal coping efforts with traumatic events. Positive changes can include better relationships, greater empathy, a deeper appreciation of life and an enhanced sense of personal resiliency.

The greatest challenges we experience in life can also be our greatest opportunities for transformation. Following this pandemic, if all we do is return to a baseline, we have missed a big opportunity for healing and growth.

In a 1980 study of prisoners of war (POWs), 61% reported beneficial changes as a result of captivity compared to 30% of control servicemen. The POWs reported having greater optimism, enhanced insight, better discernment about what is important in life and got along better with others. Interestingly, those who were held the longest and treated the harshest were more likely to report positive changes that persisted years after release.

Trauma has the ability to transform us by creating positive meaning from negative events, which is known as positive reframing. Not every traumatic event will transform us, but the potential to grow as a result of challenges lives inside each of us.

Reflection, telling new stories without denying the negatives, discovering deeper meanings, social support and honest expressive communication are all ways to nurture PTG.

What will be Molokaʻi’s opportunity to grow? Perhaps we can take this and future challenges as opportunities to improve upon aloha ʻāina, food sustainability, economic diversification, and community partnerships, giving our community members a bigger platform and personal empowerment.

The Historical Trauma of Infection

Written by: Dr. Landon Opunui, ND on May 15th, 2020

The island of Molokaʻi has a long-standing history with infectious diseases. Molokaʻi is known around the world for Kalaupapa’s history and the enduring spirit of all those affected by Hansen’s disease. Although our current pandemic is caused by a virus as opposed to a bacterial microorganism, there are parallels that bridge this infectious disease’s past with the present.

The first wave of imported diseases came to Hawaii with Capt. James Cook in 1778 when his sailors introduced tuberculosis and sexually transmitted diseases. About a quarter century later, the first recorded epidemic occurred in 1804 when the cholera outbreak known as maʻi okuʻu killed more than 15,000. This was soon followed by influenza (1820s), mumps (1839), measles and whooping cough (1848-1849), and smallpox (1853).

This succession of deadly epidemics leads scholars to believe that as much as 90% of the Native Hawaiian population was tragically reduced over a 50-year period.

The Hawaiian Kingdom was forced to respond aggressively by mandating vaccinations for certain diseases, collecting health data and instituting a Board of Health in 1850, long before any such government agency was created in the United States.

There are also historical examples of shutdowns. In 1836, Kuhina Nui Kaʻahumanu II (Elizabeth Kīnaʻu) ordered all ships entering Hawaiian waters to be boarded and inspected for smallpox. Similarly, during the 1881 smallpox epidemic, Princess Liliʻuokalani ordered a shelter in place, quarantine of infected people and the closing of ports. This response was even more intrusive than our current government’s loosely enforced 14-day travel quarantine mandate.

The greatest historical action, however, was the passage of “An Act to Prevent the Spread of Leprosy” in 1865 by King Kamehameha V. Led by the Kingdom of Hawaii, under pressure from Western advisors, those suspected of being infected with Hansen’s disease were condemned to a life of virtual imprisonment on the Kalawao peninsula to prevent the spread of the disease, which was believed to be highly contagious and without a cure.

Hansen’s disease was also referred to as Maʻi Pākē (Chinese sickness) because of the disease’s association with Chinese people, who people noted to have had the disease or who may have been more familiar with it because they had seen it in their own country. This has a frightening resemblance to our current COVID-19 pandemic as President Donald Trump has publicly referred to coronavirus as the “Chinese virus.”

Like most infectious diseases that spread throughout Hawaii, Native Hawaiians have suffered the most. One out of every 39 Native Hawaiians (2.6%) contracted Hansen’s disease, while non-Hawaiians had a rate of one in 1,847. In total over the decades, more than 8,500 men, women and children living throughout the Hawaiian islands were diagnosed with Hansen’s disease and exiled to the colony.

The forcible separation of individuals from family, friends, communities and places resulted in significant trauma that persists to this day. Although different, COVID-19 will undeniably leave a wake of destruction in its path because of the numerous impacts that it has had on nearly every household around the globe.

Health Disparity Impacts of COVID-19 Among Native Hawaiians

Written by: Dr. Landon Opunui, ND on May 8th, 2020

The United Nations has warned indigenous populations that they may be at a disproportionately high risk of being impacted by COVID-19 because of preexisting health inequalities.

Across the nation, there is strong evidence showing Native Hawaiian and Pacific Islanders (NHPI), defined as people having origins in any of the original peoples of Hawaii, Tahiti, Samoa, Guam or other Pacific Islands, are at greater risk of being infected and of having severe symptoms compared to other United States racial populations including African American, Asian, Latino and Caucasian.

This should raise alarms for the island of Molokaʻi as it has the highest number of Native Hawaiians per capita of all the Hawaiian islands, excluding Niʻihau. According to the 2010 U.S. Census, the majority of people on Molokaʻi identified as NHPI. The Ka Huakaʻi 2014 Native Hawaiian Educational Assessment further reports that 4,527 Native Hawaiians reside on Molokaʻi, which is 62% of the island’s total population.

As of April 30, 2020, 14% of Hawaiiʻs COVID-19 cases are NHPI, while this racial group only consists of 10% of the Stateʻs population. Because many Native Hawaiians may be reported in multiracial or unknown ethnic categories, these rates are likely higher.

Several other U.S. states with high percentages of NHPI communities such as California, Oregon, Utah and Washington are showing the highest case rates per 100,000 people of all racial groups, with some an order of magnitude greater.

We donʻt have this type of detailed data in a number of other places NHPIs may reside because these racial groups are commonly combined with Asian or Pacific Islanders (API), a group that includes Japanese, Chinese, Korean, Filipino, and Vietnamese, among many other ethnic backgrounds that originate throughout Asia with different genetic susceptibilities and health disparities. Through the Health Equity and Accountability Act there is hope that we as a country will work toward disaggregated health data to addresses long-standing health disparities within the API racial grouping.

There is even further discussion within the Native Hawaiian community to further disaggregate NHPI data. The indigenous people of this place are not even being counted independently from other Pacific Islanders within their own birthrights, which has implications on representation and funding. But, teasing apart this data is easier said than done.

Almost 25% of Hawaii residents identify with multiple races or ethnicities compared to a 3% national average, which makes Hawaii a truly unique melting pot. Native Hawaiians are three times as likely to identify as multiracial, making it clear that Native Hawaiians are being misrepresented in our stateʻs racial data.

Although the immediate health impacts and concerns of COVID-19 appear to be waining, there is the very real concern of worsening health disparities among Native Hawaiians, especially on Molokaʻi, because of the parallel economic impacts this pandemic has left in its wake. As a result, health disparity gaps are likely going to continue widening. The short- and long-term impacts will be challenging to fully illuminate because of ongoing racial data limitations both locally and nationally, which need to be addressed.

Finding Peace Amidst the Storm

Written by: Dr. Landon Opunui, ND on May 1st, 2020

We have been spending a lot of time with ourselves lately. This can offer us tremendous space for creativity and growth or can be a time of worsening mental health. There are increasing rates of depression among those struggling to navigate the socioeconomic impacts of COVID-19. Our current landscape is constantly evolving and there is no definitive end in sight. Our communities are faced with frustrration and worry as unemployment rates in Hawaii rise to the highest in the nation.

Molokaʻi tragically has the state’s highest rate of suicide, so it is important for us as a community to proactively address the potential downstream mental health consequences this pandemic will cause. Health care providers are great at quickly responding to people experiencing mental or emotional distress through therapy and medication, but what happens when the underlying reason why someone feels this way is difficult to address? Although socio-economic-cultural stressors are difficult to address clinically, they need to be acknowledged as important drivers of distress.

Depression and anxiety, through the conventional medical lens, are often viewed as clinical diagnoses. However, it is important to normalize these commonly experienced mental states as part of our human nature. Trials and tribulations are inherently difficult to cope with.

Depression can present itself in a number of different ways and can include short periods of fatigue, lack of interest in common hobbies, sadness, frustration, abandonment from everyday sources of joy, and withdrawal from family, friends, neighbors, and communities. The last of these symptoms is most concerning because of our ongoing social distancing requirement.

Occasional feelings of depression are perfectly normal. It is OK to just feel down. Numbing these emotions when only short-term, mild-to-moderate symptoms are present will likely yield more long-term consequences than benefits. However, there is undeniably a place for pharmaceutical interventions in chronic and acutely severe cases.

Instead of relying exclusively on medication, it is important to honor how we feel, sit with our feelings and breathe through what is happening in our lives. When we are not able to hug one another and provide physical comfort, real healing can blossom through nonphysical connection.

Loneliness and isolation are very real phenomena for many during a pandemic. Connecting to the internet and our devices are tools that we can use, but are likely not the answer to our fundamental need for peace.

We lose the opportunity for wisdom to shine through when we are disconnected and distracted. Many have difficulty calming their mind because of worry. How can we be still, grounded and present with what is happening around us?

Although there are many roads to inner peace, gratitude is a pathway most people can access. What we focus on is what we will always feel. Writing down three things we are grateful for each day is a simple exercise to shift our focus to something positive and uplifting. These donʻt need to be earth-shattering epiphanies, they can simply be a person, place or thing.

Transmission Rate Errors or Social Distancing Success

Written by Dr. Landon Opunui, ND on April 24th, 2020

As the COVID-19 pandemic continues to evolve, the good news is that it does not appear to look nearly as catastrophic as once believed. The numbers of new cases and deaths both nationally and locally appear to be either plateauing or declining.

The public health dilemma is now shifting to whether we continue to quarantine to stop the virus from further spreading or begin the process of opening up parts of our daily routines to return to something resembling “normal.”

Is the answer to why we have successfully “flattened the curve” because of our precautionary social distancing measures or because of the possibility that the COVID-19 virus is less lethal than we previously thought?

Predictions with population-based models are challenging because of key assumptions that need to be made about the accuracy of transmission and fatality rates. Even the most subtle projection errors, such as a transmission rate of 2.3 vs. 2.4, triple the projected number of infected people from 10 million to 30 million.

The accuracy challenges stem from an imperfect data set. For example, case rates (CR) – which are the number of confirmed COVID-19 positive patients – can be known, while infection rates (IR) – which are the percentage of all individuals, known and unknown, who have the virus – is next to impossible to know without widespread testing. Case rates of coronavirus are an underestimation of infection rates, which are going to heavily impact the accuracy of fatality rate predictions.

Projections are only accurate if you are able to hold all variables constant. Aggressive social distancing and the closure of all nonessential business have changed conditions dramatically.  Assumptions had to be made for these models to function and we are actually fortunate these projections have been wrong thus far.

As a result, COVID-19 cases and fatalies across the nation will likely be in line with one of the worst influenza seasons (U.S. flu death rates typically range from 12,000 to 61,000) and not the previously predicted millions.

Going back to the initial hypothesis of transmission rate errors or social distancing success, I suspect both likely contributed to our different outlook today. If this is the case, the big challenge then becomes determining how each have contributed to our current outcome. If our predictions were wrong because we misunderstood the biology of the virus, then when should we begin the thoughtful reopening of life and the economy? However, if our predictions were wrong because social distancing measures were powerfully effective, then we need to maintain our vigilance with strict social distancing until successful treatment measures become available.

One of the important data sets that will help us more confidently answer these questions is population wide testing to include asymptomatic individuals so that we can more confidently estimate the true infection fatality rate of COVID-19, which is predicted as 0.1-0.26%.

As difficult as the decision was, Mayor Michael Victorino and Gov. David Ige likely made the right decision to extend the stay-at-home order through the month of May. During this extended timeout, we should take the opportunity to better understand our opponent by offering more widespread community testing such as the free testing offered on Molokaʻi through the Hawaii Crisis Healthcare Alliance on April 7.


Dr. Opunui is the Medical Director of Nā Puʻuwai, the Native Hawaiian Health Care System serving the communities of Molokaʻi and Lanaʻi.

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