Health Transitions in Arctic Populations.

Hertzman, Clyde

Health Transitions in Arctic Populations

Edited by T. KUE YOUNG AND PETER BJEREGAARD. Toronto: University of Toronto Press, 2008. Pp. xxi, 485, bibliographical references.

The co-editors of this book, Professors Young and Bjeregaard, are respectively affiliated with the University of Toronto and the University of Southern Denmark. Under their direction, a group of twenty-three scholars representing all the Arctic countries have produced a carefully reasoned addition to a growing body of work in population health. Population health illuminates human development by focusing on systematic differences in health status among clearly defined populations and working backwards to understand their source.

The aims of this tightly edited collection of essays are to summarize the state of existing knowledge on human health in the Arctic (that is, Alaska, Yukon, Northwest Territories, Nunavut, Greenland, northern Scandinavia and Arctic Russia), stimulate further research, and provide relevant information to policy-makers and health-care providers. These aims are inherently ambiguous, since human health in the Arctic is not equivalent to human health among the indigenous peoples of the Arctic. The problem is that ninety-five per cent of the ten million inhabitants of the Arctic are non-indigenous. In general, the health status of each of the non-indigenous populations of the Arctic is similar to their home country, which in every case is at a different stage of evolution from the health status of its respective indigenous populations. Without ethnic disaggregation, it is hard to make inferences about indigenous health, which is really the topic of interest. This is a challenge throughout the book, since most of the available long-term trend data on the determinants of health, life expectancy, and disease-specific morbidity and mortality were never collected according to ethnicity. In the case of Russia, this problem is compounded by an extremely large number of different indigenous identities, overlapping traditional territories, and blurred distinctions between indigenous populations, on the one hand, and northward/eastward extensions of non-indigenous populations, on the other.

The introductory chapters provide a very useful overview of the role of the Ice Age and long-term climate change in the evolution and differentiation of the Arctic peoples. Studies in the DNA of the indigenous Arctic peoples are cited, showing that the peoples of Alaska-Canada-Greenland are part of a common migration and closely related genetically. But these groups are widely separated from the Northern Scandinavian and most of the Russian populations. Indeed, the genetic distance between the Scandinavian Sami and the New World Inuit is as large as that between the European and the Oriental.

Notwithstanding the data limitations, the book makes a strong case that, throughout the Arctic, indigenous physical health status has improved dramatically from the 1950s to the 1990s. The life expectancy difference between indigenous Alaskans and the American population dropped from twenty-two years in the 1950s to seven years in the 1990s, and infant mortality almost caught up with the American average. In northern Canada, a life expectancy difference of approximately thirty-five years in 1946 was down to approximately ten years by the mid-1990s, during which time in digenous life expectancy more than doubled. Even in Russia, by 1989, indigenous life expectancy was within ten years of the overall Russian average. But the biggest success story is among the Sami of northern Scandinavia. By the 1990s, life expectancies for Swedish Sami men (seventy-five years) and Sami women (eighty years) were the same as for Swedish non-Sami.

By the 1990s, injury mortality and infant mortality were still elevated for indigenous people in Greenland, Alaska, and northern Canada, but not in northern Scandinavia. Elevations of cancer incidence were primarily confined to indigenous people living a non-traditional lifestyle in Alaska, Canada and Greenland but among the Scandinavian Sami, overall cancer incidence rates were lower than in Scandinavia as a whole. In contrast, Russian Sami males had elevated lung cancer rates, and both males and females had elevated stomach cancer rates. The authors reach this defensible and important conclusion: "Basically, three distinct patterns emerge: that of the Sami, who, in regard to health, are more or less indistinguishable from their non-Sami neighbours; that of the Inuit in North America and Greenland as well as the Dene in Canada and Alaska, who differ from the non-indigenous majority populations; and that of the ethnic minorities in Arctic Russia, who carry a severe disease burden due to poverty and serious economic dislocation ... " (p. 405).

One of the most useful features of this book is its commitment to a "determinants of health" perspective. Following the classic writings of Thomas McKeown, the authors do not assume that the health status of the indigenous peoples of the Arctic is primarily determined by the quality of health-care services but instead search for determinants of health throughout society. They make a brave attempt with respect to environment and living conditions, using available data to demonstrate the unambiguously positive contribution of improved general living conditions since the 1950s--housing, sanitation, sewerage, water quality, improved communication systems, reduced episodes of starvation--to life expectancy gains. In terms of negative contributions, they speculate about the role of income inequality, ethnic discrimination, adverse working conditions, dysfunctional communities, living at the end of a northern food chain that accumulates toxins, and threats of new infectious disease and forced lifestyle changes from global warming. Where data on current living conditions are disaggregated according to ethnicity, the indigenous people often come out on the bottom. For example, a multi-factorial community index of well-being scores higher in predominantly non-aboriginal communities in northern Canada than in predominantly Inuit or Dene communities. In Russia, in 1999, indigenous incomes were approximately fifteen per cent of the non-indigenous in the Arctic region. In Alaska, indigenous populations had lower educational attainment, employment levels and income, but, in northern Scandinavia, education, employment, and income levels of indigenous people are, in general, not markedly different from that of the rest of the population. Moreover, indigenous children tend to be born to younger mothers in Alaska, Greenland and northern Canada but not in northern Scandinavia.

With respect to other determinants of health, the book explores smoking, alcohol and substance use. At the beginning of the 21st century Alaskan indigenous people were twice as likely to be current smokers (forty-four per cent) as the non-indigenous population; Canadian Inuit three-fold more likely (fifty-eight per cent); and in both Alaska and northern Canada indigenous adolescents seem to be taking up smoking at three times the rate of their non-indigenous peers. Once again, a Scandinavian Sami advantage is seen, with no evidence of excess smoking. The authors attribute this to less social/economic disadvantage, less passive smoke exposure, fewer smokers from previous generations as role models, lower school drop-out rates, and no cultural tradition of tobacco use. This is in contrast to young Russian Sami in the Kola peninsula, who are heavy users of alcohol and cigarettes. One adverse behaviour appears to have affected the Scandinavian Sami: gas-sniffing among adolescents. But the only data are from the Norwegian territory. No data are presented for Sami in Sweden or Finland. On the basis of geographic location rather than ethnicity, the prevalence of gas-sniffing is estimated at twenty per cent of adolescents in northern Canada and Greenland and twelve per cent of adolescents in Norway.

Nutrition and physical activity, as well as cold exposure, are dealt with in largely theoretical terms since there are little useful data on either that is specific to indigenous populations. Finally, genetic susceptibility is handled in an admirably prudent way. The authors point out that there may be both genetic vulnerability and protective factors and do not claim a big role for genetic susceptibility in the health status of indigenous populations to date.

Despite the thoroughness with which they review the determinants of health, this perspective is ignored when it comes to the analysis of specific disease trends. Most important here is tuberculosis. The incidence of tuberculosis peaked in the 1950s in indigenous Greenland, Alaska and northern Canada, then dropped precipitously by the 1980s (although it is still above the non-indigenous rate). Control of tuberculosis mortality is one of the principal drivers of life expectancy gains throughout the Arctic.

Notwithstanding strong evidence of concurrent improvements in living conditions, which were the primary cause of tuberculosis decline in the Old World during the nineteenth century, the relevant chapter focuses exclusively on the contribution of clinical prevention and intervention--despite the questionable efficacy of the anti-TB vaccine used at the time. Exclusive focus on clinical intervention is more justified in relation to control of hepatitis B. Here, there was a precipitous decline in the 1980s in Alaska with use of an effective vaccine.

The most important conclusion of the book is the following: "[T]he impacts of social change have by and large been positive on physical health and health services have improved dramatically; but negative on mental health" (p. 407). This conclusion, in turn, is validated by one of the most important population health observations of modern times. That is, the historically low suicide rates among Alaskan natives more than doubled during the 1960s and 1970s and have remained elevated ever since; in Greenland, a similar epidemic curve "took off" approximately one decade later and rose nearly three times further than in Alaska by the mid-1980s and declined only slightly since (concurrently, a much more modest rise occurred among the Norwegian Sami); and, in northern Canada, the epidemic rise began approximately one decade after Greenland, surpassing Greenland by the mid-1990s and continued to rise through the end of the 20th century. The dramatic rise in indigenous suicide during a period of improving physical health status and the remarkable temporal spacing of the epidemic curves in Alaska, Greenland and northern Canada frame a world historical question of "why?"

Elsewhere in the volume, the difficult and elusive issue of acculturation stress is identified, and three authors--Sven Hessler, Siv Kvermo and Andrew Kozlow--make a very intriguing claim: "On a psychosocial level, changes in attitudes, culture, and identity may result in acculturative stress when original political, linguistic, religious, and social institutions become altered or new ones take their place. As health status linked to acculturation experiences in a culturally pluralistic society is expected to be better than in a culturally monistic one, which often pursues an assimilationist ideology, the outcome of the acculturation process is obviously dependent on the ideology of the dominant culture..." (p. 155). In other words, have the very changes in living conditions that have led to dramatic improvements in life expectancy been simultaneously destructive of mental health? Methods of "modernization" have varied from forced collectivization in inter-war Russia to official multiculturalism in post-war Canada. Non-indigenous population incursion has varied from extensive (Alaska) to modest (Greenland). Yet, neither of these factors matches the temporal patterns of suicide very well. All that can be said for sure is that "whatever is going on, it is better for the Scandinavian Sami than for everyone else."

The book concludes with a call for an ongoing research effort in the health-care sector and the determinants of health. Yet, it is doubtful that the health-care sector will be the source of solutions to the suicide epidemic. As seems to happen so often when considering questions of health and human development, we are left with the question: why are the outcomes so much better in Scandinavia and why aren't we doing what they do?

Clyde Hertzman is professor, School of Population and Public Health, University of British Columbia.