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Health insurance and state-supported medical services typically fall short of ensuring the long-term care of frail elderly and other disabled persons, who may need not only continuous medical assistance but also help with such daily activities as dressing, bathing, preparation of meals and many other tasks. In the U.S., it is estimated that informal, unpaid family care constitutes about 80 percent of all caregiving. While multigenerational households are typical in providing care in the developing world, even this pattern is beginning to decrease. Under modem urban conditions, where both men and women are employed, where family size is small and where nuclear families are isolated from extended family networks, caregiving typically falls on a single female spouse or daughter. The absence of supportive health and social services contributes to several important problems: (1) the quality of care may fall short of adequate standards, resulting in instances of neglect and even abuse; (2) the strain of caregiving places caregivers themselves at risk for many health problems; and (3) the heavy burden falling on a single caregiver eventually results in a greater reliance on institutional care than may be necessary. These widely recognized problems are the basis for proposals for publicly supported long-term care insurance which would provide the needed funds to more adequately support both community-based care and institutional care when needed.

The article features a framework for assessing the health needs of Hawaiians. Systematic medical information on the population of Hawaii is available since the early 20th century. A report from the US Office of Technology Assessment in 1987 showed that the overall death rate of Native Hawaiians is 34% higher than for the total US population, with higher rates for diseases of the heart, cancer, cerebrovascular disease, and diabetes mellitus. Thus, epidemiological data provide clear evidence that Native Hawaiians are a high risk population for many serious health problems.