Maui fire survivors are returning to work and finding more stable housing three years after a deadly fire destroyed most of Lahaina town, but researchers worry that mental health struggles and a decline in social support could impact survivors on the yearslong road to recovery. 

The latest findings from the ongoing Maui Wildfire Exposure Study found that recovery from the August 2023 blaze “is underway, but it remains uneven,” as both adults and children who survived the fire show signs of the physical and mental health toll left by one of the worst disasters in the state’s history. 

“Maui’s experiences offer both a warning sign as well as a road map,” Ruben Juarez, co-director of the study, said Monday. “The flames may last for days but recovery is measured in years.”

The study, “a community-based partnership involving UH researchers, local health care providers, grassroots organizations and recovery partners across Maui,” is one of the most comprehensive looks at how Maui fire survivors are faring, with more than 2,500 adults and children surveyed and more than 4,000 health screenings completed. The latest results are based on 1,131 participants who completed at least two study visits.

Researchers found promising signs in the third year of recovery. Employment among returning adults increased from 62% in the first year of the study to 81% in the second year as people return to their old jobs or find new ones. Participants living in temporary housing declined from 41% to 34%, and those who felt secure in their housing increased from 72% to nearly 80%. Health insurance coverage also rose from 85% to 91%.

But food security decreased, going from 50% to 45% of returning adults affected by the fire. High social support declined from 62% to 54%, which the report said suggested “growing recovery fatigue and strain on families and community networks.”

Physical and mental health concerns were common, with nearly one in two adults continuing to report depressive symptoms. About one in four screened had moderate-to-severe anxiety, and nearly one in three reported post-traumatic stress symptoms.

“The health and emotional consequences of a disaster are often less visible and they don’t necessarily follow the same timeline as physical construction,” said Alika Maunakea, co-director of the study and a professor at the John A. Burns School of Medicine.

Three years into the recovery, Lahaina’s physical landscape has visibly shifted from leveled gravel properties to a bustling construction zone with 246 homes and non-residential buildings completed and 315 homes currently under construction, according to the county’s recovery dashboard. 

Juarez noted that post-fire rebuilding on Maui is slower than say, California, where access to workers and supplies is easier than on an island. He said he would have personally hoped to see a faster recovery.

But he said the infusion of a $1.6 billion federal disaster grant and investment in housing aid programs are paying off. Last year, using funding from the Community Development Block Grant, the county launched a series of programs known as Ho‘ōkumu Hou to help people afford to rebuild or buy homes for the first time. 

“Maui County deserves tremendous credit for its leadership on housing and for using CDBG funding to prioritize one of the most urgent drivers of recovery,” Juarez said. “The investment is making a real difference. … But housing cannot stand alone.”

The researchers said the recovery needs four interconnected foundations: housing security, food and income security, access to care and social support. All of these “are health interventions,” said Juarez, who is also the UH Economic Research Organization-Hawai‘i Medical Service Association distinguished professor of health economics. 

“They are not separate from health care,” he said. “They determine whether people can heal, manage illnesses or rebuild their lives. Resiliency is not simply something people possess. It is something communities create by ensuring that families are fed, housed, cared for and connected.”

Even before the fire, these issues existed, Maunakea said. Access to health care has always been limited in West Maui, where the nearest hospital is a 45-minute drive to Wailuku, and retaining health care workers is a challenge. Improved health care infrastructure and early treatment for the symptoms people are already reporting will prove crucial in the recovery, researchers said.

Mental health therapist Christopher Knightsbridge, who has flown to Maui every week for the past two years, said telehealth works great for adults, but not for children, who need “on-the-ground, face-to-face” support. The report found that “many child and youth survivors continue to experience emotional distress, including depression, anxiety, post-traumatic stress and low self-esteem,” and others show early signs of blood pressure and lung health problems. 

Knightsbridge said that researchers want to expand the cohort of children they’re surveying from fewer than 200 now to 1,000 in the future, but they currently don’t have enough funding. With kids, the earlier the treatment, the better, and it will likely take a combination of family support and professional help. 

“In reality, it’s going to start at home,” Knightsbridge said. “Parents need to have these kind of little tough conversations with their kids, reassure them that they’re safe and that they’re loved, and if they are feeling this way, that it’s not like their fault. They’re not crazy. They’re reacting how they should, given the horrors they’ve had to survive through.”

For survivors young and old, simply knowing they are loved and supported is crucial to recovery. The researchers found that levels of social support were connected to survivors’ health. Anxiety affected about 42% of people with low social support, compared to 19% of those with high support, Maunakea said. High depressive symptoms were reported among 25% of those with low social support, compared to 5% of those with strong support. 

And, the numbers are likely “a best case scenario” because there is still a stigma around mental health and people often underreport their symptoms, Knightsbridge said.

“Healing after trauma happens through personal and social supports,” he said. “Families, churches, schools, healthy routines, culture, and for kids, trusted adults. When adult support networks are strained, the foundation for children’s needs becomes less secure. If you are not OK, your kids are not OK.”

Based on stories he’s heard from patients, Knightsbridge added that it makes “a big difference” which temporary housing project people are living in, too. The people he works with are much happier with the state’s housing project, Ka La‘i Ola, which is supposed to last up to five years, than they are with Federal Emergency Management Agency housing, which is set to phase out in 2027 and requires monthly inspections that leave people “constantly living on edge.”

The researchers said their goal for the coming year is to establish a dedicated clinic where fire survivors could receive long-term care that draws from the findings of the research. The focus would be on early detection and prevention of chronic conditions through health screenings, diagnoses and intervention support, and personal strategies to help individuals battle their individual risk factors. 

“The idea is to be more vigilant with our health and identify these factors that we know that might emerge as a result of being affected by the disaster,” Maunakea said. 

The clinic would be known as Ho‘āla, which means “revitalize” or “awaken” in Hawaiian language and would serve as an acronym for “Health Outreach ‘Āina-Based Life Course Alliance.”

Mayor Richard Bissen said Monday that the report “shows that our recovery is moving in the right direction.”

“More families are returning to work, gaining health insurance, and finding greater housing stability,” Bissen said in a statement. “Those are encouraging signs that, together with our community and partners, we’re making meaningful progress. At the same time, the report reminds us there is still important work to do to ensure every family has the support they need to fully recover.”

Housing has been the county’s top priority because it’s crucial in reducing the cost of living and giving families stability, Bissen said. The county launched an expedited building permit system in cooperation with the company 4LEAF and set has aside about $900 million of the $1.6 billion federal grant for housing programs that include aid for rebuilding residents and first-time homebuyers and the rebuilding of multifamily apartment projects that burned in the fire. 

Funding is also going toward infrastructure and public facilities, public services, economic revitalizations and disaster mitigation.

“We’re also working alongside the state, healthcare providers, and community organizations to strengthen access to essential services, including expanded behavioral health resources through Aloha House and the Lahaina Certified Community Behavioral Health Clinic, as well as food assistance, case management, and other critical support,” Bissen added. “Recovery is strongest when families have not only a roof over their heads, but the resources they need to heal and thrive.”