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Valuing Conditions

Protecting What You Consider Special: The Star Path of Ke Ala Hoku

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If it is a healthier course that we seek, and the pragmatic talents of navigators that we need, then perhaps some of the voyagers in our midst may guide us toward more useful ways of understanding and organizing public health ventures. Humans, as a species, have evolved a remarkable prowess for wayfinding, which confers to us a distinct survival advantage (Finney, 1992). It is an advantage that goes beyond having developed unique modes of locomotion, encompassing a vast, synergistic constellation of sensory, cognitive, emotional, organizational, and cultural traits (Corning, 2003). In earlier phases of human history, physical navigation or the ability to direct movement over land, water, and air was paramount. But in the last two millennia, when patterns of cultural evolution have moved to the forefront (Doncaster, 2001), our well-being and survival grew to depend more on social navigation, or the ability to direct the course of social change toward a negotiated set of valued conditions. In our time, one of the most notable wayfinders—in both the physical and the social arena—is Nainoa Thompson, lead navigator of the Polynesian Voyaging Society (Evenari, Aginsky, Dorsky, et.al., 1999; Kyselka, 1987).

In 1976, after successfully navigating the voyaging canoe Hokule`a from Tahiti to Hawaii without instruments, in the nearly-extinct tradition of his Polynesian ancestors (Finney, 1994; Kyselka, 1987; Polynesian Voyaging Society, 2004; Thomas, 1997), Thompson became an icon at the vanguard of the Polynesian Renaissance—itself a conscious endeavor to revive ancestral traditions that had been eroded by centuries of colonialism and redirect the future of Hawaii’s social and ecological development (Dudley and Agard, 1993; Harden and Brinkman, 1999; Kanahele, 1982; Malama Hawaii, 2003).

Beyond his work as a sailor and an educator, Thompson brings a powerful navigational sensibility to the many problems facing his island home and the people who live there.¹⁰ He understands well the importance of remaining alert in the midst of a journey. He also knows that what is true on a sailing canoe in the Pacific applies equally to our evolutionary journey into the future: with sight and other senses closed to signals of location and direction, it does not take long to become disoriented, wandering in a sea of change without a map, risking life and squandering a more prosperous future. Worse than other navigational obstacles like dwindling energy, mechanical problems, or turbulent conditions, disorientation is an agonizing, wasteful, and potentially protracted state. Lacking the necessary frame for pragmatic thinking, disorientation is no mere barrier: it is the antithesis of conscious navigation and the chief impediment to effective wayfinding (Polynesian Voyaging Society, 2002).

In 1995, Thompson used his distinctive world view to help the children of Hawaii articulate their vision for a healthier future, a vision so compelling and so pragmatic that it quickly  became formalized scientifically and enacted legislatively as the Ke Ala Hoku Critical Indicators  (Hawaii Community Services Council., 1999; Hawaii State Legislature, 2000).¹¹ He even remembers the exact moment during that project in which he and a group of school children  came to appreciate the profound significance of the unfinished work that they must do to safeguard the conditions that make life in Hawaii worth living.

In February of 1995 a good friend of mine, Holly Henderson, came to me and said, “We have eighteen school children and we want to put together a visioning process so they can define their future.” It was the same visioning process that we use to plan a voyage—where do we want to go, how do we prepare to get there.

So the kids came down to where Hawai'iloa {a deep-sea voyaging canoe} was being built and we went into this shed. We sat down. The kids were very standoffish: they didn’t want to talk. But we started to talk about a vision for Hawaii’s future. I didn’t have any answers but I had questions so I asked the kids: “How many of you are born and raised in Hawaii?” Seventeen out of the eighteen were born and raised in Hawaii. I said, “How many of you are going to stay and live here in Hawaii?” They kind of slowly raised their hands. They were shy. Seventeen of the kids raised their hands; they were going to stay in Hawaii. I asked the one girl who didn’t raise her hand where she was going to live. “No. no,” she said, “I am going to live in Hawaii but I am going to travel and see the world first.” In the end, there was consensus-all eighteen were going to live here.

So then I asked, “Why? Why would you pick this small little place—this small speck of land-when you have all these other choices? What makes this place so special?” And they answered—“the culture”—“family”—“it’s a beautiful place”—and they had a whole laundry list of things that they all agreed on. Then I asked, “How many of you want to have children?” Now they were all participating. They all raised their hands. Then I asked, “Where do you want your children to live?” Without hesitation they all told me that they wanted their children to live in Hawaii. Then I asked, “Why?”. And they told me they wanted all those things that were special about Hawaii for their future children. “How do you know,” I asked, “that in twenty years those things that you consider special are still going to be here?”

At first they all raised their hands but when they really digested the question every single one of them put their hands down. In the end, there was not a single hand up. No one could answer that question.

It was the most uncomfortable moment of silence that I can remember. We all sat there, looking at each other, without an answer to a fundamental question that seemed so powerfully important to the future of our children. That was the defining moment for me. I recognized that I have to participate in answering that question otherwise I am not taking responsibility for the place I love and the people I love (Thompson, 2000b).

Thompson’s story speaks to the remarkable power that he and those 18 children possess and of the daring spirit they bring to public life. It is a tale about being moved, personally, to protect and sustain the things we love. This work—the work of directed citizenship—springs from a passion for securing and celebrating that which is precious and might easily be lost, including life itself and the freedoms that make living worthwhile.

The history of public health work is marked by examples of profound changes brought about by those with this same passion for creating and protecting what is precious to them (World Health Organization, 2000). In almost every case, such changes depended on actors entering public life in precisely the way that Arendt speaks of them, with the courage of their convictions but not necessarily credentials (Fee and Acheson, 1991). It depended on people who saw themselves as participants in public life, not onlookers. Pick your group: mothers suffering the aftermath of drunk driving (Lord, 2000), gay men first confronting HIV/AIDS (Shilts, 1987), workers exposed to hazardous conditions (Centers for Disease Control and Prevention, 1999), injection drug users lacking access to clean needles (University of California Berkeley. School of Public Health., University of California San Francisco. Institute for Health Policy Studies., Centers for Disease Control and Prevention, 1993), teens rejecting manipulative tobacco marketing (Social Marketing Institute, 2004), alcoholics and drug addicts on the road to recovery (Alcoholics Anonymous, 2004); or others; in one example after another, we see those whose health is most threatened by adverse conditions stepping up, speaking out, sparking change.

Prompted by Thompson’s poignant questions, the Hawaiian children readily identified “things that they consider special,” and even if the items on their individual lists were not widely shared, any one of them may be valued enough to inspire concerted action. Thus, the very act of defining and working to create or protect valued conditions sets in motion a new and powerful story. Therein lies the genesis—and the remarkable openness—of our endeavor to protect the public’s health. It is the same now as it was in the 1800s, when public health work first became a distinct area of scientific study, professional practice, and public concern. Historian Gil Elliot recounts the critical shift in thinking that opened the way to formal public health work.

Public death was first recognized as a matter of civilized concern in the nineteenth century, when some public health workers decided that untimely death was a question between men and society, not between men and God. Infant mortality and endemic disease became matters of social responsibility. Since then, and for that reason, millions of lives have been saved. They are not saved by accident or goodwill. Human life is daily deliberately protected from nature by accepted practices of hygiene and medical care, by the control of living conditions and the guidance of human relationships. Mortality statistics are constantly examined to see if the causes of death reveal any areas needing special attention...

When politicians, in tones of grave wonder, characterize our age as one of vast effort in saving human life, and enormous vigor in destroying it, they seem to feel they are indicating some mysterious paradox of the human spirit. There is no paradox and no mystery. The difference is that one area of public death has been tackled and secured by the forces of reason; the other has not. The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect. In doing so they had to contend with and struggle against the suspicious opposition of those who believed that to interfere with nature was sinful, and even that disease and plague were the result of something sinful in the nature of man himself (Elliot, 1972).

What inspires such vigilance and the courageous actions that flow from it? Thompson and the Ke Ala Hoku participants began by looking to the future and acknowledging that the things they consider special are vulnerable, requiring stewardship and protection amidst inevitable—even unknowable—forces of change. Instead of being paralyzed by fear or uncertainty, instead of looking for someone to blame, or some expert to step in, or some government official to hold accountable, they adopted a constructive stance. In their “uncomfortable moment of silence,” a moral and conceptual shift could take hold. For Thompson himself, and perhaps for others in the room, it was a step into the public sphere. Flooded with newfound feelings of consciousness and conscience, he and the others came to a deciding moment: looking forward and wondering what exactly it means to be responsible not just for oneself but for generations to come.

While the role of science in guiding public health action is widely acknowledged, the related roles for consciousness and conscience are only beginning to receive equal attention. All three shape the character of public health work, just as all three share the same Latin root (i.e., scire, meaning to know). Science refers to the means of acquiring knowledge of any kind through explicit procedures such as “experience, observation, identification, description, experimental investigation, and theoretical explanation of phenomena” (American Heritage Dictionary, 2000). Consciousness situates that knowledge in a larger context that includes self-awareness of the endeavor to acquire knowledge itself. Conscious science, therefore, expands the scope of knowledge to include information about “one’s environment and one’s own existence, sensations, and thoughts.” Finally, the idea of conscience places scientific inquiry—and the actions that flow from it—within a framework of evaluative judgment. That framework, importantly, is not only self-referential (i.e., applying scientific criteria to judge scientific merit) but also concerned with the role of science in resolving public dilemmas and advancing human development. When enacted with conscience, public health work includes “a moral or ethical aspect to one’s conduct together with the urge to prefer right over wrong” (American Heritage Dictionary, 2000). It is this conscience (sometimes referred to as a “moral compass”) that places public health science in service of common sense and imposes boundaries on the kinds of procedures that may be used legitimately to acquire knowledge or pursue human values (Yankelovich, 1991).

Public health scholars will recognize the Hawaiian children’s predicament as similar to the primary purpose of public health work: “to assure the conditions in which people can be healthy” (Institute of Medicine, 1988, 2002a). Since 1988, when the U.S. Institute of Medicine (IOM) famously introduced this idea of assuring conditions as the animating purpose for all public health work, it has remained a foggy notion for most professionals in the field as well as the public at large. It is beyond our scope at the moment to look for a definitive explanation, but the Ke Ala Hoku story conveys the practical meaning of what such work entails: a continuous endeavor undertaken by each us, working alone and with others, to create or protect the conditions that make it possible to be healthy in a changing world where others are doing the same. This is not easy work, for there may be stark inadequacies and inequities of power, as well as varying degrees of convergence, disagreement, or uncertainty about exactly what to do (Huxley, 1937). Also, what is valued by some may be quickly—even forcefully—contested by others. Despite these challenges—indeed because of them—our work to assure safer, healthier conditions is a vital dimension of public life. The challenges posed by uncertainty and plurality, in fact, add a distinctive public dimension to health work, making it a remarkably poignant and pressing form of human endeavor.

Temporarily silenced by Nainoa Thompson’s question about the future and wondering whether their children would be able to enjoy the same island in similar ways, the Ke Ala Hoku participants came to appreciate the serious implications of their own actions (or inactions) in directing the course of change. Their perplexity turned into something definite: a realization that each of their lives, even as youngsters, was not merely to live, but to live in a way that lets others live as well. This particular ethic encapsulates the unique relational idea that how we act today affects others, now and in the future, in ways that familiar ethical slogans like “Do no harm,” “Do unto others as you would have them do unto you,” and “Live and let live” do not quite capture (Laszlo, 2001). To live in a way that allows others to live as well acknowledges the inherent trade-offs within the choices we make in daily life. It proceeds from the premise that one person’s life and health might come at the expense of another’s, or that undue freedoms by some may entail, at least in part, greater inequity and deprivation elsewhere. Above all, it raises pragmatic questions about what we value and how we behave, without losing sight of the fact that there are differing degrees of freedom surrounding and constraining those choices in our plural world.
 

10. Demographic analyses indicate that population health in Hawaii, which had been remarkably high for centuries, declined precipitously after Western contact in 1778 (Kunitz, 1994; Nordyke, 1989; Stannard, 1989). By 1820, the Native Hawaiian population fell from approximately 795,000 to 150,000. Further declines continued throughout the 19^th century, with a pronounced shift in morbidity and quality of life occurring in 1897, when the United States forcibly overthrew the Hawaiian Kingdom (Dudley and Agard, 1990; Seward, 2001; United States. National Archives and Records Administration and Schamel, 1999). Like other indigenous people who endure the effects of colonialism, racism, and social marginalization (Haas, 1992; Kunitz, 1994; Memmi, 1970; People's Health Movement, 2004; Trask and NetLibrary Inc., 1999), who have been denied sovereignty, dispossessed of their land other material resources, and denied self-determination (United Nations, 1997), Native Hawaiians bear a far greater burden of disease than other sub-groups living in Hawaii (Blaisdell, 1993, 2002; Hawaii Health Information Corporation, 2001; Papa Ola Lokahi, 1998; The Native Hawaiian Health Research Consortium, 1985). Similar inequities are evident in educational achievement, incarceration, and an array of other social indicators. In addition, the combined forces of economic development, immigration, climate change, oceanic change, and importation of invasive plant species have put Hawaii’s fragile island ecosystem in serious jeopardy.

11. Ke ala hoku is the Hawaiian phrase for “star course”, a constellation of celestial signals like the ones that ancestral Polynesian navigators learned to follow so they could sail safely over the vast, foreboding ocean. In the modern context, the idea of a star course conjures the notion of a set of indicators by which we could navigate social change and fulfill public values. The effort to articulate indicators for guiding contemporary policy making in Hawaii began by asking 6,000 youth statewide about the kind of conditions they wanted for themselves and their children. Eventually, the group selected 58 indicators in the following six categories: Healthy Natural Environment; Safe, Nurturing Social Environment; Thriving, Diverse, Sustainable Economy; Educated Citizens; Civic Vitality; and Aloha Spirit. The International Institute for Sustainable Development describes the entire venture, which started by having adults listen carefully to children at the grassroots, as being “thoroughly intergenerational, with youth and adults working together at every level of planning and action. In addition, citizens from government, business, and nonprofit organizations have been involved in the process” (International Institute for Sustainable Development, 2004). Thus, as a public organizing venture, the Ke Ala Hoku project is remarkable not only in the degree to which it elicited input from so many whose voices tend to be excluded from policy making, but also in its deliberate resonance with Polynesian culture and its productive engagement among ordinary citizens, social scientists, program administrators, and elected officials. In other respects, however, the project is but one instance in a class of similar visioning/benchmarking ventures across the United States and beyond. For additional background on the broader “community indicators movement” see: (Gibbs and Brown, 2000; Hayes and Willms, 1990; Opdycke, 2001).

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Page last reviewed: January 30, 2008
Page last modified: January 30, 2008

Content source: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion