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The grounds of the hospital were neat and carefully manicured. The buildings white and beautifully designed. But the idyllic setting of Hawaii’s public mental hospital only made the “indescribably terrible” conditions inside all the more stark. 

“I am horrified when I make the night rounds,” the hospital’s medical director , following a report on the severe understaffing and neglect taking place at the public institution at the time. 

Dozens of people slept on urine-soaked mattresses on the floor because of a lack of beds. A building housing the most dangerous patients was at more than double its capacity. Severe budget issues meant that fruit had been eliminated from breakfast and patients were only allowed one egg a week. Many had a “gaunt appearance” and were suffering from malnutrition. 

People who should have been treated and released — including young mothers who from the sounds of it may have been suffering from postpartum depression — were being transferred to the “chronic ward”  where their hope of recovery was “either fading or gone because of inadequate treatment.” 

“Because of neglect, some patients who have had opportunity to resume life as normal persons have been mentally maimed for life,” the Honolulu Advertiser wrote in a story about a highly critical committee report on the condition of the hospital. 

If there was blame to be laid for the evils taking place at the hospital, the Honolulu Advertiser wrote in an editorial later that week, it was with the public.

“There has never been any aroused, general interest in what happens to Hawaii’s public institutions, except now and then when brief attention is called to them by some passing scandal,” the editorial writers proclaimed. 

While such a comment could apply to countless communities and the agencies that serve them, it appears particularly prescient in connection to the Hawaii State Hospital.

The fatal stabbing of a nurse at the hospital in 2023 has brought renewed attention to issues at the state-run psychiatric hospital. But Hawaii’s newspaper archive shows that decade after decade, stories and government reports have highlighted a familiar pattern of understaffing, violence and neglect — interspersed with calls for increased funding and sparks of optimism that more permanent solutions might be found.

“I was hopeful,” a Honolulu Advertiser reporter wrote in 1960 of his feelings after spending a week at the hospital, “that enough legislators, and the people behind them through the Islands, would — on the evidence — take a hard second look at the overwhelming mental health problems facing Hawaii today and meet those problems head-on — and now.”

No Place To Go

The sprawling complex in Kaneohe now known as the Hawaii State Hospital dates back to the mid-1800s, when leaders in Hawaii began calling for the kingdom to create an institution to care for — or at least more humanely house — the mentally ill.

There existed an “urgent necessity” to create an asylum for the insane, the .

“We have had many applications for the admission of this class of patients, but could only receive a few whose mental disorder was not of a character to disturb the peace of the house,” he wrote. “At present most of these unfortunates are kept in close confinement at the station house or prison, a measure calculated to aggravate and render hopeless a disease which originally might have been remediable.”

The Oahu Hospital for the Insane opened in 1866, but with little funding or regulations to mandate how patients were cared for.

In 1887, and infested with vermin and that there were not enough attendants to properly care for patients “and those that are there, have never had the proper training to enable them to perform their duties as they should.”

Patients were being put to work on private land owned by the asylum manager and there were no female attendants to take care of the bathing and dressing of female patients.

The committee made a number of recommendations for improvements, including the construction of a new building, the hiring of a medical superintendent and a number of other additional staffers. The report, yet again, emphasized the urgency of doing more than just confining the mentally ill.

“In this age of strife and competition, where everyone has to work to his utmost to obtain and hold a position in the world, it takes only a trifling reverse in the wheel of fortune, acting upon an over-wrought nervous system, to unbalance the mind, that most wonderful creation, and the most delicately arranged, and cast it into a living tomb to await the day when nature would claim the rest of a being,” the committee wrote. “With proper care and attention at the critical moment the individual might, many times, be saved and placed back into the world to take his position in society, as before.”

In 1901, 14 years after that plea was made, the condition of Hawaii’s hospital was being lambasted yet again, this time in contrast with hospitals in California, where patients were not confined to cells and were fed well and offered treatment, a former secretary of the Hospital for the Insane at Ukiah told the Honolulu Republican.

“In California we do not speak of insane asylums. There are hospitals for the insane. The Honolulu institution could hardly be called a hospital in its present condition. It is more of an old-time madhouse,” the man said, adding that he didn’t know why it was that “the public is so little interested in the insane” in Honolulu.

In 1910, there was a public battle between the superintendent of the hospital and the police department over the hospital’s refusal to admit a man. The police said they didn’t have any room for him. Neither did the hospital.

“The support rendered the insane asylum gives some the idea that there are as many idiots outside as inside,” One building was at double capacity and men were sleeping on a lanai. “He is allowed so few guards that they have to stand twelve-hour watches and each has forty or fifty patients to look after.”

In another problem that would repeat itself over and over again, the hospital was struggling with the fact that it had no place to keep the “criminally insane” ordered to be there by courts after committing a violent crime. The hospital was also arguing with the police about how to best handle the problem of patients escaping.

A Seemingly Endless Cycle

In 1921, after four decades of complaints and newspaper investigations into the terrible conditions at the hospital, politicians began to debate the construction of a new and more modern mental hospital.

A new location with better buildings and equipment was “absolutely necessary” if the hospital was to be “raised to the standard of similar hospitals on the mainland,” members of a House committee said in a Star-Bulletin report.

In 1930, a crowd of thousands gathered to watch a convoy of 33 Army trucks transfer 561 patients from the old hospital on School Street to the new Territorial Hospital in Kaneohe.

Situated in the foothills of the Koolau mountains, with a sweeping view of Kaneohe Bay, the hospital was hailed for its beautiful design and seemed to usher in a new era of mental health treatment in Hawaii.

“It’s a grand spot for a pupule house. The gentle fence around the grounds and the open wards bring home the fact that this place is designed primarily to heal the mentally sick, not to cage them,” a freelance writer penned in a 1937 story in the Star-Bulletin after spending three months observing “at first hand” the operations of the hospital.

The writer spoke glowingly of the care given to patients and the changing attitudes about mental illness, though food was still below standard and there had been an alarming increase in previous years in the number of patients being sent to the hospital. But less than a decade later, alarms were once again being sounded about the appalling conditions.

In 1946, multiple stories in various Hawaii newspapers pointed out the contrast between the outward beauty of the 16-year-old hospital campus and the dark situation unfolding inside, where patients were living in dismal conditions and lacked the most basic care.

In 1949, a retired doctor and former faculty member from the University of Hawaii wrote in the Hawaii Tribune-Herald of a series of improvements happening at the hospital, including collaboration with the university and a treatment approach where psychiatrists, psychologists and neurologists worked in “complete harmony.” But Hawaii spent only $3 a day treating people at the hospital — a third of what was budgeted to treat patients with tuberculosis at the time — despite the fact that mental illness was the No. 1 health problem in America and in Hawaii, the doctor wrote.

In 1960, when a reporter for the Honolulu Advertiser spent a week at the hospital with “a pass key for every locked door,” he found a situation by turns terrifying, depressing, infuriating and inspiring.

“In a few years, Kaneohe — the very name is still a stigma — has been transformed from a snakepit into an institution desperately trying to practice good psychiatry despite its limited staff,” the reporter wrote.

The hospital had a large number of applicants for its resident internship and pay for nurses was excellent. But there still wasn’t enough money or facilities to do the job needed.

“The state’s only mental hospital at Kaneohe is still hobbling along with inadequate staff and insufficient facilities. Even its name is outmoded,” the paper wrote. “Legally it’s still the Territorial Hospital although Hawaii became a state last year. A new name is expected to be chosen soon.”

By the mid-1960s, the state had developed a program of community mental health centers aimed at alleviating overcrowding at the hospital and treating patients closer to home with the increased availability of drug treatments.

That shift came with a brief reduction in overcrowding, but also growing concerns about what to do with violent patients and how to keep the public safe as the hospital transitioned to a mostly open institution where people could come and go outside as they pleased. In 1970, the hospital administration was trying to renovate a building to make a security ward for patients that posed a threat to public safety.

Still An ‘Abomination’

While most coverage of the institution was more favorable in the 1970s, the hospital was stripped of its national accreditation in 1975 because of more than six dozen deficiencies, including overcrowded wards, lack of privacy, poor training and improper medical record keeping.

“One State psychiatrist considers the facility to be in such bad shape that he ‘finds it morally and professionally impossible to send patients there,'” the Honolulu Advertiser wrote in 1975.

In 1980, the head of the state Mental Health Division told the Star-Bulletin that problems of but the situation still appeared fairly dire. The state was hiring private nurses on “an emergency basis” after a lawsuit filed by the Hawaii Government Association charged that sending criminal patients to the hospital was creating “conditions that were too dangerous for workers.”

At the time, one state lawmaker called for a closer look at what exactly was causing the ongoing problems. Was it really staffing recruitment or was poor management at play?

“One year from now I don’t want to see the DOH come before this committee and say ‘we’re still having problems’,” Rep. Marshall Ige said.

In 1990, federal investigators called the hospital an “abomination” and the U.S. Justice Department filed suit a year later over federal violations. A decade later, the state was still grappling with how best to address deficiencies and hold up agreements under a federal consent decree.

By the time Civil Beat started covering the issue in 2013, the hospital was still experiencing issues with overcrowding and safety. In 2014, hospital staff were being assaulted about once every three days and state senators were questioning why the hospital was still struggling after spending 15 years satisfying a federal legal agreement that “was supposed to have brought Hawaii’s state-run mental health system into the 21st century.”

In 2023, when a nurse was fatally stabbed, the hospital was experiencing so much overcrowding that patients were sleeping in conference rooms.

And the same questions posed in 1887 and 1946 and 1970 and 2014 are being asked again.

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