July 20, 2022

Native Hawaiians —Do you know what Aloha and Ha’aha’a mean? (Maile Tauali‘i, S1, Ep 3)

Native Hawaiians —Do you know what Aloha and Ha’aha’a mean? (Maile Tauali‘i, S1, Ep 3)

This is part II of our conversation with Dr. Maile Taualii about Native Hawaiians and Pacific Islanders. Please listen to the previous episode to hear the introduction to this topic and the entire guest intro. Dr. Maile Taulalii is an assistant clinical investigator for Hawaii Permanente Medical Group

In Part II of this conversation, we talk about

  •  cultural values such as aloha and Ha’aha’a
  • how to communicate about health in a way that matters to the patient
  • reconnecting with your people
  • talking about land trauma 

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  • Ha`aha`a: Consider an interaction you may be seeing among family members is based on respect
    • It is like humility, we are taught as Island people to be very humble, just very respectful of our energy of our space and how we interact with other people. So being humble isn't about being weak, it's about being respectful.


  • Supplements: Ask, “Is there anything in your culture that you're taking that you think is helping, and I should know about, so that I can make sure that whatever I'm going to prescribe won't interact with it in a way that is harmful and hurtful?”

  • Aloha: Think about how do you let your patient know that it's your joy to give that fulfills me as a provider to care for my patient. That’s the gift that I get as being a caregiver so you don't have to give back to me.
    • Aloha is an exchange of in relationship between two people, or many people
    • People may feel uncomfortable that they are unable to exchange anything for the care you’re giving
    • We as healthcare providers, have to be as willing to accept care for ourselves as much as we want to give it.
  • Family Visits: Make your next visit a family visit
    • Decisions aren’t made by individuals. For example, meals are cooked by family member and it may be disrespectful to not eat what’s cooked
  • Motivational Interviewing: Reframe goals of care as transferring legacy and generational knowledge rather than longevity
    • When you’re suffering from many aspects of life, living longer is not a motivating goal
  • Lohai Triangle: Consider making a plan for physical, mental and spiritual health.
    • For example, diabetes is the result of a disconnect from the land and our culture and our way of life.
    • Ask, “I know you're away from home, I know you're away from the things that heal you. So how are you reconnecting with things that you are missing?
  • Reconnecting with Community: Connect folks to community organizations and events in the community. Ask, “How are you fulfilling your need to say connected to your culture, especially these last couple of years?” (See community resources below)
  • Land Trauma: Ask, “I hear there's a lot of stuff going on in the land fights back home in Hawaii, is any of that bothering you?”
    • People often are still fighting to prevent destruction of their sacred lands
  • Alternative Medicine: Avoid mentioning practices that you may not fully understand but consider saying something like, “Touch can be healing. I know in Hawaiin medicine there’s different kind of massages. Is that accessible to you? Would something like that be helpful for you?”

  • Timespan: 27:23 Min
  • Transcription Type: Cleaned Verbatim
  • Speakers: 2 (Maile & Raj)


Maile: So, you can live longer. That's not a value we totally resonate with. And this isn't just a Hawaiian thing. This is all families living with a little bit of hardship and poverty. The idea that I will live longer and struggle for longer is not necessarily a good selling point.


Raj: Hey, everyone; welcome to the healthcare for humans podcast. The show is dedicated to exploring the history and culture of Washington's diverse communities. So, clinicians have the right knowledge to care for all patients.

This is Part-2 of our conversation with Dr. Miley Tawa Lee about Native Hawaiians and Pacific Islanders. Please listen to the previous episode to hear the introduction to this topic and the full guest's intro. Dr. Violate Tawa Lee is an assistant clinical investigator for Hawaii Permanente Medical Group. In part two of this conversation, we talk about cultural values such as Aloha and Ha Ha, how to communicate about health in a way that matters to the patient, reconnecting with your people, talking about land trauma, and respecting patient’s beliefs. Here's Dr. Miley Tawa Lee again. Okay. And I think you mentioned a lot about the culture just a second ago, about culture connecting to music. It's hard to distill the culture of such a diverse population. The land is important; I mentioned that already in family, right?


Maile: Aina is family. So, a lot of Pacific languages understand that family is land and land is family, and Aina is that which feeds you. “Aina” includes the word I, our word for nourishment.


Raj: Yeah. So that was one of them. And then other values. I think I sent this to you.


Maile: Yep!


Raj: It came out. Because different people have tried to capture this diversity into things understandable for folks in America, wherever they are, Aloha Malama lokai, right? Those things came up. Maybe you can help me understand them.


Maile: Sure.


Raj: and I don't know if I said that right.


Maile: We'll start with aloha. There's a misunderstanding about the meaning of the word Aloha. Aloha doesn't mean hello, or goodbye doesn't mean any of those things. Aloha is an exchange of relationships between two people or many people. “Alo” is like face-to-face, and “Ha” is my breath of life. When I greet someone from a Hawaiian community, we will embrace each other, and we will breathe; never good for COVID, but that's how a traditional greeting is done because it's an exchange of your lifeforce. And it's reciprocal, I give to you, and in exchange, you give to me. So, Aloha and the whole concept around Aloha is about having an exchange, respect, a willingness to give as much as a willingness to receive, and an understanding that both have to occur. And now that's a significant value, like just that one alone is super valuable, as a pearl to walk away as a provider, that we as healthcare providers, have to be as willing to accept care for ourselves as much as we want to give it. So, Hawaiians, all Pacific people, have a profound respect for healers, not just our traditional healers but our doctors; our college is very respected in our community. People frequently will talk about distrust of the medical system. It's not the doctor who is the distrusting part; it's the system that may not work for us. But we have a profound respect for healers who give to us. And that's an uncomfortable thing in our community just to have someone constantly giving to you; you want to give back to them. So, I remember being with older folks who always want to take a gift to the doctor or the teller at the bank machine the behind the counter. Because if someone's helping you, you want to help back so that providers understand that we see what you give us as help as service and exchange. And it puts us a little bit off because we may not always be in a position to give back to our provider, and our provider might not want us to give back. But that's an important balance. And so, I think the pearl to walk away with that from a provider perspective is to think about how you let your patient know that it's your joy to give. That fulfills me as a provider to care for my patient. And that's the gift I get as a caregiver, so you don't have to give back to me. You can just take the medication and the advice and look after yourself because that's the greatest gift you can give back to me. And understanding that something happening in the minds of Pacific people is we're indebted if we can't give back to you as a provider, so make the gift of health care something you want to give. And that, I think, would be a perfect way to kind of balance that displacement that occurs when we can't give back to you as a person. So that occurs.


Raj: I just have to say, I'm just so glad I got you on this podcast. That was really because we're also in healthcare systems in the US has become so transactional. We talk about people as customers and consumers, that makes the transaction feel like it's taking from me because I'm providing a service, but also burning people out a lot. This idea of like, wow, you actually care about me too, just knowing that and focusing on it's a joy to take care of you. This is not something I'm doing for the money or service. We're in this together. And I'm hoping to support you in this healing that idea captured by Loja. It’s amazing. Looks awesome. All right. Yeah, keep going.


Maile: Okay, I think one important within the healthcare provider space is Ha, Ha. Ha, Ha is like humility. We are taught as Island people to be very humble and respectful of our energy in our space and how we interact with others. So being humble isn't about being weak; it's about being respectful. And respect is the most important. And so, just a couple of thoughts about conversations I've had with providers. I've had a provider talk about how the parent of one of her was a pediatrician. She was seeing a patient, and the parent was like, like, almost aggressive, I want to say almost, but the parent was just like, don't talk back to the doctor like that, and almost like thinking it was a child abuse setting. But it comes down to us teaching our children to pay an incredible amount of respect to doctors to police. Respect is a reflection of us as parents. Its disrespectful if our children are not respectful. And so, for a provider to understand that, that respect, and that humility is a cultural value. And to understand that a parent is not necessarily abusive if they are trying to get their child to respect the caregiver, the doctor, and the provider. And so, to understand that this is a cultural value of humility and respect, that's a huge part of who we are as a people. Pacific people are very proud, and respect is a huge part of who we are as a people. So, Ha, Ha, I mean an important concept. This idea of Malama of Lokahi, I think, ties back to Aloha well. Kahi is like a sense of unity or unification. It's one voice together as unified. We talk a lot about this with COVID. And just how important being one solid community working together to stop the spread of illness. Making us wear masks for our family, community, and those values around caring for others, even if it's uncomfortable to wear a mask. Even if it is uncomfortable, you don't want to get an immunization. You're not doing it for yourself; you're doing it for your community. And those values are just this idea that we are in this together that resonates very well with our people. And so, thinking about ways that you think about interventions, I always think about diabetes. We offer diabetes education to the individual who has diabetes. But in a Pacific Islander family, the person with diabetes may not necessarily be cooking the food. So just educating the patient, who isn't the food preparer, actually worsens things in some ways. Because now I know I'm not supposed to eat this food. And I don't want to be disrespectful, my wife, or my grandmother, whoever's in the home is the food preparer, and they didn't go to the diabetes class. So, they don't know I'm no longer allowed to eat that. But you don't want to be rude or disrespectful; that respect is vital. I recommend that we talk to entire families when it comes to talking about food, decision-making, and meal changes. Because everyone in that house eats together and celebrates just a daily meal, one individual will not make food decisions. We make decisions as a family as to what will be eaten. So, if we're going to affect dietary changes, we have to do it for the entire family, and they have to do it. Because out of love, they will; if this changes, we all will have to do it to take care of our loved ones. We will make this change collectively as a whole family for that person. And that's why that Lokahi that togetherness that we work as a team, we as healthcare providers have to think about the advice that we're giving to a patient needs to be team-focused for the whole family. Because an individual is not an individual in a Pacific Islander family.



Raj: you need family visits, especially for a new diagnosis and education. And another thing that stood out to me was that we often make health the end goal, like you should do this because you'll be healthy. That's it like, okay, it's not convincing enough, or we want you to be healthy for your family. So, you can enjoy all these times with your family, have more energy, and live longer, like this idea of why don't we focus on being healthy, taking that next step, and connecting to what matters to the patient, rather than just saying, you should do this because it's a healthy thing,


Maile: Right. And then that's so you can live longer. That's not a value we totally resonate with. And this isn't just a Hawaiian thing; this is all families who are living with a little bit of hardship and poverty. The idea that I will live longer and struggle for longer is not necessarily a good selling point. But I am talking about the ability to transfer your life's legacy to another younger family member. So being around ensuring that they can take the knowledge that you have, and do better, and grow the family and grow the wisdom. That puts less on the timeline of how long I will have to do this. And more about the quality of the message so that the next generations will do better than me because that resonates with us. That's why the other aspect of family visits is crucial because not only do you get the entire family involved in the care team. You get some young boys who think they'll live forever to think, maybe I don't want to do dialysis. Perhaps I should hold back on the rice because I'm hearing them tell me that it could be a big problem for me. And maybe it conserves part of that prevention if we involve the whole family because nobody wants to go to dialysis three times a week. That's not anything anybody wants to sign up for. And those young kids are often driving their elders to those appointments, letting them know there's a way to avoid that. But it's not inevitable that diabetes is not a given. And that it is not in our anthropological record at all. We didn't have diabetes, and it's not a curse that we have to live with.


Raj: Yeah. And I think that hope that it doesn't have to be this way, as you're saying, like, not everybody has to get dialysis. I wonder if that's linked to also this idea of Cultural Historical trauma. Because of the Lokahi triangle, I think the part is making sure you talk about the physical, the mental, and the spiritual. When we talk about diabetes, we just talk about the physical. I think there's probably the mental and spiritual aspect that we never touched upon


Maile: So, this idea that there's something not right in the system and that's what causes diabetes, that's part of the spirit like I talked about, with the access to Kahlo, or traditional foods, as well as that mental of just missing the goodness of home in a bite. And so, diabetes is the result of a disconnect from the land, our culture, and our way of life. And now, in Washington State, how do you reconnect to that? And I think when you think about, okay, how, as a provider, do I talk about all three aspects with a patient? Here's why you have diabetes physically; here's what's happening in your body. But the mental and the spiritual aspect of it is, I know you're away from home; I know you're away from the things that heal you. So how are you as a patient? And it could be a question that each patient has to think about, like, how do I connect to the things I'm missing in the spiritual and mental aspect of trying to heal? And not everybody can get back on a plane and go home. So, Lake Washington is not exactly the Pacific Ocean. But putting your toes in the water. It's asking people what they used to do as a child to connect, and what can you do today like that? But you know, thinking about how would you heal if you were back in the islands? And can you do that here?


Raj: I think you mentioned music earlier. Anything else?


Maile: Some amazing festivals happen in Seattle and the Washington area. Folklife Festival, which occurs in May. Tell your patients to go to these things. Even if it seems like, ah, humbug, gonna wanna go to these things. They will be healed by being surrounded by other people who are just celebrating what it means to be a Pacific person wherever they are. When talking to your patients, find ways you know about these events? Do you go to these events, their civic clubs, which are basically like community organizations that were set up by our Hawaiian royalty in Washington State? There's a Washington civic club for the Hawaiian community for the Samoan community; a big part of it is the church. But I think as a provider asking, do you know how to connect? How are you fulfilling your need to still stay connected to your culture? Especially this last couple of years with COVID, we did too much social isolation.

I still think we did a disservice to the world by saying to socially distance ourselves when it’s really physically distancing ourselves from people. But don't socially distance yourself from the action whenever. That's never a good thing. And so really just reminding patients that the celebration of Pacific cultures is happening all over the country in Washington is a place where these things are happening and have been happening for years. Go to them because you'll see your people. Just connect back to the music, the sounds, the laughter, and the joy. And every provider should ask their patient are you connecting to the things that are important to you? As a Hawaiian, I dance the hula, I dance the hula. When I was in Seattle, there was halau; all sorts of things connect people to each other and culture. And people should embrace all those things. Not just as a way to stay fit. We don't dance the hula to stay fit; we try to stay fit so that we can dance the hula. That's such a great prevention conversation exercise so, you can practice your culture and stay in shape. So, you can celebrate all those things. Because people will say, oh, I can't dance anymore because of my knees. How do we get your knees in better shape so you can do it? And that's the driving force. Our culture isn't a tool, but it's what we want to work towards it to celebrate it.


Raj: what a beautiful way to frame it. I think the other question was about Cultural Historical trauma. Is there a way to bring that up or acknowledge it even as providers or clinicians? Because it's also hard to heal from it.


Maile: Yeah. When I've talked to providers about this, especially here in Hawaii, I had a provider once say to me, so I have a patient coming in the next 15 minutes. Should I ask them about the overthrow and if the overthrow has impacted diabetes? And I was like, ah, exactly what I meant. They were like, what do I say? What are the words that come out of my mouth to recognize that I get that there's something that's happened in the past? And how does that affect you today. One of the examples that I gave to this provider? And this was during the time that there was and still is a threat of the destruction of one of our mountains, Mauna Keya, the building of the 30-meter telescope, and we're fighting and still are fighting to prevent the destruction of sacred lands. So, at the time that this was happening, I told this provider, you could say something like this. You could say, hey, Mr. Kanaka Hooley, I hear there's a lot of stuff going on in the land fights back home in Hawaii, is any of that bothering you? And if the patient might say something like, nah, I don't care about that stuff; that doesn't affect me. Or they might say I can't sleep at night because I think about what's happening back home in the islands. This recognizing that there is something that could be bothering me—honoring the fact that culture and connection to land could be causing some distress. And I think when I was trying to help this provider, thinking about how to connect was just a recognition that these things could be impacting someone's health. Even though a lot of times as health care providers were trained to think about the body itself, and not necessarily the mental health, but recognizing that land trauma affects physical health. And then we get that, and I know many of my providers will be like, look, I have 15 minutes. Do I want to bring up the overthrow? So, I think in Washington State, some things that I would recommend are like, hey, when was the last time you were home? And does that being away from home? How does that affect your health? What do you miss the most about it? And have you found ways to heal some of the pain you feel because you missed it? Because I can guarantee you every single Island person that is seen in the clinic is missing home in some way or another, and it could be a second generation who's never even been home and is ashamed of not having a connection to their land, but there's a loss there. We have so much love for our lands that when we aren't connected to them, it can cause just as much harm as losing someone.


Raj: Yeah. That's a powerful thing. And something I think definitely warrants at least acknowledging. No matter how much time you have, it's such an essential part of somebody's mental health and experience.


Maile: Absolutely


Raj: Okay, the next topic is about any healing practices that we should be aware of, any ceremonies and rituals, herbs, plant-based healing, prayers, massage.


Maile: yeah. No, this isn't a Pan Pacific one size fits all response. Each island tradition will have different ways they practice traditional healing. And it'll be a generation thing. If they were raised away from the islands and may not have ever been in contact with much of that healing. I think what I would recommend for providers to understand and recognize is that there is a possibility that patients want to self-medicate with traditional plants. I think a good conversation starter is, is there anything in your culture that you're taking that you think is helping, and I should know about it? So that I can make sure that whatever I'm going to prescribe won't interact with it in a way that is harmful and hurtful. And that's one of the things we like for us.

We use Turmeric a lot; Olena is what we call it. It's a great anti-inflammatory. And I've had amazing Docs here who have said, but you can take Advil for the pain and the swelling, or you can take Olena. Especially if I'm trying to help a child with an injury, I might prefer to give that child an Olena tea versus a big dose of Advil or ibuprofen. So just that recognition that it could happen, it might be happening. And that I understand that you value that so that I don't disregard it as, oh, that stuff's Hocus Pocus, because that's the first when you get a patient to be like, I'll never tell you anything that I'm taking now. But to honor the fact that we know it might be happening, it might be really important for you to incorporate it. And do you want me to know about any of it so that I can make sure that what I give you doesn't interact with it in a way that hurts you? I think that the first place to start is honoring that I'm going to do it, whether or not I tell you about it. So having me tell you and build that trust is probably the best way to approach it.

Regarding what traditions we celebrate, it's not as common, I think, in Washington state, as it might be here in Hawaii because here in Hawaii, we have a lot of practitioners teaching and accessing our plants and our traditional processes a lot more. So, folks in Washington State may not necessarily have access to practitioners. So, it might be more like home healing remedies that they use or traditions like, we have lomi, which is massage, it's a very vigorous massage style. And I think what providers might just take away from something like that is the idea that hands heal, and touches can be very healing. It's never good for a provider to flip through a pamphlet on Hawaiian medicine, and you should just try Lomi Lomi. And never my hesitation with providers, learning about some of our practices without thoroughly learning about our practices that should be more of, I respect that these are things you might be using, and we know they can touch is good and can be helpful. So, if you're doing those things, I get that's important. And I celebrate that with you. And if you have access to that, then lucky you because this stuff is good. But that kind of respecting what folks are taking and what they're doing. I think it's just really important to have that open relationship between a provider and a patient.


Raj: Yeah, that's a good summary. Okay, last question. What does it mean to be fully seen by a provider for you? Do you have a good example of that?


Maile: Fully seen by a provider? I have an example. Yeah, and it's one of your Docs—Mark cook.


Raj: He's going to love it.


Maile: Mark, when I delivered, we had my second child. Mark was caring for me, and I told him I wanted to deliver my baby traditionally in Hawaii. And he's like, what does that involve? I said, well, we didn't have to go to a place known for birthing. And his thing was, oh, yeah, let's go. And he was. So, let's bite. He was just; it wasn't like he wasn't. I knew he wasn't coming with me to Hawaii to give birth to my child in the woods. But he understood that was important to me. He was funny and understanding and made me feel like it was a game. But then he reminded me that I have some medical issues and that it might be best not to try to get on a plane last minute to fly out to Hawaii to give birth in the woods. Not that he was against it. Its just for my health might be safer if we were to go ahead and have that baby in a Kaiser facility. But it was that fully seen. Like he didn't laugh at me that I wanted to do that. He was incorporating his traditions. He was going to have a Mai Tai on the beach after, but he got that it was important too, and he didn't make me feel like my desire to want to do that was silly or stupid. And so, I think that's important that whatever a patient requests, I'd like to do this to not necessarily go, oh, that's just stupid don't do that. But to be, let me understand a little bit more about why you want to do that. And just that understanding that a provider, even if they aren't from your culture, even if they don't understand it, to be willing to want to learn, and ask about it and be interested, that's, I think, what it means to be fully seen. And that applies not just to Native Hawaiians and Pacific Islanders but to any. Your patients want to know that you listen and understand it's important. And you want to make sure that you can do everything in your power to honor and recognize something that a patient might want or need for them to be healthy. Even if you can't do it, I think provides that I see you, I see that it's important. I can't participate in that. But I can participate if we do it here in this way. All of our patients just want that all of us want that. Even as providers, we want to be heard, seen, and respected. And to know our desires for our own wellness and what we need to be productive, helpful, valuable, loved, and to love others. We need to feel good in our skin and feel safe, and be able to talk to people about our care needs.


Raj: That was great. I feel like I need to give you a bigger platform. I honestly don't know. There were so many good parts of this podcast. I don't know what the hook is going to be. I'm stressed out about it. But thank you so much for joining us. Well, I told you when I started, all I heard when I mentioned your name to the folks were, “you are cool.”


Maile: You come out to Hawaii, Raj. I have a 20-acre farm where I grow up with all these traditional foods.


Raj: Thanks for joining me, Raj Sardar, with this episode of the healthcare for humans podcast. If you enjoyed this episode and would like to support this work, please share it with others and leave a review. Show Notes can be found over at healthcareforhumans.org

Thanks again, and I'll see you next time.


This podcast is intended for educational and entertainment purposes only. Views and opinions expressed in this podcast do not represent any of the participant's past, current, or future employers unless explicitly expressed, so always seek the advice of your physician or other qualified healthcare providers concerning your personal questions about medical conditions you may be experiencing. This Healthcare for Humans project is based on Duwamish land and makes a regular commitment to Real Rent Duwamish.

The transcript ends here.



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Maile Taualii, PhD, MPHProfile Photo

Maile Taualii, PhD, MPH

Assistant Clinical Investigator

Dr. Tauali‘i received her PhD in Health Services, with an emphasis in Public Health Informatics and Public Health Genetics, from the University of Washington, where she also completed her Master of Public Health in Social & Behavioral Sciences. Dr. Tauali‘i joined HPMG in 2018, in which she worked with CIHR on the utility and validity of health information for racial minorities. Her research focused on eliminating health disparities, specifically for Indigenous Peoples and Native Hawaiians.

Dr. Tauali‘i serves as a resource to HPMG physicians, providers, and staff in areas of research, cultural safety, and working in partnership with communities of Hawaii, especially to the Native Hawaiian population, as the first people of Hawaii.

In 2015, Dr. Tauali‘i established the world’s first global Indigenous Master of Public Health degree program and was awarded the University of Hawaii, Board of Regents Excellence in Teaching Award. Her federal commitments include serving as a member of the National Advisory Committee on Racial, Ethnic, and Other Populations, U.S. Census Bureau, a member of the National Institutes of Health, PhenX Working Group on Social Determinants of Health, and the All of Us Research Program Biospecimen Access Policy Task Force. She and her husband, five children, and three dogs live on 20-acre food forest with their ‘ohana, who aim to feed the community traditional, plant-based food from the land.