A holistic approach to health
At Kokua Kalihi Valley, health care means more than a prescription: it means empowering communities to become whole.
For 42 years, Kokua Kalihi Valley (KKV) has been providing affordable health care services to the under served Kalihi community. But the KKV is much more than just a clinic, and the approach to health care advocated by its providers is very different from the approach practiced by mainstream hospitals and clinics.
“Our organization—while we recognize the absolute importance of people having accessible, affordable, quality primary care, we don’t think that’s necessarily the most important aspect of a healthy community,” says Dr. David Derauf, the executive director of KKV. “We really put the emphasis on community health. And I think once you make that shift to thinking about community health, you start asking a different set of questions.”
Started in 1972, the project had its roots in community outreach. The first four employees of KKV, a group of women, went door to door asking people in the neighborhood what they would need in order to live a more complete, healthy life.
“I think they really saw their work as just being neighborly,” says Derauf. “But many of the stories they heard involved a lack of access to basic health care.”
Within a couple years, basic medical and dental services were being provided through KKV. But Derauf emphasizes that the organization didn’t see itself as merely a medical organization. Derauf says that in the ‘80s, with the advent of Federal recognition, community health centers (of which there are around 1200 across the country) began to focus more on providing medical services, and less on strengthening community.
“For most of us, sadly, when the conversation of health is raised, our default is to think of medical care, the medical system, and maybe the health insurance system,” notes Derauf. “There’s been so much focus on that in recent years. But the word ‘health’ actually means ‘wholeness,’ and we think there needs to be a much broader conversation around health.”
Derauf hopes people will begin to think about health in personal terms. “If you ask yourself when was the last time you felt really healthy, often times the answers I hear involve nature, or you were with your family or people you really care about,” he says. “Never have I had someone say, ‘Oh yeah, I was in the doctor’s office.’”
Building a healthy community
“It took me far too long, as a physician, to realize that the best thing I could do was to stop and listen,” relates Derauf. “At the end of the day, however good my advice might be in terms of a medical framework, it’s ultimately only as good as what meaning that has within the context of that person’s life.”
The story of Kalihi is often told in a context of poverty and want, but Derauf sees the neighborhood as a place with many gifts and the capacity to be a strong, healthy community. He believes that by finding ways to lift those positive stories to the forefront of the conversation, the Kalihi community can find ways to empower itself.
“One of the most vital parts of health is the sense that you’re in charge of aspects of your life that are important to you,” Derauf says.
Kalihi has long been a largely immigrant neighborhood—a trend that began in the plantation era, but which continues to this day. This history affects the way in which KKV can, and should, provide health care. Although sometimes presenting unique challenges, Derauf says that it also creates unique opportunities.
“The deeper story with a lot of the immigrant families we were seeing, if you listened carefully, was really about a lack of a sense of place here in Hawaiʻi,” says Derauf. “They longed for that connection that they had to their land and they were feeling very displaced.”
Derauf believes that people are much more likely to become sick if they feel out of place, uneasy or are experiencing other environmental stresses, and this lack of connection to land was a major stress factor for many immigrant families living in Kalihi.
“So our thought was to give both our Hawaiian families and our immigrant families a chance to reconnect to Hawaiʻi in a really physical way,” explains Derauf. “As that manifested, it was initially based around the growing of food.”
During a year-long, community-based strategic planning involving focus groups from the different ethnic and age groups in the community, KKV asked the people of Kalihi what was critical to them in terms of health.
“Repeatedly, what we heard were stories around strengthening their culture; making sure their children grew up understanding the value of their culture; we heard about the importance of having access to their own food stuffs; we heard about neighborliness; we heard about job opportunities for their kids,” says Derauf. “Almost nobody mentioned anything about access to doctors and dentists.”
Obviously, nutrition is also a big part of health, but Derauf says that the most important thing about having a community grow its own food is not the caloric value of the food itself, but rather the deeper connection that community forges to its own roots and that ties individuals to their families and to the larger community.
“The act of growing food and preparing it together and then eating it together is really one of the most obvious, direct ways that we all can experience those connections,” explains Derauf. “And when we build those connections through food, people are naturally healthier. Of course it’s good that they’re eating organic produce, but its equally good that they had a hand in growing it, and it was grown really lovingly, and that there’s a lot of pride when they put it on the table.”
Derauf tells me that the very first group of farmers they had in the back of the valley was comprised primarily of Micronesian women who were suffering from diabetes. KKV had spent a lot of time trying to get them to exercise, a word which apparently doesn’t really exist in their native language and, consequently, has no context for them in English. But when farming was brought up, they immediately had a positive response.
“This group of older women, many in their sixties, were actually really skilled with machetes and quickly cleared a plot of land and set to work growing native food stuffs. And the indicators that their diabetes was under control all improved dramatically,” relates Derauf.
“If we continue to think that we’ll get better outcomes at lower costs simply by doing more of the same, I think we’re kidding ourselves,” says Derauf. “So we should ask ourselves are there other ways that we can strengthen our communities and have healthier communities? And I think if you ask that question, the answer is yes.”
Derauf sees the major hurdle to moving mainstream health care toward this holistic approach as changing the mechanisms by which health care is paid for. With nearly 3 trillion dollars budgeted annually for health care, even a marginal shift in how this money is allocated could make a big difference.
“Even if we shifted how just 10 percent of that money was spent, that’s 300 billion dollars,” says Derauf. “There are some experiments going on at the margins of health care, but those are still mostly related to how we deliver medical services.”
Derauf says that if health care providers like KKV can show that their approach not only helps people and communities become healthier, but also saves the system money, there will be more room for government support as well as investment from the private sector.
“It’s important that we start to educate policy makers and key people that there are, already, a growing body of data on the return on investment in these kind of non-traditional forms of health delivery,” says Derauf.
By now, there has been 25 years worth of accumulated literature built around illustrating the cost-savings that can be achieved through these alternative health care systems, as well as evidence of improved mental health and disease outcomes.
“We have to be bold and take a chance on these alternative systems,” expresses Derauf. “Frankly, we’re doing a lot of chance-taking with our medical system. The return of investment on what we deliver in our current health care system is pretty darn low, so I don’t think it would be a hard thing to become competitive with some of that. But we have to get the word out and we have to be able to imagine different mechanisms of paying for it.”
As a concrete example, Derauf tells me about the KKV elders program, which serves about 200 senior citizens who come together for congregate dining, exercise, health care and care management.
“We have demonstrated a 98 percent track record of keeping participants out of long-term care facilities,” says Derauf.
Despite the fact that a track record like that is clearly saving the State of Hawaiʻi and the Federal government a great deal of money, Derauf says that KKV cobbles together funding for the program through numerous grants, and each year it’s a toss up as to whether they’ll be able to find continued funding.
“The system should be recognizing what we’re doing and asking how we can do more of it,” says Derauf. “That serves everyone’s needs: people want to age in their homes and the state doesn’t want to pay for long-term care. This is a win, win, win situation.”
Derauf concludes by saying that the best thing for people to do is to get involved in their own communities, at any level. “I can’t convey the joy of this work that I and my co-workers and the community members get to experience side-by-side every day,” he says. “As insane as it may be to try and make it happen from a financing standpoint, the absolute joy of doing it makes it all worth while.”