10
Chapter 3
Health Status of the Arctic Residents
ญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญญ
James Berner
Summary
current population health indicators and selects indica-
tors of maternal and child health morbidity and mortal-
In recent years there has been significant improvement
ity for the populations of Arctic countries. A section
in the general health of the indigenous peoples of the
highlighting the differences in health status of Arctic in-
North. However, significant health disparities remain
digenous residents is included to focus attention on the
between indigenous residents and majority populations.
most vulnerable Arctic populations.
For instance, shorter life expectancy and mortality re-
Among Arctic populations, advances in acute care, in
lated to suicide and injuries are still more frequent.
public health practices, such as childhood immuniza-
Lifestyle related conditions, such as obesity, diabetes
tion, prenatal care, safe water supplies and sewage dis-
mellitus, and circulatory disease have become more fre-
posal, family planning, antibiotics, and in improved
quent. Since the age structure in the indigenous popula-
transportation and communication have considerably
tions includes a large number of young persons, preven-
changed the likelihood of survival to an older age, and
tive measures are very important in reducing the burden
have improved basic health for Arctic children and
of these diseases.
adults. As an example, by the mid-1990s, the infant
mortality rate in Alaska Native infants was approaching
that for the United States as a whole (Figure 3ท1).
3.1. Introduction
Deaths per 1000 live births
The health status of Arctic residents, as it is for all peo-
140
ple, is the result of the complex interaction between
environment, genetics, nutrition, psychological factors,
120
Alaska, Natives
and economic conditions.
100
The Arctic is not a homogeneous region, and Arctic
80
residents, while fewer in number than in temperate re-
gions, are extremely diverse, with very few features in com-
60
mon except latitude of residence and hours of daylight.
40
United States
Some Arctic regions are economically depressed, such as
20
much of Arctic Russia, while most others do provide at
least adequate economic opportunities and support for res-
0 1945 '50 '55 '60 '65 '70 '75 '80 '85 '90 1995
idents. Some regions do not keep ethnic-specific health
data, while others separate health data by ethnic group.
Figure 3ท1. Infant (under 1 year) mortality rates in the United States
Some countries combine the sparse Arctic population
general population and in Alaska Natives, 1945 to 1995. Source:
Alaska Area Profile FY2000.
data with that of the remainder of the country so that
regional differences in health status are not discernible.
This improvement in the infant mortality rate is re-
In some regions, data are difficult or impossible to obtain.
lated to safe water supply, sanitation improvements, and
Despite these limitations, examination of available
on-site village primary health care providers, which were
health status information can provide useful insights
all steadily improved in the period 1960 to 1970. These,
into major public health problems, and can suggest
along with improvements in transportation, infant im-
where, over time, useful information on the possible
munizations, and medical care have lowered the infant
health impact of contaminants might be obtained. As
mortality rate to present levels.
this chapter will show, there are significant differences in
the age structure of the various Arctic populations. In-
3.1.1. Data sources
digenous (or largely aboriginal) populations such as
those found in Alaska, Greenland, and Canada (the
The primary data sources utilized in this section in-
Yukon, the Northwest Territories, Nunavut, and north-
clude NOMESCO (2001), NWT (1999), the World
ern Quebec and Labrador ญ referred to collectively as
Health Organization, the State of Alaska, and other
Arctic Canada) have a larger percentage of younger per-
cited literature.
sons and fewer elderly persons than the non-indigenous
A series of basic health status indicators are utilized,
populations of Iceland, Sweden, Norway, Finland, and
as well as trend data, where available. Data used in this
the Faroe Islands. For this reason, most population data
section for Canadian Arctic residents are labeled `North-
are age-adjusted to compensate for these differences.
west Territories (NWT)'. During the period reflected
Data for Greenland are presumed to represent the domi-
by the data, the Northwest Territories contained vir-
nant (90%) Inuit population.
tually all of Arctic Canada (excluding the Yukon).
This chapter does not include information on the
In 1999, a large part of the Northwest Territories (some
current health care system in each country, nor on access
60%, or one fifth of the Canadian landmass, including
to health care, as these are both outside the scope of
most of the Canadian Arctic islands) became the new
AMAP. Rather, it reviews current population structure,
territory of Nunavut.

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11
Data from sources such as published studies of Arctic
most common ages at which women bear children, and
populations, which usually focus on single conditions or
the number of children each woman bears. The base is
a narrow set of risk factors, are also utilized. Such data
also affected by infant mortality. The middle portion of
are usually representative of a single period of time, and
the pyramid can be decreased by any major source of mor-
are often not directly comparable in all respects with
tality in the early and middle adult years. The narrowing
other populations. Often, however, such data may repre-
of the pyramid for the elderly ages reflects the incidence
sent the only information available.
of chronic disease, access to medical care, and the qual-
ity of medical care. A stable population, reproducing at
3.2. Population demographics
a replacement rate, with no major sources of unusual pre-
mature mortality, would have a population pyramid ta-
3.2.1. Population structure
pering only slightly from its base to the fifth decade, when
The age composition of the residents of Arctic countries
it would more rapidly attenuate to the eighth decade.
varies greatly, as can be seen in Figure 3ท2. Due to their
A population pyramid can effectively predict numbers of
shape, these representations are often referred to as pop-
population in certain age groups, aiding in planning the
ulation pyramids.
infrastructure for the country or area concerned.
A population pyramid is influenced at its base by the
From these figures, for the population of Alaska Na-
number of women in the 15 to 45 year age ranges, the
tives, the Canadian Arctic, and Greenland, the average
Alaska
Canada, NWT
Greenland
Age
Males
Females
Age
Males
Females
Age
Males
Females
80+
80+
80+
75-79
75-79
75-79
70-74
70-74
70-74
65-69
65-69
65-69
60-64
60-64
60-64
55-59
55-59
55-59
50-54
50-54
50-54
45-49
45-49
45-49
40-44
40-44
40-44
35-39
35-39
35-39
30-34
30-34
30-34
25-29
25-29
25-29
20-24
20-24
20-24
15-19
15-19
15-19
10-14
10-14
10-14
5-9
5-9
5-9
0-4
0-4
0-4
6 5 4 3 2 1
0 1 2 3 4 5 6 %
6 5 4 3 2 1
0 1 2 3 4 5 6 %
6 5 4 3 2 1
0 1 2 3 4 5 6 %
Iceland
Faroe Islands
Norway
Age
Males
Females
Age
Males
Females
Age
Males
Females
80+
80+
80+
75-79
75-79
75-79
70-74
70-74
70-74
65-69
65-69
65-69
60-64
60-64
60-64
55-59
55-59
55-59
50-54
50-54
50-54
45-49
45-49
45-49
40-44
40-44
40-44
35-39
35-39
35-39
30-34
30-34
30-34
25-29
25-29
25-29
20-24
20-24
20-24
15-19
15-19
15-19
10-14
10-14
10-14
5-9
5-9
5-9
0-4
0-4
0-4
6 5 4 3 2 1
0 1 2 3 4 5 6 %
6 5 4 3 2 1
0 1 2 3 4 5 6 %
6 5 4 3 2 1
0 1 2 3 4 5 6 %
Sweden
Finland
Russia
Age
Males
Females
Age
Males
Females
Age
Males
Females
80+
80+
80+
75-79
75-79
75-79
70-74
70-74
70-74
65-69
65-69
65-69
60-64
60-64
60-64
55-59
55-59
55-59
50-54
50-54
50-54
45-49
45-49
45-49
40-44
40-44
40-44
35-39
35-39
35-39
30-34
30-34
30-34
25-29
25-29
25-29
20-24
20-24
20-24
15-19
15-19
15-19
10-14
10-14
10-14
5-9
5-9
5-9
0-4
0-4
0-4
6 5 4 3 2 1
0 1 2 3 4 5 6 %
6 5 4 3 2 1
0 1 2 3 4 5 6 %
6 5 4 3 2 1
0 1 2 3 4 5 6 %
Figure 3ท2. Population pyramids for Alaska (1998), Canada (NWT, 1996), and Arctic countries (1999). Source: Alaska Area Profile FY2000
(Alaska); NWT, 1999 (Canada); NOMESCO, 2001 (Faroe Islands, Finland, Greenland, Iceland, Norway, and Sweden).

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12
AMAP Assessment 2002: Human Health in the Arctic
Life expectancy
Females
F
Alaska Natives 1997 Males
Females
F
Canada, NWT 1999 Males
Females
F
Greenland 1991-95 Males
Females
F
Iceland 1998/99 Males
Females
F
Faroe Islands 1996-2000 Males
Females
F
Norway 1999 Males
Figure 3ท3. Life expectancy in the
Females
F
Sweden 1999 Males
1990s of Alaska Natives, residents
of NWT/ Nunavut in Canada, and
Females
F
Finland 1999 Males
general populations of other Arctic
countries. Source: WHO Statistical
Females
F
Russia 1994-96 Males
Database; US IHS, 2000; NWT,
1999; NOMESCO, 2001.
0
10
20
30
40
50
60
70
80
90
Age, years
age is younger, the proportion of children greater, and
such as prenatal use of alcohol and tobacco, breast feed-
the proportion of elderly less than the reference popula-
ing, maternal nutrition, and poverty.
tion statistics for the other countries shown. The popu-
In Greenland, the ratio of male to female live births
lation structure for Russia is unique in this dataset and
has changed from 1.05 (the usual ratio for humans) to
shows a lower proportion of both children and the eld-
1.02 over the past 30 years (Bjerregaard and Young,
erly, the highest average age, and a smaller man to
1998). If this ratio persists it may reflect, among other
woman ratio, this is primarily due to the absence of
influences, prenatal exposure to endocrine disrupting per-
older men, one effect of devastating wars, where several
sistent organic chemical compounds (Bjerregaard and
million young men were killed. The fertility rate and in-
Young, 1998).
fant mortality rate graphs show how these factors influ-
In western Arctic Russia, occupational stress, to-
ence the base of the Russian population pyramid (see
bacco use, and heavy metal exposure have all been asso-
sections 3.3.3. and 3.3.5.).
ciated with adverse pregnancy outcome (see section
8.4.2.) (Odland et al.,1999b).
3.3. Health status indicators
3.3.1. Life expectancy
3.3.3. Fertility rates
In most countries, the largest single contributor to an
Fertility rates are highest in Russia, Arctic Canada
improvement in life expectancy is a decrease in infant
(NWT/Nunavut), Greenland, and Alaska (Natives) be-
mortality. Other factors include population diet, tobacco
tween the ages of 20 and 24, whereas in the other loca-
and alcohol use, lifestyle choices, access to medical care,
tions the peak fertility rates occur in the 25 to 29 year
and socio-economic factors. In Figure 3ท3, the Nordic
age group (Figure 3ท4). A large number of factors affect
countries have a stable life expectancy for women, ex-
fertility, especially socio-economic conditions and access
ceeding 80 years, with that for men about four years
to family planning. One such factor is the increasing
less. The life expectancies for the indigenous Arctic pop-
ulations in other countries are considerably lower for
Live births per 1000 females
men and women alike, one cause being higher infant
200
mortality rates (see section 3.3.5.).
150
3.3.2. Maternal and infant indicators
Many persistent organic pollutants, and certain toxic
metal contaminants, have the ability to act as agonists or
100
antagonists of steroid hormones. Chronic low-level ex-
Alaska Natives
Greenland
posure to these compounds in fetuses, pregnant women,
Canada, NWT
and young infants is being investigated for possible asso-
50
ciation with adverse health effects. Effects under investi-
Russia
Faroe Islands
gation include decreased fertility, an increased likelihood
Iceland
of spontaneous abortion, abnormal intrauterine growth,
Norway
Finland
Sweden
0
and abnormal neurodevelopment in infancy, increased
15-19
20-24
25-29
30-34
35-39
40-44
susceptibility to infection in infancy, and blood pressure
Age, years
elevation in children (see chapters 6 and 9). Regularly
Figure 3ท4. Fertility rates for Alaska Natives (1998ญ1999), residents
gathered health status indicators that reflect maternal
of NWT in Canada (1992ญ1996), and populations of other Arctic
countries (Faroe Islands/Greenland, 1991ญ1995; Iceland/Norway/
and/or infant health do not provide specific data for
Sweden, 1999; Russia, 1994ญ1997); circles indicate peaks.
most of these impacts, and subtle effects may be difficult
Source: WHO Statistical Database; US IHS, 2000; NWT, 1999;
to separate from the impact of confounding factors,
NOMESCO, 2001.

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Chapter 3 ท Health Status of the Arctic Residents
13
Alaska Natives
U.S. All Races
Canada, NWT
Figure 3ท5. Low birth weight rates in
Canada All Races
Arctic countries (general populations:
Greenland
Canada All Races, 1996; Russia, 1994ญ
1997; Sweden / Norway/Iceland/Finland/
Norway
Greenland/Faroe Islands/Denmark, 1998;
Denmark
U.S. All Races, 1995) and some indige-
nous populations (Alaska Natives, 1994ญ
Sweden
1996; Canada NWT/Nunavut 1996).
Finland
Source: US IHS, 2000; Health Canada,
Russia
1999; WHO Statistical Database;
NOMESCO, 2001.
0
1
2
3
4
5
6
7
8
Low birth weight births per 100 live births
proportion of women in the work force, which delays
3.3.5. Infant mortality and morbidity
child bearing and is reflected in the older age of mothers
in the Nordic countries.
Infant mortality is generally subdivided into deaths in
days 0 to 28 of age (neonatal mortality) and deaths in
days 29 to 365 (post-neonatal mortality) (Figure 3ท6).
3.3.4. Low birth weight
Neonatal mortality reflects prenatal care and the
In general, low birth weights (less than 2500 grams) may
availability of intensive perinatal care. The most impor-
reflect shortened duration of pregnancy, poor maternal
tant contributor to this indicator is pre-term delivery;
nutrition, maternal use of alcohol and/or tobacco, hyper-
before 37 weeks gestation.
tensive complications of pregnancy, and prenatal mater-
Post-neonatal deaths are influenced by the rate of
nal/infant infection. There is a possibility that a low birth
Sudden Infant Death Syndrome (SIDS) in a population,
weight predisposes to certain chronic diseases in older age,
as well as by infection, congenital anomalies in fetal
like high blood pressure, cardiovascular disease, and asth-
development, and socio-economic conditions such as
ma (Forsdahl, 1977; Barker, 1990). It is thus desirable to
poverty.
reduce the proportion of babies with a low birth weight.
In Greenland, Arctic Canada (NWT/Nunavut), and
Methods to bring this about include improving the socio-
Alaska, infant mortality among the indigenous popula-
economic conditions for the fertile population together
tions, particularly post-neonatal mortality, is higher than
with early access to high quality prenatal care. In the Na-
for the other Arctic countries shown. In Alaska Natives,
ryan-Mar region of Arctic Russia, prenatal exposure to
the excess post-neonatal mortality above the U.S. All
polychlorinated biphenyls (PCBs), DDE, and DDT have
Races rate is due to the higher incidence of SIDS.
shown a weak, but significant correlation with lower
Serious morbidity in indigenous infants in the first
birth weight (Polder et al., 2002b), suggesting that envi-
year of life usually reflects their predilection to infec-
ronmental factors may significantly affect health status.
tion, and, for each region, is usually dominated by
The incidence of low birth weight in circumpolar
types of infection that reflect environmental condi-
populations, with the exception of Russia (at 7%), is be-
tions. Rate of respiratory infection often reflect crowded
tween 4% and 5.8%, similar to the Nordic countries
housing. Gastrointestinal illness may reflect the quality
(Figure 3ท5). This may reflect the increase in efforts to
of the water supply (Berman, 1991; Maynard and
provide early access to high quality prenatal care.
Harmmes, 1970).
Deaths per 1000 live births
20
15
10
Figure 3ท6. Neonatal and post-neonatal
mortality rates in Arctic countries (gen-
Neonatal
eral populations: Russia 1994ญ1997;
Post-neonatal
Sweden/Norway/Iceland/Finland/Green
land/Faroe Islands 1998; U.S. All Races,
5
1995) and some indigenous populations
(Alaska Natives, 1994ญ1996; Canada
NWT/Nunavut, 1994). Source: US IHS,
2000; Health Canada, 1999; WHO Stat-
0
istical Database; NOMESCO, 2001.
Iceland
Norway
Sweden
Finland
Russia
Greenland
Alaska Natives
U.S. All Races
Canada, NWT
Faroe Islands

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14
AMAP Assessment 2002: Human Health in the Arctic
Percentage of deaths
Wide variation between populations/cultures exists,
100
especially in intentional injury mortality, and may reflect
90
All other
differences in cultural stress, economy, or rates of de-
80
Cancer
pressive illness (Bjerregaard and Young, 1998).
Congenital anomalies
In both sexes, over age 45 years, chronic disease be-
70
Injuries
comes increasingly prominent in both mortality and mor-
60
bidity indicators. Atherosclerotic heart disease, strokes,
50
and cancer are the primary causes of mortality in this
40
age range, partly reflecting an increasingly western life-
30
style (Figure 3ท8). In many countries, strokes and heart
20
disease are combined in a single category called circula-
10
tory disease. As use of tobacco, a sedentary lifestyle, and
0
a western diet have become more common, cancer, heart
Alaska Natives
Greenland
disease, obesity, and diabetes mellitus have become more
Figure 3ท7. Percentage distribution of causes of child mortality (age
frequent in indigenous Arctic residents. In certain Arctic
1 to 16 years) in Alaska Natives (1994ญ1996) and Greenland (1998).
regions environmental factors have been shown to be as-
Source: US IHS, 2000; Annual Report from the Chief Medical Offi-
sociated with health status. Studies of the Republic of
cer in Greenland 1999.
Karelia residents in western Russia, where naturally low
levels of calcium and magnesium are found in the water
3.3.6. Child mortality and morbidity
supply, indicate that these residents are associated with a
Among Alaska Natives and Greenland Inuit, about 70%
high risk of hypertension, and strokes (Dorshakova and
of all deaths between 1 year and 16 years are related to
Karapetian, 2002).
injury, either intentional or unintentional. Less than
10% are attributed to cancer and congenital anomalies,
3.4. Health status of indigenous Arctic residents
respectively (Figure 3ท7).
Disparities in health status of indigenous Arctic residents
are presented in sections 3.2. and 3.3. Limited data
3.3.7. Adult mortality and morbidity
availability restricts the possibilities for a detailed exam-
Causes of adult mortality and morbidity vary with age
ination of health status differences among Arctic resi-
and sex. Mortality in the young adult age range is
dents, especially among indigenous peoples. The most
largely related to injury, both intentional and uninten-
useful datasets exist for Alaska Natives, Canadian First
tional. Among Arctic men, suicide is a major cause of in-
Nations peoples, and the Inuit of Greenland. Nowhere
jury mortality, and injury mortality from all causes is
are the datasets for Arctic populations as continuous or
greater for men than for women. In general, morbidity
as comprehensive as the health data for the majority na-
tends to be related to injury and infections. Morbidity
tional populations of the relevant countries (United
for certain infectious diseases and for diabetes is dis-
States, Canada, and Denmark). The reasons for the dif-
cussed in section 3.4.
ferences described in this section are multi-factorial and,
Cause specific mortality per 100 000 of the population
Cancer
250
Heart disease
Stroke
Injury
200
Suicide
150
100
50
0
Alaska Natives Canada, NWT
Greenland
Iceland
Faroe Islands
Norway
Sweden
Finland
Russia
Figure 3ท8. Adult age-standardized population mortality rates for cancer, heart disease, strokes, injury, and suicide within the Arctic countries
(general populations: Greenland/Faroe Islands, 1991ญ95; Iceland/Norway, 1995; Russia, 1997; Sweden/Finland, 1996) and some indigenous
populations (Alaska Natives 1994ญ1996; Canada NWT/Nunavut 1991ญ1996). Source: WHO Statistical Database; US IHS, 2000; NWT,
1999; NOMESCO, 2001.

---

Chapter 3 ท Health Status of the Arctic Residents
15
United States and Alaska
Malignant neoplasms U.S. All Races
Alaska Natives
Heart diseases U.S. All Races
Alaska Natives
Unintentional injuries U.S. All Races
Alaska Natives
Suicide U.S. All Races
Alaska Natives
Figure 3ท9. Percentage compari-
son of causes of death in U.S. All
Alcohol related U.S. All Races
Alaska Natives
Races (1998) and Alaska Natives
(1996ญ98). Source: Alaska Native
Other causes U.S. All Races
Alaska Natives
Tribal Health Consortium (ANTHC)
Statistics.
0
5
10
15
20
25
30
35
40
Percent of deaths
Homicide
Greenland
Accident
Cerebrovascular
Lung diseases
Circulatory diseases
Figure 3ท10. Percentage distribu-
Suicide
tion of causes of death in Green-
Cancer
land in 1996. Source: Report
Other causes
from the Chief Medical Officer
in Greenland 1999.
0
5
10
15
20
25
Percent of deaths
Perinatal
Canada, NWT
Congenital causes
Injury and poisoning
Circulatory diseases
Figure 3ท11. Percentage distribu-
Cancer
tion of causes of death in Canada
Other and unknown
NWT / Nunavut, 1991 to 1996.
Source: NWT, 1999.
0
5
10
15
20
25
Percent of deaths
in some cases, poorly understood. Major differences
shown in Figure 3ท12, for males and females, compared
exist in the categories of injury, infant mortality, infec-
to U.S. Caucasians.
tious disease, cancer, cardiovascular disease, and child
The incidence of all invasive cancers has increased
health that are described in the compiled national/re-
significantly for both sexes, with the major statistically
gional statistics. The population age structure is gener-
significant increases for Alaska Native men in lung, col-
ally quite similar among various groups of indigenous
orectal, and prostate cancer. In Alaska Native women,
Arctic residents, with more children, and fewer elderly
significant increases were seen in lung and breast cancer
(see section 3.2.1). For this reason, it is useful to compare
(Lanier et al., 2001). Lung cancer increases are probably
causes of death by percentage of cause with the corre-
Incidence per 100 000 of the population
sponding data for a non-indigenous population to better
450
understand the way indigenous communities perceive the
Cancer
most common causes of death in their communities. From
400
Figure 3ท9 it is apparent that the main difference between
Alaska Natives and U.S. All Races causes of death is
350
due to suicide, unintentional injuries and alcohol-related
300
deaths. A somewhat smaller proportion of Alaska Na-
tives die from heart disease. Also, in Greenland (Figure
250
3ท10) and Arctic Canada (Figure 3ท11), violent death by
homicide, suicide, and accidents is common and ac-
200
counts for about 20% of all deaths.
150
Alaska Natives
U.S. All Races
} Males
3.4.1. Cancer
100
Alaska Natives
Females
U.S. All Races
}
The incidence of invasive cancer has risen steadily from
50
the mid-1970s in most populations studied (Nielsen et
0
al., 1996; Lanier et al., 2001).
1969-73
1974-78
1979-83
1984-88
1989-93
1994-98
Although comparison data since 1988 from other
Figure 3ท12. Trends in age-adjusted invasive cancer incidence rates
Arctic countries are not available, the incidence of all in-
in Alaska Natives (1969ญ1998) and U.S. All Races (1974ญ98).
vasive cancers in Alaska Natives from 1969 until 1998 is
Source: Lanier et al., 2001.

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16
AMAP Assessment 2002: Human Health in the Arctic
Standardized incidence ratio (SIR)
Circumpolar Inuit
100.0
Male
Female
10.0
1.0
0.1
Colon
Liver
Lung
Rectal
Breast
Cervix
Uterus
Salivary
Kidney
Stomach
Bladder
Pancreas
Gallbladder
Lymphoma Leukemia Prostate
NasopharynxEsophageal
Cancer site
Figure 3ท13. Standardized incidence ratio for selected cancer sites among male and female circumpolar Inuit, 1969 to 1988. Source: Bjerre-
gaard and Young, 1998.
related to tobacco use, with tobacco becoming readily
ously endemic hepatitis B infection is greatly increased.
available throughout rural Alaska in the years following
Other well established malignancies with increased fre-
the Second World War. Changes in diet, and other rele-
quencies, such as nasopharyngeal cancer, might well be
vant factors, along with the increase in the number of
related to other infectious agents such as the Epstein-
elderly probably contribute to the overall rise in cancer
Barr Virus, as well as other unidentified genetic or envi-
incidence (Nielsen et al., 1996). Although tobacco is the
ronmental factors (Nielsen et al., 1996).
major risk factor for lung cancer, the rise in colorectal
cancer may be related to genetics, increased use of west-
3.4.2. Infectious diseases
ern foods, and other factors.
The incidence of various types of cancer differs in
Immunizations, antibiotics, and basic sanitation have
pattern from that apparent in non-indigenous residents,
greatly lessened mortality from infectious diseases, but
as seen in Figure 3ท13, which shows relative risk for
the burden of infectious disease continues to be a major
Inuit men and women for developing certain cancers,
over the period 1966 to 1988, compared to the risk ex-
Percentage seropositivity of the population
perienced by the majority populations, which is ex-
0.7
pressed as 1.0.
H I V
Certain cancers, notably prostate for men and breast
0.6
for women, appear to be less common in indigenous
populations (Nielsen et al., 1996). In Alaska Natives,
0.5
prostate and breast cancers remain less frequent than
in the U.S. reference population, however comparable
0.4
data for the Greenlandic and Canadian indigenous pop-
ulations are not available (Lanier et al., 2001). Figure
0.3
3ท13 represents a compilation of all cancer incidence
data for western hemisphere Inuit men and women,
0.2
between 1969 and 1988, expressed as a `standardized
incidence ratio' (SIR). This is compared to national pop-
ulations in Canada, Denmark, and the United States.
0.1
Thus, a malignancy with an SIR of 1.0 occurs with equal
frequency in Inuit and the majority populations used for
0
comparison. A malignancy with an SIR of 7.0 occurs
Iceland Norway
seven times more frequently in the age-adjusted Inuit
Denmark Sweden Finland Russia
population, while a malignancy with an SIR of less
Alaska Natives U.S. All Races
than 1.0 occurs less frequently in the age-adjusted Inuit
Alaska All RacesCanada All Races
population.
Figure 3ท14. Percentage of population living with HIV/AIDS in Arc-
Other malignancies related to known risk factors,
tic countries (general populations: Alaska All Races/U.S. All Races,
1998ญ99; Canada All Races, 1999; Denmark/Finland/Iceland/Nor-
such as lung cancer (tobacco) are at least as frequent as
way/Sweden, 1999), and among Alaska Natives (1998ญ99). Source:
in other populations, and liver cancer related to previ-
US IHS, 2000; Health Canada, 1999; NOMESCO, 2001.

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Chapter 3 ท Health Status of the Arctic Residents
17
source of disproportionate morbidity for Arctic indige-
Percentage seropositive of the population
nous residents. The majority of serious morbidity falls in
100
the 0 to 4 year age range, and the over 50 years age
Alaska Natives, males
90
groups. The exceptions are sexually transmitted diseases
80
(STDs), and Human Immunodeficiency Virus (HIV) in-
fections, which are predominantly seen in the 15 to 45
70
Alaska Natives, females
year age range. The prevalence of people living with
60
HIV/AIDS is fairly low in most Arctic populations with
Helicobacter pylori infection
50
(IgG positive)
the exception of Canada (0.30%) and the United States
40
(0.61%) (Figure 3ท14).
30
20
3.4.2.1. Bacterial diseases
10
Streptococcus pneumoniae and Hemophilus influenza,
0
type B, cause diseases most frequently seen in infants
0
10
20
30
40
50
Age, years
and the elderly. The incidence of invasive disease from
both these bacteria were 10 to 20 times higher in Arctic
Figure 3ท16. Rates of Helicobacter pylori infection among Alaska
Natives by age and gender, 1980 to 1986. Source: Alaska Native
indigenous infants compared to Caucasian infants, with
Tribal Health Consortium (ANTHC) Statistics.
frequent severe illness leading to mental retardation,
hearing loss, and death (Singleton et al., 1994). The re-
are not all known, but could include crowded housing
cent availability of vaccines for these organisms has
and poor sanitation. The infection is common in the de-
begun to lessen the frequency of disease dramatically.
veloping world, and is endemic among Alaska Natives,
who begin to acquire the infection in early childhood
Tuberculosis is no longer a significant cause of mortality,
(Figure 3ท16) (Parkinson et al., 2000).
but infection is more frequent among indigenous resi-
Whether other Arctic peoples are endemically in-
dents, primarily due to re-activation of tuberculosis in
fected is not known, but the similarity of environmental
elderly people previously infected during the 1920 to
conditions suggests that it is possible. Alaska Natives
1960 period. Notable is the incidence in NWT/Nunavut
have the highest prevalence of Helicobacter pylori infec-
Canada (over 50 per 100 000 population) and Green-
tion of any U.S. population.
land (110 per 100 000 population) (Figure 3ท15).
3.4.2.2. Sexually transmitted diseases
Incidence of infection per 100 000 of the population
120
There are many different organisms, both bacterial and
viral, which cause disease and are transmitted by sexual
Tuberculosis
100
contact. There are four for which comparable data exist:
HIV, gonorrhea, syphilis, and Chlamydia trachomatis.
HIV has not shown penetration into the Arctic indige-
80
nous populations in amounts greater than (and is in
most places less than) in the Caucasian population (Fig-
60
ure 3ท14). Syphilis has, in recent times, not been detected
in amounts exceeding that in the Caucasian population
(Bjerregaard and Young, 1998).
40
The rates of gonorrhea and chlamydia infection in
Alaska Natives, however, are regularly reported to be
20
two to four times the rate for Caucasians in Alaska.
Among Canadian and Greenland Inuit, rates range from
0
ten to 100 times the rates seen in Canada and Denmark
Alaska
Alaska
U.S.
Canada,
Canada Greenland
(Bjerregaard and Young, 1998).
Natives All Races All Races
NWT
All Races
Figure 3ท15. Crude incidence rate of tuberculosis infection, 1998 to
2000. Source: US IHS, 2000; Tuberculosis Control in Alaska, July
3.4.2.3. Viral diseases
2001, State of Alaska; NWT, 1999; Annual Report from the Chief
Arctic residents, including indigenous residents, are con-
Medical Officer in Greenland 1999.
nected by air transportation to the rest of the world, and
In settings of small, crowded housing and with high
experience regular seasonal viral epidemics of respira-
smoking prevalence, early symptoms, such as coughing,
tory illness such as influenza, at the same times as cities
are often not seen as alarming or significant and as a re-
in the subarctic and northern temperate zone.
sult disease spread by airborne droplets is very efficient
Conditions of crowding and poor sanitation con-
and effective.
tributed to endemic hepatitis B in Alaska, Arctic Canada
and Greenland, although universal immunization, be-
Helicobacter pylori is a relatively recently discovered
ginning at birth, has virtually eliminated new hepatitis B
bacterium infecting the stomach, and capable of causing
infections (Bjerregaard and Young, 1998).
ulcers, stomach inflammation and bleeding. It has also
Hepatitis A swept the rural Arctic populations in epi-
been associated with increased risk for certain types of
demics on a 10 to 20 year cycle, infecting up to 90% of
stomach malignant disease. The risk factors for infection
village populations in some regions (Bjerregaard and

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18
AMAP Assessment 2002: Human Health in the Arctic
Injury mortality per 100 000 of the population
450
400
350
300
Alaska Natives, males
250
200
150
Alaska Natives, females
100
Figure 3ท17. Injury mortality rates
for Alaska Natives, 1991, by age-
50
group and gender. Source: Bjerre-
gaard and Young, 1998.
0
0-4
5-9
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
65+
Age group
Young, 1998). Using an aggressive hepatitis A immu-
also with an increase in the rates among the 65+ age
nization effort, in the year 2000, no new hepatitis A in-
group (Figure 3ท17).
fection was clinically recognized in the State of Alaska,
demonstrating the potential of this vaccine (Middaugh,
3.4.4. Intentional injury
pers. comm., 2001).
Among Alaska Native infants, the Respiratory Syn-
Suicide is more common in young men and women
cytial Virus (RSV) causes far more severe lower respira-
among Arctic indigenous peoples, than the All Races
tory illness than in other populations studied (Karron et
data from the United States, Canada, and Denmark (Fig-
al., 1999), at rates from ten to 25 times higher. In studies
ure 3ท18). The rates for Alaska Native men in the 15 to
of risk factors for severe RSV disease in Alaska Natives,
24 year age group is four times the rate for women.
premature birth, smoking in the home, and congenital
Cultural stress, erosion of traditional lifestyles, and
heart disease increased risk, while breast feeding was
substance abuse are all considered to be contributory
found to decrease risk. Even so, 50% of severely ill in-
factors (Bjerregaard and Young, 1998). In a Greenland
fants did not have identified risk factors.
study of risk factors, for both men and women, the pres-
ence of alcohol problems in the parental home and sexual
abuse as a child were strong independent risk factors for
3.4.3. Unintentional injury
serious suicidal thoughts (Bjerregaard and Young, 1998).
National injury data was previously presented in section
3.3.7. All indigenous Arctic residents have higher rates
3.4.5. Diabetes mellitus
of mortality for unintentional injury, related to multiple
factors, including the severe climate and weather, and
Diabetes has historically been thought to be absent from
substance abuse. The excess mortality is seen in all age
Arctic indigenous peoples, but recent data suggest that
groups with a dominance in the 20 to 24 year age group,
rates of type II diabetes among some indigenous popula-
Suicides per 100 000 of the population
250
Greenlanders
Alaska Natives
Canada, NWT, Inuit
200
Denmark
U.S. All Races
Canada All Races
150
100
Figure 3ท18. Suicide mortality rates
in different age-groups of Green-
landers, Alaska Natives, and Inuit
50
in Canada NWT/Nunavut com-
pared to general populations in
Denmark, Canada, and the United
States, 1980 to 1989. Source: Bjer-
regaard and Young, 1998.
0
0-14
15-24
25-34
35-44
45-54
55-64
65+
Age group

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Chapter 3 ท Health Status of the Arctic Residents
19
Prevalence per 1000 of the population
often involving gasoline or glue sniffing, is a problem in
25
many Arctic communities, usually among children and
adolescents, with rates of adolescents stating that they
Diabetes
had inhaled solvents at least once ranging from 7% to
26%, and with current rates of between 1% and 8%
20
(Bjerregaard and Young, 1998). Data for Alaska Natives
reveal that solvent inhalation in childhood is a strong
predictor of alcohol and illegal drug use in later life
15
(Prinz, pers. comm. 2001).
Consumption of alcohol during pregnancy can result
in damage to the developing fetus, including cognitive
impairment, small stature, poor growth, and altered de-
10
velopment of facial bones. In its most severe form, the
combination of poor prenatal or postnatal growth,
poorly developed mid-facial bone structure, and a vari-
5
ety of brain function impairments is referred to as Fetal
Alcohol Syndrome (FAS). Lesser degrees of prenatal al-
cohol exposure can result in brain dysfunction without
growth impairment or altered development of facial fea-
0
tures (Egeland et al., 1998b).
Active surveillance for FAS carried out in the Alaska
Native health care system from 1988 to 1994 indicated
Alaska, Inuit
Alaska, Aleuts
Alaska, Indians
U.S. All Races
Yukon, Indians
a rate of 4.2 per 1000 live births, compared to rates of
Canada, NWT, Inuit
0.3 to 1.0 per 1000 live births in the U.S. population.
Canada, NWT, IndiansChukotka, Indigenous
Among Alaska Natives, FAS is the most common cause
Figure 3ท19. Age-standardized prevalence of diabetes mellitus in in-
of preventable congenital mental retardation (Egeland et
digenous populations of Chukotka, Alaska, Yukon, and NWT/
al., 1998b).
Nunavut, and in U.S. All Races in the late 1980s. Source: Bjerre-
gaard and Young, 1998.
It is quite possible that rates of FAS are also elevated
in other Arctic populations, but active surveillance has
tions have increased to levels approaching those of other
not regularly taken place.
developed countries (Figure 3ท19) (Bjerregaard and
Young, 1998).
3.4.7. Indigenous infant and child health
Rates of obesity have also increased which may be
one explanation for the increase in type II diabetes, and
3.4.7.1. Infant mortality
for the increase in gestational diabetes which has also
Infant mortality steadily decreased between 1950 and
occurred. Increased rates of obesity may be partly re-
1995 for all Arctic indigenous residents, but remains
lated to the increased consumption of western foods,
elevated above the rates for the United States, Canada,
lower consumption of traditional foods, and lifestyle
and Denmark (see section 3.3.5.). Anecdotal evidence
factors, such as decreased exercise.
about adverse trends in, e.g., infant mortality rates
among Russian Arctic indigenous populations in the late
1990s, is a matter of concern. Disruption to essential
3.4.6. Substance abuse
services (food supply, fuel, employment opportunities,
The data sources for use of alcohol and illegal drugs,
and health care services, etc.) following the change to a
such as marijuana, cocaine, opiates, amphetamines, and
market economy is proposed as a major contributary
solvents abused by inhalation, are incomplete, and rarely
factor in these negative developments. There is an urgent
comparable across groups (see section 8.2.3).
need for reliable statistics to confirm these indications
A survey of Greenland residents showed that 39% of
and to document recent trends.
men and 12% of women meet criteria for `binge drink-
When neonatal (age 0ญ28 days) and post-neonatal
ing' or `high consumer.' Among Inuit residents in Arctic
mortality are examined separately, larger disparities are
Canada, the results of the Indigenous Peoples Survey in-
present in indigenous post-neonatal mortality rates with
dicate that the prevalence of problems with alcohol (self-
much smaller differences seen in neonatal mortality.
reported for at least one incident of an alcohol-related
SIDS is a major contributor to post-neonatal mortality
problem, such as missed days of work, arrest related to
among all indigenous residents in the Arctic. The cause
driving a vehicle while under the influence of alcohol,
of SIDS is unknown, but smoking in the home is a major
etc.) in the population range from 13% to 29%, and are
risk factor.
highest in the 20 to 24 year age range, with only slight
Injury deaths in infancy are also elevated among in-
differences between men and women (Bjerregaard and
digenous peoples, as in all other age groups.
Young, 1998).
The results of the Alaska Behavioral Risk Factor Sur-
3.4.7.2. Oral health
vey indicated that for Alaska Natives 34% of men and
21% of women practised binge drinking (5 or more
Oral health status in children is recorded as the number
drinks on at least one occasion within the last month)
of teeth which are decayed, missing, or filled (DMF) at
compared to the U.S. rate of 14% for men and women
certain ages. Although the ages and time periods repre-
together (Bjerregaard and Young, 1998). Inhalant abuse,
sented are somewhat different, the rates of DMF teeth,

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20
AMAP Assessment 2002: Human Health in the Arctic
Number of DMF teeth
10
9
8
7
6
Figure 3ท20. Oral health, meas-
5
ured as the number of Decayed,
Missing and Filled (DMF) teeth in
4
indigenous children in Alaska, Can-
3
ada (NWT/Nunavut and Labra-
dor) and Greenland, and children
2
from Ontario, Canada, 1988 to
1
1999. Source: Bjerregaard and
0
Young, 1998.
Alaska
Canada,
Canada,
Canada,
Canada,
Green-
Green-
Native,
NWT, Inuit,
NWT, Inuit
Ontario,
Labrador, Inuit,
land,
land,
age 5-13
age 6
age 12
age 13
age 5-22
age 6
age 6
1999
1990-91
1990-91
1990-91
1994
1988
1996
compared to majority populations, is higher among in-
efforts. Data on behavioral risk factors, such as alcohol
digenous populations (Figure 3ท20).
consumption, or domestic violence, are inconsistently
Tooth decay is greatly enhanced by simple sugars in
gathered among rural, isolated Arctic populations.
foods, and, in Greenland was virtually unknown until the
Illness associated with infections, especially infant
twentieth century (Bjerregaard and Young, 1998). The
respiratory disease, and sexually transmitted diseases
bacterium Streptococcus mutans is the causative agent
(STDs), are far more frequent among some Arctic resi-
of common childhood tooth decay and is often passed
dents. Better housing, less crowding and advice aimed
from mother to child during infancy. Measures such as
at increasing the proportion of breast-feeding mothers
fluoridation of water supplies and other public health
would lead to a reduced burden of infectious disease
dental practices can also reduce the DMF rates in child-
among infants. Innovative STD prevention programmes
hood, but access to these measures is limited in many
currently in use in some Arctic countries should be con-
rural Arctic communities, as is restorative dental care.
sidered as models for those Arctic regions with high inci-
dence rates.
Among certain Arctic peoples, the incidence of obe-
3.5. Conclusions and recommendations
sity and type II diabetes have increased to rates equal to
Arctic regions, in general, have much smaller, more iso-
those in most developed western countries. This may, in
lated, younger populations, with fewer elderly people
part, reflect an intake of more western foods, with a
and larger families. Their mortality patterns are chang-
shift away from the traditional diet, sometimes as a re-
ing as increasing life expectancy and western influences
sult of community concern about the safety of tradi-
on diet, lifestyle, and culture alter health status. As is the
tional food sources.
case in the more populated temperate regions of Arctic
Data on cultural factors, such as regular subsistence
countries, cancer, strokes, and heart disease have be-
diet information, traditional harvests and celebrations,
come leading causes of death.
use of native language in the home, and traditional
The younger age structure of the population in the
health practices are infrequently gathered, and would be
Arctic regions provides an opportunity for effective em-
useful in planning prevention programmes for a variety
phasis on preventive measures for cardiovascular disease
of medical and behavioral health problems.
and general health promotion. Availability and access to
The net effect of medical and public health advances
comparable data for the different populations in the cir-
has been to increase life expectancy. However, as the im-
cumpolar region is still a problem and hampers the de-
pact of western influences on indigenous cultures be-
velopment of detailed comparisons and evaluations.
comes more apparent, lifestyle changes have made
This lack of data should be addressed by the health min-
chronic diseases a negative factor in the lives of Arctic
istries of the Arctic countries.
residents.
Injury remains a disproportionately prominent cause
As well as improving living conditions for the popu-
of death and the suicide rate appears strikingly different
lation in the reproductive age range, it is also important
in some regions. Crude indicators, such as suicide and
to improve the quality and number of `healthy mother
homicide rates, would seem to point to a need to better
and baby programmes' to reduce pre- and postnatal
identify prevalence and trends in behavioral risk factors,
morbidity and mortality, and possibly also to decrease
in order to better target early interventions and prevention
the burden of adult chronic disease.

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