The 2023 firestorm that devastated Lāhainā, Maui, resulted in the deadliest wildfire in modern US history, leaving the Hawaiian Kingdom’s former capitol in unrecognizable, charred ruins. Without any warning, residents found themselves trapped in the inferno without direction for how to escape, all while witnessing their homes burning to ashes. The catastrophe upended thousands of homes and businesses, with many residents losing everything. Although the exact cause of the fires is still under investigation, it is certain that mental and physical health consequences on survivors are imminent and must be addressed proactively.1^,2 With our knowledge of Kānaka ʻŌiwi (Native Hawaiian) physicians and having personal ancestral roots in Maui, we share concern for the immense health impacts of these wildfires and offer our vision for the health of Native Hawaiians and local residents moving forward.

Deemed the “worst mental health disaster” in modern Hawaiʻi history, residents and first responders who survived the Lāhainā fires experienced significant psychological trauma.2 In the weeks after the catastrophe, survivors overwhelmed with the incalculable loss faced by their community reported nightmares, anxiety, and depression.² With thousands of residents newly displaced, there were growing concerns for housing instability and mental health disorders that exceeded the available resources, which is particularly true for the Native Hawaiian population, who already had the highest rates of being unhoused and mental health disorders across all racial and ethnic groups.³

Prior studies demonstrated that natural disasters have been associated with posttraumatic stress disorder and depression.1 A large systematic review found that in the wake of major wildfires, up to 60% of adults and more than 90% of children experienced posttraumatic stress disorder and mental illness, which persisted for up to 10 years.¹ The loss of life, housing, and socioeconomic instability after natural disasters contributes to acute increases in mental health service visits and hospitalizations that frequently follow natural disasters. Moreover, a perceived lack of support from the government is a notable risk factor in developing mental health disorders following wildfires.¹ Thus, the government response to natural disasters, including the Lāhainā fires, can play a critical role in mitigating long-term mental health consequences.¹

Beyond psychological trauma, Lāhainā residents have also experienced serious threats to their physical health. Survivors with burns too extensive for the Maui hospitals required air transport to Oʻahu, the only North Pacific island with a burn unit between Asia and California. The buildings themselves, burned to ashes, also contaminated the environment with lead, arsenic, and asbestos, which pose major long-term risks to human health. Extensive exposure to these toxins raises concerns for increased morbidity and mortality, especially among Native Hawaiians, who already face a disproportionate burden of nearly all chronic health conditions.4 These threats to the health of the Lāhainā community underscore the urgent need for expanded access to specialty health care.

Despite the significant health care need, the Hawaiʻi Department of Health was not easily able to activate emergency resources after the fires, in part because the Pacific Islands have some of the most isolated health care systems in the world. Before the fires, Hawaiʻi was already grappling with a severe physician shortage. Thus, in the wake of the Maui wildfires, local mental health resource limitations required mobilization of supplemental assistance.2 Volunteers had to be flown in from as far as the Midwest United States to provide acute mental health services.² However, foreign recruitment can be counterproductive if the personnel lack familiarity with Hawaiʻi and its nuanced culture. Thus, it is paramount that emergency responders who respond to tragedies on Indigenous lands be sensitive to any skepticism toward Western medicine, which is often rooted in a history of structural racism, systemic oppression, and colonization.⁴

A potential solution to the Hawaiʻi physician shortage and need for culturally sensitive care may lie within bolstering the Native Hawaiian and Other Pacific Islander health care workforce. In the context of the Lāhainā wildfires, increasing the number of Native Hawaiian physicians would address both the short- and long-term health care needs across Hawaiʻi. However, recent studies have also demonstrated that Native Hawaiian and Other Pacific Islander physicians are not only significantly underrepresented compared with the total US Native Hawaiian and Other Pacific Islander population but also are decreasing across nearly all medical specialties.5 There is clear evidence that racially concordant care provided by Native Hawaiian and Other Pacific Islander physicians to patients of the same race has been associated with improved patient satisfaction, medication adherence, and health outcomes.⁵ Therefore, investments in the Native Hawaiian and Other Pacific Islander workforce are investments in the health of the Native Hawaiian and local communities across Hawaiʻi.

In addition to enhancing the physician workforce, reenvisioning how Lāhainā rebuilds will also be essential for the future health and well-being of Native Hawaiians. Akin to that of other Indigenous people, the overall health of Native Hawaiians is inherently tied to the relationship they have to their ancestral lands. This association is reflected in public health models such as the One Health approach, which advocates for policies that promote the unity of human and environmental health.6 The One Health framework aligns with Native Hawaiian values of ideal health and wellness, which is rooted in the deep connection between kānaka (humankind) and ʻāina (land and natural environment).⁷ Public health researchers have shown that among Native Hawaiian adults from both urban and rural parts of Hawaiʻi, there was a unanimous sentiment that the intergenerational health and resilience of people are reflected through connectedness with ʻāina.⁷ This deep connection between kānaka and ʻāina involves land stewardship that has been taken from Native Hawaiians over the centuries. Therefore, Native Hawaiian voices should be integrated in decisions made by the local, state, and federal government as Lāhainā is rebuilt.

It is critical to invest in both short- and long-term health needs of individuals affected by the Lāhainā wildfires. In the short term, mental health professionals responding to natural disasters need to be culturally sensitive to truly serve communities throughout Hawaiʻi, especially Native Hawaiians. In the long term, there is a clear need for further investment to recruit and retain the next generation of Native Hawaiian health care professionals, especially to mobilize in states of emergency. Moreover, the rebuilding of Lāhainā must be framed through the lens of the Native Hawaiian people, whose health is intimately connected to their relationship with their ancestral lands. These sentiments were championed by the late historic Native Hawaiian physician and advocate Noa Emmett Aluli when he said, “Ola ka ʻĀina, ola ke Kānaka”: the health of the land is the health of the people.7 Only with a unified, culturally conscious approach will we ensure the future health and prosperity of Native Hawaiians and the land that sustains them.

Corresponding Author: Kekoa Taparra, MD, PhD, Stanford Health Care, 875 Blake Wilbur Dr, Palo Alto, CA 94304 (ktaparra@stanford.edu).

Published Online: November 6, 2023. doi:10.1001/jama.2023.21427

Conflict of Interest Disclosures: Dr Taparra was supported by the Stanford Cancer Institute, a National Cancer Institute–designated Comprehensive Cancer Center; and was funded by a Stanford Cancer Institute Women’s Cancer Center Innovation Award, Stanford Cancer Institute Fellowship Award, Stanford Health Care Sustainability Seed Grant Award, and the American Society for Clinical Oncology Dr. Judith and Alan Kaur Endowed Young Investigator Award. No other disclosures were reported.