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In a normal year, psychologist Nicole Wright sees about 200 patients in her practice at the Waianae Coast Comprehensive Health Center.

Since the pandemic began, her patient load has multiplied to about 1,000.

“It has been crazy,” said Wright, who also directs the community health center’s divisions that provide substance abuse and mental health treatment services. “The pandemic really emphasized a lot of existing issues in the Native Hawaiian community, especially in the Leeward Coast.”

Hawaii has for years struggled with a statewide shortage of mental health professionals, part of a broader shortage of physicians and other medical staff. That gap has been compounded by the pandemic, which has exacerbated mental health problems both nationally and locally.

The mental and emotional toll of the pandemic is still unfolding, but health professionals and service professionals who work with the Native Hawaiian community say the recent delta surge’s disproportionate impact on the community has exacerbated existing mental health concerns.

Stacelynn Eli, a Native Hawaiian legislator representing communities in West Oahu that were hit hardest by the latest virus surge, said the pandemic wrought shock, fear and confusion in her community. Now what’s left is grief.

“It’s just another historical traumatic moment here in our history as Native Hawaiians here in Hawaii,” she said. “We’ve lost so much in just such a short amount of time.”

It wasn’t always that way. For the first year of the pandemic, Hawaii residents who were at least part Native Hawaiian didn’t have disproportionately high rates of Covid-19. The communities facing the worst Covid disparities in Hawaii were other Pacific Islanders and Filipinos.

But after vaccinations became available, Native Hawaiians were less likely to get the shot than other communities, according to state data, making them especially vulnerable to the highly contagious virus strain.

On June 19, Hawaii reported 5,414 total cases of Covid among Native Hawaiians since the pandemic began in March 2020. Days later, the state reported several strains of delta had been detected in Hawaii. By Labor Day weekend, Covid cases among Native Hawaiians had more than doubled.

Since the variant was introduced in Hawaii, Native Hawaiians have comprised 29% of all of the state’s Covid cases, even though they’re just 21% of the population.

The highest death rates for the pandemic overall are still among other Pacific Islanders and Filipinos, but Native Hawaiian community leaders and advocates have worried their high Covid case and hospitalization rates might drive a disproportionate death rate, too.

Part of the difficulty is that most of the Covid deaths that have occurred in the Native Hawaiian community have been concentrated over the past few months. During the first year of the pandemic, the state reported 45 members of the Native Hawaiian community died from Covid. As of Nov. 3, that number had more than tripled.

Wright says at the Waianae Coast Comprehensive Health Center, where about half of the patients are Native Hawaiian, she’s seeing many more patient requests for mental health services, including grief counseling, as families grapple with the loss of loved ones.

“We definitely don’t have enough mental health services for the people who need services, especially for youth,” she said.

Amplifying Effect

Before Covid, Hawaii often did well on national analyses of mental health by state, but an October study by the Centers for Disease Control and Prevention found since the pandemic, the 50th state’s anxiety and depression levels are worse than most others.

Jack Barile, interim director of the Social Science Research Institute at the University of Hawaii Manoa, wrote that . The state had the highest unemployment rate in the nation last year.

Belinda Danielson, who oversees community programs in the Department of Health’s adult mental health division, says during 2020, the state’s behavioral health line also served as a Covid crisis line and calls went up by the thousands. Many were people who didn’t previously have mental health issues.

“It was really apparent that callers were a different breed,” she said. “It was folks that normally wouldn’t have called a crisis or suicide hotline.”

In 2021, the state set up a new crisis line for Covid help. Calls to that line tripled in August and September as delta spiked. Danielson said the state doesn’t have demographic data on who is calling, but Native Hawaiian service providers said that was a particularly stressful time for the community.

“It is a very vulnerable community in terms of the social determinants of health, and always has been, and that has an amplifying effect on the greater number of Covid cases.” — Jacob Schafer, an epidemiologist at Waianae Comprehensive Health Center

Eli remembers getting texts and calls from her neighbors and friends whenever someone was in the intensive care unit with Covid. The West Oahu legislator doggedly sought to connect her community with vaccination resources and information. But it was hard to stay strong as so many people she knew got sick, hospitalized or died.

To her, the pandemic is just the latest source of trauma for a community that has faced generations of systemic challenges, from the overthrow of the Hawaiian Kingdom in 1893 to the continuing struggle to get off the waitlist for Hawaiian home lands and own land in Hawaii.

Native Hawaiians faced disproportionate health problems prior to the pandemic, such as high rates of diseases like obesity and diabetes that are associated with poor Covid outcomes. Historically, the Hawaiian population was decimated by diseases introduced by Europeans like smallpox and measles, with one estimate saying the diseases cumulatively killed over 100,000 people.

Colonization also fueled cultural loss that Jacob Schafer, an epidemiologist at Waianae Comprehensive Health Center, says the pandemic has worsened.

“There is a significant loss of culture, heritage and history, specifically with kupuna deaths related to Covid,” said Schafer.

The effects of Covid have been clearest to him in West Oahu, . About two-thirds of the center’s patients are below the federal poverty line.

“It is a very vulnerable community in terms of the social determinants of health, and always has been, and that has an amplifying effect on the greater number of Covid cases,” he said.

Crisis Ongoing

Wright said the mental health issues that have been worsened by the pandemic vary.

More patients at the Waianae Comprehensive Health Center want couples and family counseling. Former substance abuse patients who have been sober for 10 or 15 years are tempted to relapse. More medical professionals are seeking help dealing with their own stress.

Every time Covid regulations change, she and other providers get more calls for help, as families grapple with the financial challenges of unpredictable industry shutdowns and layoffs. She’s seen an increase in patients with anxiety, which she said is one of the most debilitating issues.

“For general psychology there is often a waitlist. For specialty treatment there’s an even longer waitlist,” she said. “I was going to call you yesterday after my last patient but then four more patients walked in.”

In many ways, the pandemic has been receding in Hawaii and life has slowly been going back to normal. Gov. David Ige last week , restaurants and social establishments. Fans can finally attend University of Hawaii football games.

But despite falling Covid case counts, Wright’s office is still slammed.

“I have to be honest, it has just been nonstop,” she said. “It’s just been a high level of stress overall.”

Like Wright, Andrea Hermosura has seen an increase in patient requests that her private practice hasn’t always been able to fulfill.

Part of the tension and stress has involved disagreements about whether to get vaccinated within families. Hermosura remembers being anxious in August when she was invited to a 300-person wedding for a close member of her large Native Hawaiian family that had no vaccination requirements for attendance.

Her anxiety was two-pronged as she navigated “how to maintain harmony and close relationships but also safety,” she said.

The family stress caused by opposing views on vaccinations has taken a toll on the Native Hawaiian community, with some siblings who have stopped talking, said Eli.

She hopes that families can start finding ways to heal as Covid eventually becomes endemic rather than a pandemic, but for now she is still in crisis mode.

“I haven’t given myself the time to really process the loss,” she said.