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When Dr. Noa Emmett Aluli died suddenly in November, doctors across the state asked what they could do to help fill the void created by the loss of a family medicine physician who provided comprehensive, day-to-day health care to roughly 1,700 patients on Molokai.

“I was pretty straightforward and said, ‘We need doctors on Molokai,’” said Donna Gamiao, Aluli’s former nurse and office manager.

In January, Dr. Ka‘ohimanu Dang Akiona, a Big Island physician and advocate for equity in health care, reached out to Gamiao with a proposal to open a new branch of her Kohala Coast practice on Molokai.

This week that vision comes to fruition. Absorbing Aluli’s medical supplies and rehiring his staff, Dang Akiona has opened the doors to , a primary care, urgent care and street medicine practice located at Aluli’s former office in Kaunakakai.

“A lot of his patients just want to come back,” said Dang Akiona, 42. “So we want to give them a place to come back to.”

Doctors have long been in short supply on Molokai, where residents must board a plane to access specialized care and routine treatment is propped up by fly-in physicians.

For decades, primary care on this island of roughly 7,000 residents was buoyed by a pair of doctors who embedded themselves in the community, earning the trust of families across generations.

Then, in a span of three months late last year, Aluli, 78, and Dr. William Longfellow Thomas, 63, died, sending thousands of Molokai patients scrambling for a doctor on an island left with fewer than four full-time primary care physician equivalents.

For months in Honolulu sent several doctors and advanced practice providers to to help fill gaps in patient care, according to Jan Kalanihuia, hospital president. This extra help ceased in February.

Aluli had tried throughout his 47-year practice on Molokai to lure new doctors to the island, in part by taking on medical students as interns and trainees, exposing them to the unique rewards, challenges and day-to-day dynamics of rural medicine. But he was unable to secure a successor.

Now, with Dang Akiona’s arrival, Aluli’s former patients have a replacement who, like Aluli, is a Native Hawaiian passionate about rural medicine. 

“The biggest thing I think he would be happy about is knowing his patients would be taken care of,” Gamiao said. “It will provide at least another option to go to without sacrificing your pocketbook and your time and all the headache of coordinating a medical trip to Honolulu.”

Dang Akiona estimates that the new clinic will have the capacity to treat up to 30 patients a day at an operating cost of roughly $40,000 to $50,000 a month.

Figuring out how to finance a rural medical clinic that officers revenue-intensive outreach — such as street medicine for homeless residents and mobile health care for homebound patients — is expected to be the biggest challenge to the clinic’s success, Dang Akiona said. So the doctor launched a nonprofit through which she’s soliciting private donations to help the practice get off its feet.

In the meantime, she’s opening the clinic’s doors and forging ahead because she said she knows the medical services the clinic provides can’t wait.

“Your zip code dictates a lot of your life,” Dang Akiona said. “It’s starting to predict the trajectory of your life, what kind of health care you have access to. I think that’s kind of what’s making us do this. It’s a lot of people’s mothers and fathers and brothers getting left behind out here.”

At first, Dang Akiona said she and two other doctors she’s recruited will be on Molokai to treat patients. But eventually she expects to fly back and forth between her Molokai practice and her Big Island clinic, .

Launched in 2022 on the sixth floor of , Dang Akiona’s Big Island practice offers routine community health care. It also caters to tourists and wealthier residents, offering Covid-19 testing and numerous out-of-pocket services, such as Botox and IV drip therapies.

The latter helps fund the clinic’s revenue-draining operations, such as homeless outreach. Now Dang Akiona hopes it will also prop up .

“If this all comes together like it should, the vacationers and the more well-to-do patients that I see in Hapuna can actually support the needs that we have on Molokai,” Dang Akiona said. “And in that way doing rural health get a little bit more sustainable.”

The Molokai clinic also has grassroots support. A local family has offered free lodging on Molokai to Dang Akiona and her team of Big Island-based health care workers to help ensure its success.

Maui County Councilwoman Keani Rawlins-Fernandez put forward an amendment to the county budget to appropriate $50,000 for the clinic. The budget is set for first reading on Tuesday.

The councilwoman said she supports Dang Akiona’s venture, noting that the doctor has relationships with people on Molokai in part through her studies years ago in rural medicine on the island.

But she said Aluli can’t easily be replaced. He visited patients at home, ushered in drop-in and after-hours patients and forged trust in families over generations.

“Health care on this island is not transactional,” Rawlins-Fernandez said. “It’s not just about health care as a service so much as the relationship and the trust between the patient and the doctor. There are people here that won’t go to any other doctor. They only want to go to their doctor and in many cases their doctor was Dr. Aluli.”

Judy Mikami, vice president of the , said she’s thankful for the addition of another doctor on Molokai. What patients really want, she said, is a doctor who won’t be gone in a couple of years. 

“Someone once told me when you see someone here as a provider it’s 90% talk story and then you go in for what you’re really there for,” Mikami said. “For a lot of our old-timers, that’s what they’re used to and that’s what they’re looking for.”

Encouraging young doctors to take up practice in rural areas is challenging. But new incentives are afoot.

State lawmakers this session set aside $30 million to help bolster Hawaii’s strained medical workforce by offering a loan repayment program for doctors, nurses and social workers.

The state budget also provides $72 million for Medicaid payments to health care providers, which are sometimes so low as to barely cover the cost of care. Nearly two-thirds of Molokai’s residents are covered by , the state’s version of Medicaid, compared to about one-third of all Hawaii residents.

“Investments like these will help shrink the state’s physician shortage and ensure better health outcomes for communities across the state, including rural communities like on Molokai, or in Kau, where I served for years,” Gov. Josh Green, who is a medical doctor, said in a statement.

Civil Beat’s coverage of Maui County is supported in part by grants from the Nuestro Futuro Foundation and the Fred Baldwin Memorial Foundation.

Civil Beat’s health coverage is supported by , Swayne Family Fund of Hawaii Community Foundation and the Cooke Foundation.