Doctors Who Make a Difference in Hawai‘i
Meet five Hawai‘i physicians that are doing important work in our local communities.
Doctors have a noble calling. Whether they’re diagnosing a child’s allergy, setting a broken bone or excising a life-threatening brain tumor, they spend days and nights helping others. While it’s hard to single out only a few, we wanted to spotlight Hawai‘i physicians doing important work in our local communities. We found fascinating and heartwarming stories including doctors who are helping the blind see, trailblazing a new cancer drug made from noni, finding a neighborhood-level approach to fighting diabetes and more.
The first surgeon to do a face transplant has brought his transformative skills to Hawai‘i.
By Don Wallace
Dr. Daniel Alam won fame leading the first face transplant operation in the United States.
Photos: Olivier Koning
“I THINK IT WAS THE PINK FLOODING BACK IN,” says Dr. Daniel Alam when asked to describe the peak of his career to date.
Seven years ago, Alam orchestrated a team of 32 specialists for the first facial transplant in the United States. And, as lead micro-vascular surgeon, he personally removed the dying donor’s face, then carried it into the next room to sew it onto the recipient.
Alam had been up for 24 hours, in the operating suites for 16; he had to sew together blood vessels only two millimeters in diameter using sutures much finer than human hair. “If these vessels fail, this face will not survive,” he remembers thinking.
Alam stood frozen. “A moment before, I was holding a dead human face in my hands, a face fresh off the donor who was still technically alive, heart still pumping. Now I’d totally lost my confidence. The face was gray, inert; it couldn’t possibly come back to life.”
At that moment, he recalled what the patient who was to receive this face had said to him before she went under the anesthetic. Connie Culp had lost her face to a shotgun blast and had spent years as a recluse due to the frightened reactions of people she encountered. She couldn’t go to the store without a child shrieking and calling her a monster.
“If you weren’t the right person to be doing this, I wouldn’t be doing it,” she told him. “I know you will take good care of me.’”
And so Alam went to work. An hour later, primary vessels were done. “The moment of truth for the patient had arrived. I said a prayer to myself and released the vessel clamps,” he later wrote in his journal, which he shared with HONOLULU.
“As our patient’s blood began to flow into her new face, I witnessed a miraculous transformation. Life streamed into the ghostly façade. Within seconds, her lips became red, her skin became pink. I felt like our patient embraced this new face as her own.”
The success of the Cleveland Clinic transplant, and one Alam assisted on a few months later on a woman who had been mauled by a chimpanzee, vaulted him to the pinnacle of his profession. But the moment of doubt that preceded the triumph was equally important, Alam insists. It helped him make up his mind about where to go next: Hawai‘i.
“My personality has always led me to seek out the undiscovered country,” he says, “the field of knowledge where I can make my contribution.” He could go almost anywhere and write his own ticket. But, in Alam’s case, he found himself drawn to Hawai‘i because, “I discovered the acute need that existed in the Islands and throughout Micronesia for complex reconstructive surgery.”
INSTEAD OF GOING IN THE DIRECTION of more difficult and spectacular surgeries and transplants, he wanted to go where he was most needed by the most people. That meant pairing up with reconstructive surgeon Christopher Klem at the newly formed Head and Neck Institute of The Queen’s Medical Center and serving as clinical professor of surgery at the John A. Burns School of Medicine. “I’m backfilling a void that was not met here—people either were going to the Mainland or, if they lacked resources, would be offered suboptimal treatments.”
To this day, he says, the revelation during the face transplant surgery centers him. “If I’m taking a little mole off your face, then that’s the most important thing. I owe it to you to repay your faith in me in the best way possible.”
Alam describes himself as self-critical and process-minded, to the point that, years ago, he started videotaping himself doing microsurgery in order to critique his own work. His teaching at the medical school allows him to pass along a core truth.
That’s what happened when he finished the 42 sutures needed to sew the face together, he says. “I saw that the result was still nowhere near as good as what came from the original factory.”
Living in Honolulu with his wife and two children suits Alam’s generous nature. “The beautiful thing about Hawai‘i is how people think here, the ‘ohana concept, it’s remarkable,” he says. “I’ve been at big institutions on the Mainland. There’s no talk story; it’s staccato, a much more structured relationship. Here, no matter what your social and financial status, the roles your aunties and uncles play allow complex things to happen. They don’t even have to be related by blood.”
And this, he says, rewards him as a surgeon. “Like when we had a complex reconstruction on this lady and there were 17 grandchildren in her post-operative waiting room. Those kinds of moments are really wonderful.”
Seeing the Light
Ending blindness via an implanted computer chip and video-cam eyeglasses.
By Don Wallace
Dr. Gregg Kokame performed the first bionic-eye implant in the Pacific Rim.
Photos: Olivier Koning
A HONOLULU WOMAN IN HER 60s, who lost her hearing as a child and later, as a grandmother, her sight, is quietly making Hawai‘i medical history with a bionic eye and high-tech eyeglasses.
It started when a hereditary genetic condition called retinitis pigmentosa began narrowing her vision. Then, two years ago, her world went black—robbing her not just of her sight but her ability to communicate easily with family and friends.
Enter ophthalmologist Dr. Gregg Kokame, director of Retina Consultants of Hawai‘i, who has been studying the disease for decades. He saw potential for a device he’d been watching develop, a type of bionic eye.
Officially, it’s the ARGUS II Retinal Prosthesis, which consists of a pair of video-camera eyeglasses that send images to a video-processing unit worn on a belt, which transmits wireless signals to a chip—the “eye”—that has been implanted on top of the retina.
It was 20 years in development by Dr. Mark Humayun of the USC Eye Institute, and Kokame had been following its path since 2008, when he’d invited Humayun to Hawai‘i to speak about his work.
Kokame, 58, was born in New Orleans, the son of a surgeon from Kaua‘i. His dad moved the family home to Hawai‘i when Gregg was 10 years old. After schooling at ‘Iolani, Pomona College and UCLA medical school, Kokame got inspired by the science of the eye.
A retinal chip relays signals from video-glasses to the optic nerve.
Once FDA approval was granted in 2013 for the retinal prosthesis, Kokame started planning. “The first thing is finding a patient,” he says. “They have to have had vision so they know how to interpret sight. You want to make sure they’re motivated, that they want to go through training before and retraining after.” He had a patient in mind, one who, when informed that she would be the first person in Hawai‘i and Asia to receive the bionic eye, showed no hesitation. “She is a sweet old lady who was able to adjust to losing her sight. But she was very interested in being part of the process, and her family also was very involved.”
A YEAR BEFORE SURGERY, Kokame flew out to meet with the company founded to produce the device, Second Sight, in California. Then, Kokame explains, “We developed a research center at Pali Momi, worked to create a surgical suite at the Eye Surgery Center and started training people to perform the surgery.”
Humayun himself flew out to observe the four-hour surgery, which seemed successful. But they wouldn’t know for sure until two to three weeks had passed and the eye had healed. “There is no ability in the (retinitis-pigmentosa-afflicted) retina to receive light,” says Kokame. “We’ve replaced the input of light with the signals of a video camera, sent wirelessly. The glasses have a transmitting device, and the eye has a receiving device. That’s the amazing thing.”
Only when Kokame threw the switch would there be light.
Kokame recalls the scene when the new eye went on: “The room was filled with about 20 people, including family, medical residents, people from the research group.” A bioengineer began by fitting the eyeglasses to the patient’s face and plugging in the video processor. The next move—testing each of the 60 microelectrodes inside up to 80 times in sequence to ensure they were all responding to the retina—required the camera to be switched on. From that point, says Kokame, “The patient would receive impulses and the patient would gradually start to perceive things.”
The switch flipped, video signals stimulated the retina and the array triggered electrical impulses to the brain via the optic nerve. “You could see it in her face,” Kokame recalls. “In the smile on her face. Once the device was turned on, when she initially saw the light, that was one of the most touching moments.”
Next Kokame stood across the room and pointed a flashlight in her face. “‘Walk toward the light,’ I said. And she was able to actually walk all the way toward me, toward the light.”
The room broke into applause, as well as tears.
While ARGUS II is inarguably a breakthrough, the early results are modest. The recipient doesn’t see color, the resolution is extremely fuzzy. “You see light intensity versus dark intensity,” says Kokame. “But, with the implant in place, all the processing technology can be upgraded over time without surgery. And the technology is going to evolve.” Continuing research is expected to enhance the experience so that patients will eventually see detail and color.
The technology behind the ARGUS II shows promise for the relief of symptoms of other eye diseases, including macular degeneration, which affects 11 million Americans.
As for Hawai‘i’s first patient, the dramatic moment of seeing her first light in two years had barely passed when she opened her purse and began handing out hand-crocheted gifts she’d made without sight. She has since, Kokame reports, gone back with new enthusiasm to one of her favorite pastimes, making lei.
“Before, she would just make lei and not understand what was dark lei and what was light lei. Now she can differentiate between the flowers.”
The Gene Switch
From diabetes in adults to autism in children, a trailblazing researcher reshapes the way we think about our genes and the environment.
By Ikaika Ramones
Dr. Alika Maunakea looks at genes and diet as well as ancestral knowledge to solve modern problems.
GROWING UP ON A NĀNĀKULI HOMESTEAD, Dr. Alika Maunakea saw firsthand how Native Hawaiians were disproportionately devastated by diseases and also shortchanged on medical services. And he witnessed how his great-grandmother Katherine Maunakea—a preeminent kahuna lā‘au lapa‘au, or Hawaiian medicine practitioner—filled those gaps by treating members of the community. “That’s probably why I fell into studying the role of the environment in health. In lā‘au lapa‘au practices, that’s a fundamental philosophy. ”
After medical school at the University of California San Francisco and post-doctoral research at the National Institutes of Health, Maunakea returned to Hawai‘i as an assistant professor and researcher at the University of Hawai‘i School of Medicine’s Department of Native Hawaiian Health. “It’s my home, and I’m kanaka maoli. My motivation to become a scientist was to serve my community. My great-grandmother’s role in the community was that; I saw there was a need to address the health problems I saw as commonplace where we lived.”
Today, Maunakea leads pioneering new research to improve diagnoses and treatment. But, he says, “Understanding the biological rationale for a disease is only one way of trying to reduce these health disparities. It’s also not enough; you need people to incorporate the cultural knowledge and the modern technology to implement them in a way that makes sense for our communities here.”
As an epigeneticist, he researches how environmental factors influence particular genes on the molecular level to turn on or off and thus lead to disease. Rather than waiting for symptoms to show up, his projects look for the root causes of a disease.
And that’s how one community-based research project on diabetes began at a Papakōlea homestead. While traditional academia would study the community like a sample in a petri dish, this project invited the community’s input at every step. “We actually talked to them about concerns first; we didn’t make any assumptions. We asked them what they thought they needed.” The answer: help with diabetes.
Ailments like diabetes and cardiovascular disease disproportionately target certain populations, including Native Hawaiians. But, Maunakea says, “It’s not really genetic differences that underlie these health disparities in different populations. There are certain things—stress, toxicants, pollutants, nutrition and even cultural trauma—that can contribute to these health disparities. Once we identify those, then we can actually inform policy.”
After a 12-week program of lifestyle changes designed by the community (including diet and exercise programs tailored to the community and culture), researchers measured not only participants’ weight and glycemic control, but also looked at whether the molecules around the genes were changing. While most, but not all, patients showed improvements in their symptoms, “We saw changes across the board in all participants; their epigenetic patterns reflected a normal, nondiabetic condition in those cells playing a role in inflammation. This suggests that the lifestyle change really is impacting individuals at a molecular level.” After another 12 weeks, those who at first only exhibited epigenetic changes also began to show clinical improvements such as glycemic control. “We found that the change in molecular epigenetic profiles preceded the clinical outcomes,” so while the individuals may have technically been diabetic, the cells Maunakea studied were already beginning to normalize.
BREAKING FROM THE NORMS of traditional studies, Maunakea went to the community with the results. “They actually said the epigenetic information had more of an impact on them personally and their families than their clinical data like weight. The results suggested that all individuals are becoming nondiabetic, at least on the molecular level, which gave them hope and motivated them to continue to adhere to the lifestyle intervention and talk to their families about it too.” The community even wanted Maunakea to share the information.
Studying the molecular functions of cells leading to a disease can mean both earlier detection and also more targeted therapies. “It might lead to new drugs, alternative medicine or nutrition that might help us treat individuals specifically,” based not on their genes, but on the connection between the environment and their genes.
In another trial, at Shriners Hospital for Children in Honolulu, Maunakea also looks at the therapeutic effects of a ketogenic diet, one that is low in carbohydrates and high in fat, on children with autism. “With autism, there are few interventions that work and are cost-effective in modifying some of the behavioral and social issues that patients have. But a diet is simple,” he says.
“In diabetes for adults or autism for children, you can see that we’re trying to understand the ideologies of the diseases at the molecular and epigenetic level, and taking that information to figure out how we can improve therapies or predict individuals with these diseases at an earlier state. We’re really trying to shift the focus of modern healthcare from treatment to prevention.” And Maunakea believes that knowing what’s going on at the molecular level can help prevent disease.
Maunakea’s research and respect for traditional knowledge continue his kūpuna’s traditions of helping the community. “A lot of the problems we face today with health, sustainability, the environment, all of that we can solve using our ancestral knowledge. Applying that not only to restore our culture and our practices, but really to solve those modern problems, that’s exactly why I’m in this lab and back in Hawai‘i.”
Thanks to a local doctor, diagnosing sleep apnea in Hawai‘i is easier than ever.
By Katrina Valcourt
Dr. Shanon Makekau brought home testing to Hawai‘i, expanding access to sleep testing beyond overnight lab stays.
Photos: Olivier Koning
A GOOD NIGHT’S SLEEP CAN BE HARD TO COME BY. In fact, not sleeping well can be a real health problem: Sleep apnea, a condition in which you stop breathing in your sleep, affects more than 18 million people nationwide. Certain populations are more prone to the disorder than others and, in Hawai‘i, our diverse ethnicities and climbing obesity rates make the state a hotbed for the condition.
“Of all the different specialties in medicine, sleep medicine is probably one of the newest, if not the newest, fields,” says Dr. Shanon Makekau, director of the Sleep Lab in Kaiser Permanente Moanalua’s Department of Pulmonology. It’s the only lab in the state to test for apnea in patients’ own homes, rather than having them come in and spend the night hooked up to wires and monitors and videotaped as they sleep.
With home testing, patients strap to their wrists a watchlike device connected to a finger sensor that measures blood pressure, heart rate, oxygen levels and breathing with every heartbeat. The sensor sends data back to the watch, which stores it until the next morning, when patients return the device to the lab to download the results. Over the past few years, this little device has consistently proven very capable of diagnosing sleep apnea, and it only takes about five minutes to download the data.
A Maui native (and granddaughter of the founders of the Tasty Crust restaurant), Makekau became medical director of the lab eight years ago at age 32. She first saw home testing on the Mainland, where she did her training for sleep medicine, and decided to bring it back home to Hawai‘i because, at Kaiser, there are only six beds dedicated to the Sleep Lab.
“That’s six sleep studies per night,” she recalls thinking, “and a population of 200,000 patients, many of whom have undiagnosed sleep apnea. How are we going to close that gap?” The lab began home testing six and a half years ago, and Makekau expects that within three years 50 percent of Kaiser’s sleep studies will be done in the home. “With home testing, we’re able to expand access to sleep testing in a way that was unheard of before.”
This is especially important now, when we know that, in addition to patients who are obese, Pacific Islanders, Asian-Americans, Hispanics and African-Americans are more prone to sleep apnea. Hawai‘i’s cultural mix makes it the ideal place to pioneer innovative studies and further knowledge about this disorder, which is linked to other health issues. “The impact of sleep disorders is more far-reaching than almost anything I can imagine in medicine, and the ability to make a change and impact on all these different medical issues is tremendous,” Makekau says. And, as the mother of a 1- and 3-year-old who wake her up at dawn, she knows the importance of a good night’s sleep.
THE OTHER MAJOR THING Makekau wanted to change when she came to the Sleep Lab was patient education. “We can’t rely on telling patients what to do and expecting them to do it. That doesn’t really work. We have to be partners,” she says. She started holding forums a few times a month, in which people who were being tested for sleep disorders could learn more and find out what kinds of treatment to expect after diagnosis. “Nationwide, people who are diagnosed with sleep apnea tend to use the treatment only about 40 percent of the time,” she says, probably because the CPAP (continuous positive airway pressure) machine, which provides constant air pressure into patients’ lungs, is so intrusive. Since starting the forums, Makekau has seen an increase in patients sticking to their treatments and following through. “That partnership based on education is what makes our region in Hawai‘i very special. …
“I am proud to be able to give back and participate in the health and wellness of the families and communities in which I was raised,” says Makekau. “I think that a great accomplishment for any physician is to be able to have roots and wings, and I am so fortunate to have both.”
A Hawai‘i doctor is poised for success with two key clinical trials, one based on a familiar Island fruit.
By Don Wallace
Dr. Charles Rosser’s clincical trials offer hope in prostate and bladder treatment.
A FOLK MEDICINE FAMILIAR to Native Hawaiians, noni could make a difference in the lives of the 6,900 new patients diagnosed with prostate cancer each year in Hawai‘i, if Dr. Charles Rosser succeeds in his mission.
A new approach is badly needed for prostate cancer, the most common cancer in men, with about 220,000 new cases nationally each year; in Hawai‘i it’s the second-most-common male cancer, after skin cancers. Treatment of prostate cancer in its early stages has been virtually paralyzed since 2012, when the U.S. Preventive Services Task Force found that taking a PSA blood test created more harm than good, due to a 13 percent false-positive rate.
“Treatment is very controversial,” says Rosser, 46, the father of twin 2-year-olds and a principal investigator of clinical trials at the University of Hawai‘i Cancer Center. “Yet a lot of newly diagnosed patients don’t want to sit around and do nothing,” while waiting to see if the cancer will advance to Stage 2. “We went to studies we’d done here at the UH medical school and were able to demonstrate” the promise of noni as an anti-inflammatory drug that will slow down and even halt the progress of cancerous cells in the prostate. One obstacle that could’ve derailed a clinical trial, a lack of patients willing to try noni, was neatly solved by basing the test at the UH Cancer Center.
“This one is going to be all local,” says Rosser. “On the Mainland, the doctors would be less likely to embrace it. We’re going to do a major push here in Hawai‘i to let people know this study is available in Hawai‘i.”
ROSSER’S PROCESS of “searching journals, reading the latest things around, going to international meetings, keeping the feelers out to the pharmaceutical companies,” is probably not what comes to mind when we think of medical research. But he’s on quite a hot streak. Even as he was homing in on noni, he struck clinical-trial gold with the discovery of a possible breakthrough test for bladder cancer—like prostate cancer, frustratingly hard to treat in early stages, but much deadlier. The five-year survival rate for men newly diagnosed with prostate cancer is 99 percent; for bladder cancer, “every year, 200 patients here in Hawai‘i will be diagnosed with it,” says Rosser. “About one-sixth (33) will die.”
Rosser says, “We knew there hadn’t been any bladder cancer drugs approved by the FDA in 15 years,” but a study of Interleukin-15 caught his eye. When they got in touch with the company, “They weren’t interested in cancer of the bladder, but in kidney and melanoma.” Once Rosser and his lab completed experiments combining L-15 with a conventional cancer drug on mice, however, the manufacturer “did an about-face—now much of what they’re doing is for bladder cancer.” A Phase I clinical trial started last summer was completed this spring with clearly promising results: “People realize this is such a groundbreaking drug. There was only one cancer center, us, when we started a year ago. Now we are leading the nation as it goes into Phase II. There are going to be up to 10 hospitals across the nation following our plan.” Rosser’s lab will coordinate.
While drug approvals are still a few years away, awaiting a third clinical trial and an FDA evaluation, it looks like Hawai‘i may lead the way to a double breakthrough in cancer treatment.