Public Health Practice in

Circumpolar Regions:
Lessons for Canada

Report prepared for the

Public Health Agency of Canada
Public Health Practice in
Circumpolar Regions:
Lessons for Canada
Report prepared for the Public Health Agency of Canada

Kue Young, MD, FRCPC, DPhil, FCAHS

Professor and TransCanada Pipelines Chair
Dalla Lana School of Public Health
University of Toronto
Toronto, ON

and

Susan Chatwood, BScN, MSc

Executive and Scientific Director
Institute for Circumpolar Health Research
Yellowknife, NT

December 2009

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© 2009-2011 Institute for Circumpolar Health Research
All Rights Reserved.

Publications of the Institute for Circumpolar Health Research can be obtained from:

P.O. Box 11050 • Yellowknife, NT X1A 3X7 Canada

Tel: 867.873.9337 • Fax: 867.873.9338 • Email: info@ichr.ca • Web: www.ichr.ca

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 TABLE OF CONTENTS

Part 1 Background and Introduction ...................................................................................................... 5

1.1 Context and Objectives of Review ........................................................................................................................ 5
1.2 Methods and Data Sources ..................................................................................................................................... 5
1.3 Defining Circumpolar Regions .............................................................................................................................. 5
1.4 Population Health Status ........................................................................................................................................ 7
1.5 National Health Systems ......................................................................................................................................... 9
1.6 Organization of Public Health Services ............................................................................................................. 11

Part 2 Public Health Programs............................................................................................................. 14

2.1 Public Health Surveillance ................................................................................................................................... 14
2.2 Emergency Preparedness and Response ........................................................................................................... 16
2.3 Health Promotion .................................................................................................................................................. 17
2.4 Disease and Injury Prevention ............................................................................................................................ 19
2.5 Health Protection................................................................................................................................................... 22
2.6 Maternal and Child Health .................................................................................................................................. 23
2.7 Determinants of Health ........................................................................................................................................ 24

Part 3 Cross Cutting Themes................................................................................................................. 26

3.1 Governance, Financing, and Management ....................................................................................................... 26
3.2 Policy and Planning ............................................................................................................................................... 27
3.3 Public Health Human Resources and Capacity .............................................................................................. 29
3.4 Health Disparities and Inequalities .................................................................................................................... 31
3.5 Performance Measurement and Evaluation ..................................................................................................... 32
3.6 Citizen Engagement and Public Education ...................................................................................................... 33
3.7 Intersectoral Coordination and Collaboration ................................................................................................ 33
3.8 Knowledge Translation ........................................................................................................................................ 33

Part 4 Lessons for Canada ................................................................................................................... 35

References Cited and Additional Resources ......................................................................................... 42

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 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
Part 1 Background and
Introduction
1.1 Context and Objectives of
Review
This report is commissioned by the Public Health
Agency of Canada (PHAC), which is currently
examining its role in Canada’s North and working
toward the development of a PHAC Northern Public
Health Agenda. This Agenda will provide a roadmap
for future PHAC engagement around key public
health issues in the North. It will allow PHAC to set
priorities, strengthen its relationship with Territorial
governments and stakeholders, and collaboratively
provide a package of public health services and
programs that better meet Northerners’ needs. It will
also assist PHAC in contributing to the Government
of Canada’s broader Integrated Northern Strategy.
The consultants were tasked with the development of
a literature review to highlight best and/or promising
practices in the circumpolar regions related to public
health policy and implementation in several thematic
areas. They are as listed in the Table of Contents.
The report is in four parts. Part 1 provides basic
information about the health status and health care
systems, including public health, in the circumpolar
regions and countries. There are similarities to
Canada but also important differences, especially in
how government operates, which must be taken into
account when comparing public health programs and
services. Part 2 describes different components of
public health, how they are organized and delivered.
Part 3 highlights several cross-cutting themes within
public health. The focus of Part 2 and 3 is on other
circumpolar countries and not on Canada. In Part 4,
the relevance of other countries’ experience to Canada
is discussed, and examples of how Canada can learn
from others and where Canadian innovations may be
applicable elsewhere are provided.
1.2 Methods and Data Sources
The main sources of information used include the
published, peer reviewed scientific literature, and
1.1 Context and Objectives of Review
parts of the grey literature such as government
publications that are freely accessible on the web. In
general, only those documents published within the
past decade were consulted. Language is clearly an
obstacle, given the diversity of national languages in
the circumpolar world. Fortunately for the Nordic
countries, many - but not all - official documents are
available in English, but this is not the case for Russia
or Greenland. The reliance on English-only
documents is a potential source of bias.
Time and cost considerations prevented travel to
consult printed documents in various libraries in the
circumpolar regions or conduct key informant
interviews with policy makers and public health
officials. However, the authors have visited many
circumpolar regions, observed their health systems,
and met and discussed public health issues with
circumpolar colleagues at international conferences.
They have also drawn on their extensive network of
personal contacts. This review can therefore be
considered as “informed” but no claim is made that
the conclusions have been validated by direct
observation or discussion with stakeholders.
Overall, the available literature is heavily unbalanced
in that we know a lot about what public health
agencies say their policies are, what they intend to do,
and what they have achieved. There is a dearth of
evaluative literature or impact measures, and so what
is “best” or “promising” practice boils down to mainly
personal opinion.
1.3 Defining Circumpolar Regions
It is not often recognized by Canadians outside the
North that we have neighbours to the north, east and
west of us. The term “circumpolar” will be used
interchangeably with “Arctic” in this review. While the
Antarctic is not entirely irrelevant to public health it
will not be considered. Although geographers,
oceanographers, climatologists and biologists have
different ways to define and circumscribe the Arctic,
for public health the most logical approach is to use
political-administrative boundaries, since health
statistics are collected and health services and
programs delivered based on such divisions (Table 1
and Figure 1).
5
 Public Health Practice in Circumpolar Regions: Lessons for Canada

Table 1. List of circumpolar countries and regions

[US] United States [DK] Denmark [RU] Russian Federation
[Ak] Alaska [Gl] Greenland [Mu] Murmansk Oblast
[CA] Canada [Fo] Faroe Islands [Ka] Kareliya Republic
[Yk] Yukon [IS] Iceland [Ar] Arkhangelsk Oblast
[Nt] Northwest Territories [NO] Norway [Ne] Nenets AO
[Nu] Nunavut [Nd] Nordland [Ko] Komi Republic
[Tr] Troms [Yn] Yamalo-Nenets AO
[Fm] Finnmark [Km] Khanty-Mansi AO
[SE] Sweden [Tm] Taymyr AO
[Vb] Västerbotten [Ev] Evenki AO
[Nb] Norrbotten [Sk] Sakha Republic
[FI] Finland [Ma] Magadan Oblast
[Ou] Oulu [Ky] Koryak AO
[La] Lappi [Ck] Chukotka AO
AO = autonomous okrug; the 2-letter country and region codes are used in Figure 1

The whole of Alaska and Greenland are included.
Northern Canada includes only the three northern
territories, all located above 60o N latitude. While the
Nunavik region in northern Québec and the
Nunatsiavut region in Labrador are often regarded as
part of the Canadian North, they fall under provincial
jurisdiction and will not be considered here. The
northernmost counties in Norway, Sweden, and
Finland constitute the northern regions of those
countries. [“County” here refers to fylke in Norway,
län in Sweden, and lääni in Finland].
The term Scandinavia has different usages and
meanings. In the broadest sense it includes all the
Nordic countries and their dependencies. More
narrowly it refers only to Denmark, Norway, Sweden
and Finland, or only the three contiguous countries of
Norway, Sweden and Finland. Sometimes Finland is
excluded, and when Finland is included the term
Fennoscandia is often used. In this review both terms
are used interchangeably, and which countries are
referred to should be evident from the context.

6 Part 1 Background and Introduction

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada

Figure 1. Map of circumpolar countries and regions

The situation in Russia is quite complex. The Russian
Federation is composed of different types of
administrative divisions called federal “subjects”
(subyetkty), including republic, kray, oblast,
autonomous okrug, and federal city, with varying
degrees of autonomy. Terms such as kray, oblast and
okrug are inconsistently translated as “territory”,
“region” and “area”. Autonomous okrugs (hereafter
AO), with the exception of Chukotka, are generally
part of some higher level units such as an oblast or
kray, and usually represent the traditional territories
of some indigenous ethnic groups. For further
information on definitional issues of the Russian
North, see Kozlov and Lisitsyn (2008). Note that as
of January 1, 2007, the Taymyr, Evenki and Koryak
AO ceased to exist as distinct federal subjects.
1.4 Population Health Status
In North America, the three northern Canadian
territories and Alaska constitute less than 0.5% of the
total population of Canada and the USA respectively.
Both Greenland’s and Faroe Islands’ population is
only 1% that of Denmark. In contrast, a much higher
proportion of the national population of Norway
(10%), Sweden (6%) and Finland (12%) reside in
their northern counties. In Russia, it is about 5%.
From a policy perspective, it is to be expected that the
extent to which northern regional issues and needs

1.4 Population Health Status 7

 Public Health Practice in Circumpolar Regions: Lessons for Canada

occupy the attention of national governments would
reflect their share of the population.
Within the circumpolar North, indigenous people
account for 4.5% of the total population. Indigenous
people are a substantial minority in regions such as
Alaska (19%), Yukon (25%), and Finnmark (31%),
comprise about half of the population of the
Northwest Territories, and constitute the
overwhelming majority in Nunavut (86%) and
Greenland (88%). In Arctic Russia, in none of the
autonomous okrugs (AO), where the traditional
homelands of indigenous people are located, do
indigenous people form the majority, ranging from
2% in the Khanty-Mansi AO to 41% in the Koryak
AO.
In North America, life expectancy at birth (LE0) for
the State of Alaska is the same as that of the United
States all-races combined. For Alaska Natives, there is
a drop of about 5 years. In Canada, the territorial
values decline as the proportion of indigenous people
increases, such that there is a difference of 11 years
between the Nunavut and the Canadian national
value. In Fennoscandia, there is essentially no
difference between the northern and the national LE0.
Russia as a country is suffering from an
unprecedented health crisis, with the male LE0 less
than 60 years. Among the northern regions, the
difference in LE0 between the best region (Iceland)
and the worst (Koryak AO) is 29 years in men and 21
years in women.
A similar pattern is observed for infant mortality rate.
The lowest rates (below 5 per 1000 livebirths) are
observed in the Nordic countries (with little
difference between North and South), an
intermediate group consisting of northern Canada,
Alaska and Greenland, and worst of all the Russian
regions. There are substantial disparities between the
Alaska Native and Alaska all-state rates, and
Nunavut’s is almost three times the Canadian national
rate. The highest northern regional rate, reported
from the Evenki AO in Russia, is 13 times that of the
Faroe Islands.
Note: the term Alaska Native refers to “American Indians,
Eskimos, and Aleuts”, comparable to “Aboriginal people” in
Canada. The term “Native” is not prejorative, and is used in
self-identification (e.g., the Alaska Federation of Natives).
Note it is Alaska Native and not Alaskan Native.

Table 2. Selected demographic and health indicators of circumpolar countries and regions
Life expectancy
Total at birth (years) Infant
Estimated Population fertility mortality TB
population density rate Male Female rate incidence
United States 304060000 33 2.03 74.6 80.0 6.9 5
Alaska 686300 0.5 2.36 74.5 80.1 6.8 10
Canada 33311400 3.7 1.52 77.2 82.2 5.3 5
Yukon 33100 0.07 1.60 74.9 80.1 7.4 5
Northwest Territories 43300 0.04 1.96 74.6 78.8 6.0 21
Nunavut 31500 0.02 3.04 66.6 70.9 15.3 108
Denmark 5489000 127 1.76 74.9 79.6 4.7 8
Greenland 56300 0.03 2.39 64.6 70.4 12.7 138
Faroe Islands 48600 35 2.51 77.0 81.3 1.7 3
Iceland 319400 3.1 2.00 79.0 82.6 2.6 4
Norway 4768200 16 1.81 76.6 81.7 3.6 6
Nordland 235200 6.5 1.82 76.7 82.0 3.9 5
Troms 155100 6.2 1.80 76.5 81.5 4.0 6
Finnmark 72400 1.6 1.91 74.6 80.6 4.7 10

8 Part 1 Background and Introduction

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada

Sweden 9219600 21 1.64 77.8 82.3 3.3 5

Västerbotten 257700 4.7 1.56 77.6 82.1 3.8 5
Norrbotten 250100 2.5 1.67 76.6 81.6 4.6 3
Finland 5313400 18 1.74 74.8 81.6 3.3 9
Oulu 468200 8.2 2.15 74.3 81.6 2.7 9
Lappi 184200 2.0 1.84 73.7 81.1 3.8 9
Russian Federation 141956000 8.3 1.27 58.8 72.1 13.3 89
Murmansk Oblast 846700 5.8 1.20 57.6 70.5 11.0 72
Kareliya Republic 689100 4.0 1.25 55.1 69.6 9.7 79
Arkhangelsk Oblast 1267000 2.2 1.31 55.9 70.5 10.1 92
Nenets AO 42000 0.2 1.95 53.8 69.0 10.1 50
Komi Republic 963400 2.3 1.30 56.6 69.5 8.6 90
Yamalo-Nenets AO 543200 0.7 1.61 61.8 72.2 13.4 97
Khanty-Mansi AO 1512600 2.9 1.56 61.3 73.0 6.9 104
Taymyr AO 37400 0.0 1.91 54.2 67.5 17.3 70
Evenki AO 16600 0.0 2.01 53.6 64.6 22.5 172
Sakha Republic 950600 0.3 1.82 57.9 70.4 13.4 91
Magadan Oblast 164400 0.4 1.27 56.6 69.4 11.8 98
Koryak AO 21500 0.1 1.81 49.9 61.7 14.7 334
Chukotka AO 49900 0.1 1.63 53.6 63.7 20.3 68

Population estimates from 2008; other indicators are mean of 2000-04; IMR per 1000 livebirths; TB incidence per 100,000; data
revised from Circumpolar Health Indicators (Young 2008).

In general, substantial health disparities exist across
different circumpolar regions. In terms of disparities
between “the North” and the nation-states to which
they belong, two extremes can be identified. In
Scandinavia, the northern regions are almost
indistinguishable from the country-at-large in terms of
most health indicators. At the other extreme are
Greenland and the northern territories of Canada,
especially Nunavut, where the disparities with
Denmark and Canada are substantial. Alaska as a state
tends not to differ much from the all-race USA rates
but Alaska Natives within Alaska generally fare much
worse than the State average. The health and
demographic crisis in Russia is evident – in certain
indicators, e.g., tuberculosis incidence, certain
northern regions are at particularly high risk, within a
country that is itself also at substantially elevated risk
relative to other circumpolar countries.
1.5 National Health Systems
It should be recognized that there are fundamental
differences in the political systems of the circumpolar
countries which affect the way public health, indeed
most government services and programs, is organized.
Canada, the United States, and the Russian
Federation are federal states, with clear division of
authority between the national and sub-national levels
of government. There are ministries/departments of
health at both the national and sub-national levels,
with some duplication of roles and responsibilities.
The Nordic countries are unitary states where there is
a national ministry of health with delegated service
delivery functions to various regional/local
governments. The Faroe Islands and Greenland are
both parts of the Kingdom of Denmark but quasi-
independent states as far as domestic affairs are
concerned. Until 2009, both enjoy “home rule”
[Hjemmestyre], whereas in 2009 Greenland advanced
to “self-rule” [Selvstyre], close to complete
independence except for the armed forces and foreign

1.5 National Health Systems 9

 Public Health Practice in Circumpolar Regions: Lessons for Canada

affairs. The health ministries of Greenland and Faroe
Islands are completely separate from Denmark’s.
Pubic health is an integral component of the health
care system in any country, which comprises also the
curative, rehabilitative and long-term care sectors.
Public health tends to account for only a small
proportion of total health expenditures. Before
comparing public health across circumpolar health
regions it is instructive first to describe briefly the
national health care systems that currently exist.
Across the circumpolar world, there is substantial
variation in how health care is organized, financed,
and delivered. The various national health systems
basically fall into three groups: (1) the U.S. with its
much higher level of resources (either as percent of
GDP or in per capita dollars) devoted to health care,
and a strong role for the private sector; (2) Canada
and the Nordic countries with their predominantly
publicly financed systems and similar levels of health
expenditures, accounting for roughly 10% of GDP
(with Finland at the low end); and (3) Russia, with its
extremely low level of health expenditures (Figure 2).
The per capita health expenditures of the Yukon are
1.3 times, the NWT 1.7 times, and Nunavut 2.5 times
that of Canada as a whole (CIHI 2008). Compared to
all the countries in the world, Nunavut’s per capita
expenditures are the highest, and health care alone
consumes almost 30% of the territory’s GDP. Such a
high level of resourcing is by no means the norm in
the circumpolar North. Alaska spends only 1.2 times
that of the USA, the northern counties of the Nordic
countries are indistinguishable from the more
southerly located counties, and Greenland’s per capita
expenditures is only 70% that of Denmark. Only in
various Siberian republics and regions do we see per
capita expenditures that range from 2.5 to 8.8 times
the Russian national level.

Figure 2. National health expenditures in the circumpolar countries: per capita in US dollars-purchasing
power parities, as % of gross domestic product, and share of private and public sources of financing.
See Young (2008) for data sources.

What are some of the remote health service delivery
models that are characteristic of individual
circumpolar regions? Alaska Natives have a separate
health care system from non-Native Alaskans (18% of
whom are completely uninsured) that is federally
funded and tribally administered. It pioneered the
training and deployment of village-based Community
Health Aides who provide primary care, supported by
physicians based in regional clinics. Unlike Canada
there is no tradition of using nurses in an extended
role. Greenland has opted for a system of small
hospitals in all the main towns staffed by 1-5 general
medical officers. Scandinavian countries have well
developed system of general practitioners based in
health centres serving assigned and territorially
defined populations. The Soviet health care system

10 Part 1 Background and Introduction

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
developed a middle-level cadre of medical
practitioners called feldschers; in remote areas, mobile
medical teams have served remote reindeer herding
brigades. The end of the Soviet Union had seen
upheavals in the health care system in the North and
nationally, and health reform is still very much in the
air.
1.6 Organization of Public
Health Services
No attempt is made here to define “public health”, the
concept of which differs slightly from country to
country. We know what it is not – hospitals and
nursing homes, but the boundary between “primary
care” and “public health” becomes blurred in
jurisdictions where such services are well integrated in
terms of facilities and service providers. A focus on
prevention is essential, but preventive services are not
the exclusive concern of public health. An operational
definition, namely that “public health” is what public
health agencies do may be all one can use, although
this too has limitation in that public health involves
players other than traditional public health
departments or agencies.
In this review, rather than discussing how each
country/region organizes and delivers public health
services and programs, references are made to the
“Alaska model”, the “Greenland model”, and the
“Nordic model”. The “Nordic” model focuses on
northern Norway, Sweden and Finland, and only
peripherally on Iceland and the Faroe Islands.
Denmark itself without its Arctic dependencies is a
densely populated, agricultural country less relevant
to the Canadian North. Little reference will be made
to Russia due to the lack of documentation in English.
The Alaska model
As an American state, Alaska is comparable to a
Canadian province. And prior to achieving statehood
in 1959, Alaska was a “territory”, which in some sense
is analogous to the Canadian northern territories’
present status of “not-yet” provinces. The unique
aspect of health care in Alaska, including public
health, is the entitlement of Alaska Natives (less than
20% of the state’s population) to federally funded
(and previously also federally delivered) health
1.6 Organization of Public Health Services
services. There is thus a parallel with the Canadian
North prior to “transfer” in the late 1980s and early
1990s from the federal to the territorial governments.
However, in Alaska, the federal government does not
provide health services to non-Native Alaskans.
The State Department of Health and Social Services
[www.hss.state.ak.us] by and large provides direct services
to the non-Native population and funds Native tribal
health authorities to deliver services to the Native
population. On the “Health” side are divisions of
health services delivery, primarily involved in
delivering Medicaid programs (for low-income
residents), and public health, the latter reporting to
the Chief Medical Officer. In addition to programs
found commonly in public health departments, the
medical examiner, vital statistics, and public health
laboratories are also within its purview. Below the
State level, local governments are not mandated to
provide public health services, although a few do, such
as the Municipality of Anchorage and the North Slope
Borough, which have public health departments
comparable to city and county health departments
elsewhere in the United States. Note that Alaska also
has another parallel health care system for active
military personnel in its Air Force and Army bases. As
well, there is another system for veterans.
The Alaska Native population is provided publicly
funded health care by the US Indian Health Service
(IHS), an agency of the Public Health Service,
Department of Health and Human Services
[www.ihs.gov/FacilitiesServices/AreaOffices/Alaska]. The IHS is
unique in the United States as a rare example of a
comprehensive, national health care program directed
at a defined civilian population. In the 1990s, the
policy of “compacting” was instituted, transferring
much responsibility to tribal governments and Native
corporations (Kunitz 1996, Fortuine 2006).
Some 99% of IHS funds earmarked for Alaska are
administered by nine tribally operated service areas
under a variety of funding arrangements, providing
comprehensive health services from primary care at
the village to the tertiary care facility – the Alaska
Native Medical Center in Anchorage (ANMC). The
Alaska Native Tribal Health Consortium (ANTHC)
undertakes certain statewide functions for all Alaska
Natives, including co-managing ANMC, construction
and inspection of health and sanitation facilities,
11
 Public Health Practice in Circumpolar Regions: Lessons for Canada
training of community health aids, research,
professional recruitment, information technology, and
public health [www.anthc.org]. The Division of
Community Health Services administers programs
such as surveillance, tobacco control, nutrition, injury
prevention, immunization, screening, emergency
preparedness, suicide prevention, etc.
The Centers for Disease Control and Prevention
(CDC) has a presence in the state through its Arctic
Investigations Program which has conducted
important research into the surveillance, prevention
and control of mainly infectious diseases, but also
chronic diseases and more recently climate change
and health. [www.cdc.gov/ncidod/aip].
The Nordic model
Norway, Sweden and Finland generally have very
similar public health systems. At the highest national
level there is the Ministry of Health and Care Services
in Norway [Helse- og omsorgsdepartementet
www.hod.dep.no] with a subsidiary Department of Public
Health [Folkehelseavdelingen]; the Ministry of Health
and Social Services in Sweden [Socialdepartementet
www.sweden.gov.se/sb/d/2061]; and the Ministry of Social
Affairs and Health in Finland [Sosiaali- ja
terveyministeriö www.stm.fi]. These ministries prepare
legislations, allocate resources, design policies, and
monitor their implementation.
Subordinate to such central ministries are specialized
agencies dealing with issues such as food safety,
radiation protection, and the regulation and licensing
of drugs. Of relevance to public health are those
concerned with disease control, health monitoring
and surveillance (including the maintenance of health
registries and databases), and the design and
implementation of national health promotion and
disease prevention programs. These agencies are:
» National Institute of Public Health in Norway
[Nasjonalt folkehelseinstitutet www.fhi.no] and the
Norwegian Directorate of Health [Helsedirecktoratet
www.helsedirektoratet.no]
» Swedish National Institute of Public Health [Statens
folkhälsoinstitut www.fhi.se] and Swedish Institute for
Infectious Disease Control [Smittskyddsinstitutet
www.smittskyddsinstitutet.se]
» National Institute for Health and Welfare in Finland
[Terveyden ja hyvinvoinnin laitos www.thl.fi] –
12
amalgamating the former National Public Health
Institute [Kansanterveyslaitos KTL] and National
Research and Development Centre for Welfare and
Health [Sosiaali- ja terveysalan tutkimus- ja
kehittämiskeskus STAKES]
Direct service delivery of both curative and preventive
services are the responsibilities of lower-level
governments, namely, municipalities. These number
in the hundreds (448 in Finland, 290 in Sweden, and
431 in Norway). For specialized hospital services
there are also intermediate-level hospital regions or
districts. Decisions on the planning and organization
of local health care are made by municipal health
committees or councils, which are accountable to
elected municipal authorities. The municipal medical
officer is the local public health officer who advises the
local council on health matters and is comparable to
the medical officer of health in Canada.
The Swedish system differs slightly from this model in
that municipalities are responsible for long-term care
and home care only, whereas public health, hospital
and primary care are the responsibilities of 18 county
councils.
Local health services are monitored and supervised
nationally by the National Board of Health and
Welfare [Socialstyrelsen www.socialstyrelsen.se] in
Sweden, Board of Health Supervision [Statens
helsetilsyn www.helsetilsynet.no] in Norway, and the
National Supervisory Authority for Welfare and
Health [Sosiaali- ja terveysaian lupa- ja
valvontavirasto www.valvira.fi] in Finland, which ensure
that national standards on quality are met and equity
of services exists across regions.
Of particular note in the Scandinavian model is the
integration of preventive and population-oriented
health care into primary health care delivered at
health centres in the municipalities under the
supervision of general practitioners, district nurses
and midwives (e.g., blood pressure and cholesterol
screening, education programs on tobacco, diet and
alcohol, immunizations, mother and child health).
The Greenland model
The Greenland government has a separate and
independent health care system from that of
Denmark, although much of the bureaucracy is still
staffed by ethnic Danes. While Greenlandic –
Part 1 Background and Introduction
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada

linguistically close to Inuktitut – is the official

language, Danish is still the lingua franca among the
professional and technical staff. The ministry of health
[Departementet for Sundhed / Peqqissutsimut
Naalakkersuisoqarfik dk.nanoq.gl/Emner/Landsstyre/-
Departementer/Departement_for_sundhed.aspx], is overall
responsible for all health services, from the operation
of the tertiary care Queen Ingrid Hospital in Nuuk to
health centres and rural hospitals in towns and
villages. Under the ministry is the National Board of
Health and Prevention with the task of developing
strategies and the coordination and implementation
of public health programs [Styrelsen for Sundhed og
Forebyggelse / Peqqissutsimut Pitsaaliuinermullu
Aqutsisoqarfik dk.nanoq.gl/Emner/Landsstyre/Departementer/-
Departement_for_sundhed/Styrelsen_for_Sundhed.aspx].
Reporting to the Board is an intersectoral Family and
Prevention Agency [Paarisa www.paarisa.gl, roughly
translated as “taking care of ourselves”] which has a
special focus on health promotion services. The Office
of the Chief Medical Officer, who reports directly to
the Minister of Health, is responsible for disease
surveillance and health monitoring, preventive health
services, forensic medicine, medical advice to the
government and public, patient complaints, and also
the certification of nurses [Landslægeembedet /
Peqqinnissakkut Nakkutilliisoqarfik dk.nanoq.gl/Emner/-
Landsstyre/Departementer/Landslaegeembedet.aspx]. The
Greenland health portal [www.peqqik.gl] provides
further information on a variety of health topics in
Greenland but it is in Danish and Greenlandic only.

1.6 Organization of Public Health Services 13

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Part 2 Public Health
Programs
2.1 Public Health Surveillance
Critical to the practice of public health surveillance is
the availability of accurate data on the population
“denominator”. In the Circumpolar North there are
two systems. The Nordic countries (including
Greenland) have well established population
registries, which are continuously updated, and thus
capable of generating the precise population of the
country and its regions at a point in time. Canada,
United States and Russia rely on periodic censuses –
once every 5 years in Canada, once every 10 years in
the USA, and irregularly in Russia (the last Soviet
census was completed in 1989 and the first post-
Soviet census in 2002). In the “intercensal” years,
these jurisdictions produce annual estimates of the
population, taking into account data on births, deaths,
and migrations, so-called “components of population
change”.
The Nordic model
The Nordic countries have a clear advantage over
Canada and the USA with their population registries
and the ability also for data linkage to various health
databases and registries which enable them to
undertake high-quality disease surveillance, health
monitoring and health system research.
Norway has 7 national health registries, 6 of which are
operated and maintained by the National Institute of
Public Health [NIPH], which ensures quality, access,
and protection of privacy and confidentiality. The 6
registries are: Causes of Death, Medical Births,
Communicable Diseases, Tuberculosis, Childhood
Vaccinations, and Prescriptions. The Cancer Registry
is separately administered by the Institute of
Population Based Cancer Research [Institutt for
populasjon-basert kreftforskning www.kreftregisteret.no].
Similar registries and databases are also available in
Sweden and Finland.
Of more interest to health services researchers and
planners is the Norwegian Patient Registry [Norsk
pasientregister www.helsedirektoratet.no/norsk_pasientregister]
operated by the Directorate of Health. It is
14
comparable to the health administrative databases
that Canadian provincial and territorial health
insurance plans maintain, which provide data for
utilization of hospital and medical specialist services.
For further information about the Nordic countries’
medical births registries, see for example Irgens
(2000) on the development of the Norwegian
registry. An evaluation of the quality of the Swedish
registry is available in English from the National
Board of Health and Welfare (Swedish Centre for
Epidemiology 2003).
The Alaska model
There are basically two systems in Alaska, one
exclusively for Alaska Natives, and the other for all
State residents. State surveillance reports generally do
provide breakdown into Natives and non-Natives. At
the regional level, the State tends to report by
boroughs and census areas, which differ from the
Indian Health Service “areas” for Alaska Natives.
The Alaska Native Epidemiology Center
[www.anthc.org/chs/epicenter/index.cfm] in the Division of
Community Health Services of the Alaska Native
Tribal Health Consortium performs surveillance
activities. It maintains databases and registries
(Tumour, Cardio-vascular Disease, Diabetes, Stroke,
and Trauma) that go beyond the usual public health
ones, primarily because of the close link between
public health and clinical care, up to the tertiary level,
within the same population-based organizational
structure.
The Greenland model
Public health surveillance is not as well developed in
Greenland as in the Nordic countries. The Chief
Medical Officer is the agency within the Self-Rule
Government responsible, and its annual reports show
that it tracks vital statistics, legal abortions, childhood
vaccinations, and infectious diseases. Some
surveillance functions are carried out by Danish
agencies, such as the Danish Cancer Registry which is
part of the National Board of Health
[Sundhedsstyrelsen www.sst.dk]. A research database on
causes of mortality in Greenland is maintained at the
National Institute of Public Health in Copenhagen
[Statens Institut for Folkesundhed www.si-folkesundhed.dk].
The Statens Serum Institute [www.ssi.dk] in
Part 2 Public Health Programs
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
Copenhagen also provides epidemiologic advice and
operates the reference lab for Greenland.
International models: Cancer
The Association of Nordic Cancer Registries, in
collaboration with the International Agency for
Research on Cancer, maintains the NORDCAN
website and database which generates free-of-charge
online tables and graphs of the number and rates
(incidence, mortality and prevalence) of cancer by
age, sex, country, region, and site. The entire database
is also downloadable [www-dep.iarc.fr/NORDCAN/english/-
frame.asp]. This is by far the most user-friendly and
accessible health database. NORDCAN is particularly
useful for the circumpolar North because regional
data within countries can be extracted. However,
while Faroe Islands is included, Greenland is not. It is
also noteworthy that the Nordic countries do not have
the same responses to privacy issues as, for example,
Statistics Canada, which suppresses the reporting of
small cell sizes, rendering impossible the analysis of
rarer cancer types, or even the common cancers in
small geographical regions.
International models: Infectious diseases
The International Circumpolar Surveillance (ICS) on
selected infectious diseases was launched as an Arctic
Council endorsed project in 1999, creating a network
of hospital and public health laboratories in certain
Arctic countries and regions. The initial priority for
ICS was invasive bacterial diseases caused by
Streptococcus pneumoniae, Haemophilus influenzae,
Neisseria meningitidis, and Group A and B
streptococcus. These organisms were chosen because:
(1) rates of diseases caused by many of these
pathogens were elevated in the indigenous peoples of
the Arctic, (2) strains of S. pneumoniae were rapidly
acquiring resistance to antibiotics commonly used to
treat these infections, (3) most clinical laboratories in
Arctic countries routinely cultured these pathogens
from clinical specimens, and (4) vaccines were
available for clinically important serotypes of S.
pneumoniae, H. influenzae and N. meningitidis. While
no vaccine is available for diseases caused by groups A
and B streptococcus, surveillance is important in
detecting outbreaks and assessing the effectiveness of
control measures. Other infectious diseases of
concern, such as tuberculosis, hepatitis B, respiratory
2.1 Public Health Surveillance
syncytial virus, HIV/AIDS and pertussis, have been
planned for the future.
When a case of invasive disease caused by an organism
under surveillance occurs in an ICS member country,
the identified case is reported to local public health
personnel who perform a chart review to capture
relevant clinical, demographic, and laboratory data.
Local laboratories send the isolate to national
reference laboratories for confirmation, serotyping
and antimicrobial susceptibility testing. These data
are then forwarded to the ICS coordinator at the
CDC’s Arctic Investigations Program in Anchorage
for analysis, report generation and information
dissemination. Data are reported in “real time” from
northern Canada and Alaska to ICS headquarters as
cases occur, whereas cases from other countries are
reported as end-of-year summary data.
The collection of standardized laboratory and
epidemiological data on infectious diseases among
ICS member countries has led to the formulation of
prevention and control strategies. In 2000, ICS
assisted with the identification of an outbreak of
invasive disease caused by S. pneumoniae serotype 1
occurring among young adults in two northern
regions of Canada. The extent of the outbreak was
determined using ICS data and resulted in vaccination
of adults with 23-valent polysaccharide vaccine, and
routine vaccination of children with 7-valent
pneumococcal conjugate vaccine (PCV-7) starting in
2002 (Proulx et al, 2002; Macey et al, 2002). Norway
began routine vaccination of children with PCV-7 in
2006 and this vaccine may come into routine use in
other northern European countries in the future. ICS
will continue to monitor the impact of this vaccine in
all member countries.
In early 2004, an increase in the number of cases of
invasive disease caused by non-type b encapsulated H.
influenzae was detected in both Alaska and northern
Canada. Non-type b H. influenzae (serotypes a, c, d, e,
f) is an uncommon cause of invasive disease in
children; however, with the decline in Hib disease in
the post-vaccine era, the importance of infections
caused by other non-vaccine serotypes has increased.
ICS data, shared among Arctic countries, contributes
to the detection of outbreaks occurring in the
circumpolar north, and is also a valuable tool in
15
 Public Health Practice in Circumpolar Regions: Lessons for Canada

evaluating vaccine effectiveness in northern countries Emergency preparedness and response are
with variable dates of vaccine introduction. approached similarly in most industrialized countries,
and the circumpolar North is no exception. The aim is
Further information on ICS is available from
to protect citizens’ health and security during times of
Parkinson et al (2008) and in the monograph by Zulz,
unexpected, extraordinary crisis situations, mobilizing
Bruce and Parkinson (2009).
and coordinating resources for assistance from
different sectors.
2.2 Emergency Preparedness In Norway, for example, as is the case with its health
and Response care system, responsibility is devolved to
municipalities and other local authorities, which also
Emergency preparedness has become a core public
implement preparedness exercises. Guidance is
health function in most jurisdictions. Although
centrally provided by the Directorate of Health of the
preparing for epidemics of infectious diseases has
Ministry of Health and Care Services, which is also
always been a task of public health, increasingly
responsible for national stockpile of selected
sundry types of disasters, both natural (hurricanes,
medicines (such as antivirals for pandemic influenza)
floods, earthquakes, fires) and man-made (terrorism,
and potassium iodide against radioactive iodine, a
industrial and transportation accidents, etc) have
possible contaminant from a nuclear accident. Finland
been added to the plate. Clearly public health agencies
has a 190-page preparedness plan, which is actually a
are only one of many players in any emergency
comprehensive and informative resource handbook
preparedness plan.
on all aspects of influenza and its control.
In the circumpolar North, Alaska is unique in being
All these national and regional plans have now been
prone to earthquakes and tsunamis, the result of plate
put to a severe test with the H1N1 pandemic. A cross-
tectonics in the circum-Pacific “ring of fire”. It actually
national comparative study, with special attention to
experienced the 1964 Good Friday Earthquake, the
the North, would be extremely instructive, in
strongest ever recorded in North America. The
understanding how and why the epidemic behaved
Nordic countries had their disaster experience being
differently in different regions, and how and why the
downwind from Chernobyl in 1986.
public health system responded to the epidemic
differently in different regions.

Figure 3a. Public tsunami warning sign in Seward, in

coastal southcentral Alaska
Figure 3b. Anchorage after the 1964 Earthquake

Alaska had a sort of “dry-run” with an outbreak of Kuskokwim Delta in February 2008 and managed to
respiratory syncytial virus infection in the Yukon- implement its plan and prevented the spread outside

16 Part 2 Public Health Programs

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
the region. The state health department also
undertook mass dispensing clinic exercises involving
thousands of citizens in 8 cities and towns. It also
tested the Strategic National Stockpile distribution
system throughout the state for vaccines, drugs and
ventilators received from national sources. These are
practices that Canada could have attempted in
preparation for the H1N1 pandemic in 2009.
2.3 Health Promotion
Nutrition and physical activity
Norway appears to be particularly proactive in
producing action plans on promoting healthy
lifestyles. Twelve ministries in Norway were involved
in the design and implementation of an action plan on
nutrition called Recipe for a Healthy Diet for 2007-
2011 with 73 recommendations grouped under 5
strategies: (1) availability of healthy food products;
(2) consumer knowledge; (3) qualifications of key
personnel; (4) local partnerships; and (5) nutrition
focus in health care services. Examples of specific
actions include healthy meals in kindergartens and
daycares, vitamin D supplementation for immigrant
infants, food marketing directed at children, and
nutritional training in the workplace and health care
system. The nutrition action plan followed on the
heels of an earlier action plan on physical activity for
2005-2009, again characterized by multi-ministry
collaboration.
In Sweden, a review of health promotion activities at
the municipal level indicates that 26 out of 290
municipalities had an action plan for physical activity
and only 13 had one for healthy diets (cited by
Backhans and Moberg 2008).
Finland has a particularly strong tradition in
partnerships with non-governmental organizations
such as the Diabetes Association and the Heart
Association in developing disease-specific strategies
and programs in health promotion.
The Greenland prevention program Inuuneritta has
intervention against poor diet and a sedentary lifestyle
as one of several focus areas. In addition to usual
public education activities, much emphasis is put on
training courses for health care workers and other staff
in these topics and also in funding school programs.
2.3 Health Promotion
Municipalities can apply for subsidies for school meal
programs.
Alaska’s Nutrition and Physical Activity Plan grew out
of the Alaska Obesity Summit in 2003, a multisectoral,
multiagency gathering which resolved to develop a
statewide plan. First and foremost of its overarching
goals is to increase awareness, followed by behavioural
change strategies to improve physical activity level,
healthy food choices, and healthy weights. It develops
separate targets for programs based in schools,
healthcare settings, communities, and mass
communication.
Several evaluation studies from Alaska have been
reported in the literature. A pilot study was conducted
among Alaska Native women in 2000-2001 by the
Southcentral Foundation as part of the
WISEWOMAN study, a randomised controlled heart
disease prevention program. The intervention
consisted of 12 weekly 2-hour educational sessions
taught by a multidisciplinary team (nutritionist,
exercise specialist, health educator, and traditional
wellness coordinator). At 12 weeks, significant
improvements were noted in moderate walking and
physical activity self-efficacy. Also observed was
substantial movement from the contemplation and
preparation stages to the action stage regarding
physical activity and heart–healthy eating (Witmer et
al, 2004).
In the Bering Sea region of Alaska, a 4-year diabetes
prevention program consisted of risk factor screening
and personal counselling focussing on increasing
consumption of traditional foods and decreasing
specific store-bought foods high in palmitic acid. It
reported significant reductions in plasma cholesterol
and improved glucose tolerance, although no weight
change was detected (Ebbesson et al, 2005).
Smoking
Control of smoking requires behavioural change
which can be induced through both individual
education and broader societal measures such as
enacting and enforcing laws to regulate sales and
promotion, prohibit smoking in public places and the
workplace, and increase taxation of tobacco products.
Such measures reflect the growing social
unacceptability of smoking, and they in turn reinforce
and promote non-smoking as a social norm. It is
17
 Public Health Practice in Circumpolar Regions: Lessons for Canada

noteworthy that both Nunavut and the Northwest
Territories have passed comprehensive Tobacco
Control Acts which prohibit sale of tobacco products
to youths under the age of 18, advertising/public
display, and also smoking in public places.
Alaska’s tobacco control program claimed credit for
the 38% reduction in adult smoking prevalence in the
decade since 1996. However, the overall prevalence is
still higher than the United States national rate, and
within Alaska, the Native rate is twice that of the non-
Native. The State health department provides Health
System Cessation Grants to tribal health authorities
for treatment services. Other activities include
enforcement of illegal tobacco sales to children, a quit
line, and grants to schools. The Southcentral
Foundation, one of the Alaska Native health
corporations, integrates smoking cessation in their
primary care settings, where every clinic visitor
undergoes screening on tobacco use and readiness to
quit; within their primary care team, the person is
then referred to a counsellor for follow-up and
pharmacist for nicotine dependence pharmaceuticals
(Fenn et al 2007). This is another example of the
opportunities for health promotion in primary care,
within a comprehensive integrated preventive-
curative health care system. A smoking cessation
program in the early 1990s at the Alaska Native
Medical Center in Anchorage involving behavioural
modification and transdermal nicotine patches
resulted in a quit rate of 20% at 12 months (Hensel et
al 1995).
In Greenland, although the smoking rates are still
high, the combined effort of legislations, taxation,
public campaigns and cessation programs have
reduced the prevalence from over 80% in the early
1990s to around 65% today.
Whatever Norway did, it had been successful.
Smoking prevalence peaked around 1970, with some
of Europe’s toughest legislation and a designated
government agency for tobacco control. It produced a
National Strategy for Tobacco Control 2006-2010,
which focuses on reducing uptake in tobacco use,
through restrictive legislation, high prices, and school
education; and smoking cessation, with a “quit line”
and cessation courses offered throughout the country
to train counsellors.
A report from the European Network for Smoking
Prevention evaluated tobacco control policies in 28
European countries and ranked them on the basis of
their efforts in six cost effective interventions. Iceland
comes up top, Norway third, Sweden sixth, Finland
ninth and Denmark sixteenth (Joossens 2004).
However, no such evaluation has been conducted
among the northern regions of these countries.

Table 3. Evaluation of tobacco control policies in the Nordic countries among 28 European countries
Policies (score allocated) Iceland Norway Sweden Finland Denmark
Price (30) 24 23 15 13 13
Public and workplace smoking ban (22) 16 16 15 16 2
Tobacco control budget (15) 15 6 3 2 3
Advertising ban (13) 13 12.5 11.5 12.5 10
Labelling/health warning (10) 6 6 6 7 6
Cessation treatment (10) 2 3 4 2 6.5
Total score [out of 100] 76 66.5 54.5 52.5 40.5
Rank [out of 28] 1 3 6 9 16
Decrease in prevalence 1985-2003 >25% >25% >25% <15% >25%

Source: European Network on Smoking Prevention (Joossens 2004).

18 Part 2 Public Health Programs

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada

1959 all tuberculosis patients were treated in

2.4 Disease and Injury Prevention Greenland. A hospital ship, the Misigssut, sailed along
the west coast every year from 1955 to 1971 to visit all
The circumpolar literature is substantially richer in settlements and summer camps to carry out
evaluative studies on disease control programs, tuberculosis examinations. By 1962 the situation was
especially in infectious diseases and cancer. firmly under control and the sanatorium was
converted to a general hospital. By the 1970s the
Control of infectious diseases incidence was approximately 10% of that in the 1950s.
The control of TB is of historical interest in that Because of this reduction, Greenland abandoned
different approaches were used among the Inuit in routine BCG-vaccination in 1990 (Stein 1968, Soborg
Alaska, Canada and Greenland in the second half of et al, 2001).
the 20th century. In all regions, the incidence of Alaska adopted a different strategy. Following a survey
tuberculosis had fallen quite dramatically since the in 1949-52 which showed that 25% of susceptible
1950s, although a substantial gap still existed between Yupiks in the Yukon-Kuskokwin Delta were infected
the Inuit and the national rates of Canada, Denmark each year, an intensive case finding, hospitalisation,
and United States. Tuberculosis remains a significant and out-patient treatment program was initiated. In
health threat in the Arctic. By the 1990s, the decline 1954 home-treatment with a combined regimen of
had slowed or even reversed, as shown in Figure 4. para-amino-salicylic acid (PAS) and isoniazid (INH)
In Greenland in 1949, a BCG vaccination campaign was started as a trial and accepted for broad use two
was carried out on the west coast, with the aim to years later. In 1957, a field trial of INH prophylaxis
vaccinate all tuberculin negative children. An was started in the Bethel area and in 1963 it was
increasing number of patients were sent to Denmark offered to all residents in the region (Comstock et al
for treatment. In 1954 Queen Ingrid’s Sanatorium in 1979, Fortuine 2005).
the capital Godhåb (now Nuuk) was built and by

2,500

Canadian Inuit
2,000

Greenland
TB incidence (per 100,000)

1,500 Greenland
Alaska Native
Canadian Inuit
Canada
Alaska Native
1,000

500

Canada

0
1955-59 1960-64 1965-69 1970-74 1975-79 1980-84 1985-89 1990-94 1995-99 2000-04

Figure 4. Trends in tuberculosis incidence among Canadian Inuit,

Greenlanders, and Alaska Natives, 1955-2004

2.4 Disease and Injury Prevention 19

 Public Health Practice in Circumpolar Regions: Lessons for Canada
The resurgence of TB in Greenland was attributed to
microepidemics in small, isolated settlements in the
south. Molecular epidemiological studies showed the
outbreaks to be locally confined. The increase made
the authorities to reintroduce BCG-vaccinations of
newborns in 1997 and to strengthen TB monitoring
and control. Drug resistance remains low in
Greenland (only 0.5% during 1998-2002), compared
to Inuit patients in Denmark (13%), offering hope for
effective medical treatment (Thomsen et al, 2004;
Skifte 2004).
Alaska had spectacular successes in its efforts to
control hepatitis A and B. In 1992, an HAV
vaccination program of more than 5,000 young
persons in 25 villages was able to halt an epidemic
within 3 weeks after administration in each
community. Universal childhood HAV immunization
was later initiated state-wide to all Alaskan children
age 2 and 18 years in 1996, resulting in the rate of
acute HAV falling from the highest in the country to
the lowest within 10 years. The use of
immunoglobulin proved to be unsuccessful during
previous epidemics, as the pace of the epidemics were
only slowed down temporarily while the public health
system was disrupted. In Canada and Greenland no
such vaccination campaigns have been initiated, but
the reduction in HAV epidemics may be caused by
increased sanitary standards (McMahon et al 1996).
For hepatitis B, a program of mass HBV screening and
vaccination of seronegative persons were
implemented in the 1980s in Alaska. Furthermore, all
infants were also routinely vaccinated. This program
had a profound impact, as the rate of acute HBV
infection fell from 200/100,000 in 1981 to <5/-
100,000 in 2002, and 10 years after routine
vaccination no children <10 years of age had
developed chronic infection. In Canada, targeted and
routine vaccination was introduced in 1985-1989 and
1995-1999 respectively. Target groups included
communities with high HBV prevalence, health care
workers, family contacts of chronically infected
persons, and infants. This has led to a progressive
decline in cases of acute HBV infections across
northern Canada. In Greenland, HBV vaccination is
offered to health care workers and to newborns of
chronically HBV infected mothers, but the impact of
this program has not been evaluated (McMahon et al
1987; Harpaz et al 2000).
20 Part 2
Incidence rates of invasive pneumococcal disease
(IPD) in Inuit are approximately four times that of
non-Inuit, with children under 2 and seniors aged 65
and above at the highest risk. Common serotypes
reported in the Arctic during the period 1999-2004
were 1, 3, and 14. As all three are included in the 23-
valent polysaccharide vaccine, and one serotype in the
7-valent conjugate vaccine, it has been estimated that
80% of IPD occurring in Alaska, northern Canada and
Greenland are potentially preventable with use of
these vaccines. In Alaska and select regions of
northern Canada, routine use of the 7-valent vaccine
began in 2001 and 2002, respectively. After its
introduction in Alaska, a 90% reduction in vaccine-
type IPD rates among Alaska Native children < 2
years of age and a 80% among non-Native children <
2 years of age were observed. In addition, there was a
40% decline in vaccine-type IPD in adults and a
reduction in antimicrobial resistant IPD for the entire
population (Hennessy et al 2005).
Haemophilus influenzae type b (Hib) is the
commonest cause of childhood meningitis prior to the
introduction of childhood conjugate vaccines in the
early 1990s. Prior to 1991, rates of invasive Hib
disease among Alaska Natives were among the highest
in the world, with rates >300 per 100,000 among
those under 5 years of age, four times the non-Native
rate in the state. Since the introduction of universal
infant vaccination, rates of disease have rapidly
decreased. By 2001-2004, the Native rates had
decreased by 98% to 5 per 100,000; however, the
disparities persist as in the non-Native population and
the rest of North America, the disease has virtually
been eliminated. Continued surveillance for invasive
diseases caused by all serotypes of Haemophilus
influenzae is needed to monitor the impact of
immunization programs and the emergence of other
serotypes (i.e. a and f) that may replace Hib and cause
severe illness. Singleton et al (2006) reviewed Hib
surveillance data from 1980-2004 in Alaska and
documented the disease’s near elimination since the
introduction of vaccination. There was a brief re-
emergence during 1996-2000 when the vaccine was
changed.
Cancer control and prevention
The control of cancer requires multiple strategies
directed at different stages in the natural history of the
Public Health Programs
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
disease: (a) primary prevention, by reducing the
prevalence of risk factors such as tobacco, alcohol and
diet, before the occurrence of disease; (b) early
detection or screening, sometimes referred to as
secondary prevention, to abort the progression to
invasive cancer; and (c) treatment for those
diagnosed with cancer, to improve survival and quality
of life.
While most cancer risk factors involve individual
behaviours or lifestyles, the physical environment also
plays a role. The accumulation of organic pollutants
and heavy metals in the Arctic food chain has
attracted a lot of attention. Their importance in
cancer development, however, is difficult to assess.
Although some have shown mutagenic and
carcinogenic potential in animal studies, the evidence
from human observational studies is inconclusive.
Their effect is likely small or the induction period for
these contaminants too long for the influence to be
detectable in cancer trends.
The viral etiology of HPV in cervical cancer and HBV
in hepatocellular carcinoma opens up the exciting
possibility that some types of cancer can now be
prevented by vaccination. The population-wide
effectiveness of HBV vaccine is now well established,
whereas the use of HPV vaccine was only licensed in
2006, and its long-term impact remains to be
determined.
Early detection of cancer either through organized
screening or medical vigilance is dependent upon a
well-organized health care system. The Arctic
generally lags behind in terms of such efforts. In
Greenland, a centralized population-based program
for cervical cancer screening was not implemented
until 1999, decades after its implementation in
Denmark. In Nunavut, only about 50% of eligible
women received a Pap smear during the period 1998-
2000, making it the jurisdiction with the lowest
screening participation rate in Canada (Healey et al
2003). However, by 2005, according to the Canadian
Community Health Survey (Statistics Canada
CANSIM Table 105-4042), the proportion of women
aged 18-69 who had at least one Pap test in the
preceding three years had risen to 79% in Nunavut,
exceeding the Canadian national average of 73%. The
other two northern territories also had higher than
national rates (Yukon 79%, Northwest Territories
2.4 Disease and Injury Prevention
84%). Clearly, intensive promotion of participation in
preventive services in the target population can be
achieved. The use of innovative technology is
particularly suitable for the Arctic with its scattered
and sparse population. In the Kivalliq region of
Nunavut, a colposcopy suite was established in the
1990s in the regional hospital for the diagnosis and
management of cervical intraepithelial neoplasia,
eliminating the need to transfer patients another
1,000 km further to the south to Winnipeg (Martin et
al, 1998).
Definitive diagnosis of most cancers requires
sophisticated and complex tools (such as computed
tomography, magnetic resonance impedance scans,
endoscopy, surgical pathology and biomarkers), and
by necessity such tools are concentrated in regional
centres. The unique challenges of health care delivery
in the Arctic is the need to strengthen primary health
care at the community level to ensure that patients
with possible cancer are identified and referred
promptly for further investigations.
The treatment of cancer is also highly specialized and
includes surgery, chemotherapy and radiotherapy.
Thus, patients are often required to travel long
distances and to be away from home during
treatment. Some of the more basic chemotherapy
treatments, i.e. the treatment of lung and breast
cancers, have been moved from Denmark to
Greenland. While such decentralization of treatment
will likely increase in the future, given the small size of
the Inuit populations, it will only be restricted to the
commonest types of cancer.
There is some evidence that the management of
cancer in the Arctic is less than optimal. Data from
Alaska suggest that Alaska Natives tend to be
diagnosed at later stages of their disease than U.S.
Whites. Their survival rates were lower, in both men
and women, for all sites combined. However, there is
ground for optimism as the survival rate had increased
between 1969-83 and 1984-94, particularly for
colorectal and live cancer (Lanier, Holck et al ,2001).
Finally, comprehensive cancer control requires
ongoing surveillance and monitoring. An
international working group has collected consistent
and comparable incidence data for the circumpolar
Inuit covered the period 1969-2003 (Young et al
2008).
21
 Public Health Practice in Circumpolar Regions: Lessons for Canada
In 2009, the Centers for Disease Control and
Prevention (CDC) provided funding to the Alaska
Native Tribal Health Consortium to establish an
Alaska Tribal Health System (ATHS) Colorectal
Cancer Control Program. The goal is to increase CRC
screening with a focus on those aged 50-64 using fecal
occult blood test, sigmoidoscopy and colonoscopy.
Injury prevention
Injuries in the Arctic comprise those that happen
wherever humans congregate – such as motor vehicle
crashes – and those that are unique to the Arctic
environment such as cold exposure, and accidents
from hunting or reindeer herding. Norway has an
action plan for the 2005-07 period which emphasizes
local injury prevention efforts under the WHO Safe
Community concept, and also the development of
comprehensive statistics to map injuries and
accidents. A number of Scandinavian municipalities
have been designated Safe Communities, the criteria
for which include programs aimed at both high-risk
environments and particular vulnerable groups.
An example of a community-based intervention
directed at reducing traffic injury which has been well
documented is the Harstad Injury Prevention Study
(HIPS), which was initiated in the northern
Norwegian city of Harstad (population 23,000) in
1988 (Yetterstad and Wasmuth, 1995; Ytterstad
2003).
The project utilized multiple interventions. Among
active measures were:
» Dissemination of local injury statistics and narratives
in a quarterly newsletter
» Promotion of traffic safety in local media
» Counselling to increase parental vigilance in traffic
safety for children
» Speeches to community organizations, clubs, service
agencies and schools
» Participation in health fairs
Passive measures include:
» Local restrictions on beer sale in grocery stores and
curfews for serving alcohol in bars and restaurants
» Building of separate pedestrian and cyclist roads,
lowering of speed limits, installing speed bumps, and
road modification in black spots
22
» Checks on vehicle for mechanical fitness and speed
limit enforcement by police
» Installation of additional high-mounted stop lights
» National law making local health authorities
responsible for injury prevention
Of particular interest was the use of injury statistics as
a tool of health promotion. HIPS responded to
requests for local data from school districts, city
planners, and private and public agencies. Based on
local injury data, media campaigns were launched to
lobby for road improvements. Data were also
provided to clubs and schools to promote behavioural
change.
To evaluate the effectiveness of the interventions,
traffic injury rates over 10 years were compared
between Harstad and Trondheim, the non-
intervention city (population 140,000) in the central
part of the country. Between Periods 1 and 4, traffic
injury rates declined 37% in Harstad, compared to
only 5% in Trondheim. Sample surveys were also
conducted post-intervention among 1,500 adults in
each city to evaluate changes in knowledge, attitude
and behaviours. The surveys showed that a higher
proportion of Harstad residents reported “often” and
“quite often” discussions among friends and family on
traffic safety issues. A higher proportion of Harstad
residents also reported that traffic injuries were
preventable. More than half of Harstad respondents
reported having acquired useful information or advice
from the traffic injury newsletter, the majority of
whom cited it as providing the stimulus for initiating
discussions on traffic issues.
2.5 Health Protection
Health protection, especially environmental health
issues related to air and water quality, often involves
ministries of the environment as well as health.
Subsidiary to these ministries are also special agencies
responsible for radiation protection and food safety.
Nordic countries such as Sweden and Finland are also
subject to European Union laws, regulations and
directives relating to the environment, for example, on
air pollution, pesticides, handling of chemicals, etc.
Swedish environment ministry cites several measures
as having positive impact on air quality: a system for
nitric oxide charges, environmental zones for heavy
Part 2 Public Health Programs
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
traffic, an environmental classification system for
motor fuels, the introduction of district heating, and
the provisions of the sulphur ordinance on sulphur
levels in oil.
A good built environment is one of Sweden’s
environmental quality objectives, and it is focussed on
physical aspects that affect health, such as radon levels
in homes and noise. The goal is that by 2020 buildings
should no longer have a negative impact on health.
Municipalities are responsible for physical planning,
including housing, roads and protection from
environmental noise. Preventive work against air
pollution takes place within the framework of
international negotiations, for example, within the
European Union.
Given the importance of Native subsistence hunting,
Alaska’s state health department’s environmental
health program [www.epi.hss.state.ak.us/eh/default.stm] is
very much focused on contaminants in fish and
wildlife. Its communication strategy is based on the
balance between nutritional benefits and health risks
of contaminants present in country foods. Its “Fish
Consumption Calculator” assigns points to different
fish species and the amount consumed per meal so
that consumers can mix and match its fish meals up to
a certain point score per week to avoid exposure to
mercury. Its maternal hair mercury biomonitoring
program is targeted at women in child bearing age;
through their health care providers samples are
submitted to and analysed by the state public health
laboratory. Individuals at risk are offered follow-up
investigations and mitigation strategies.
2.6 Maternal and Child Health
Maternal and newborn services are a key feature of
public health programs and serve as the first entry
point to the public health system for most families in
circumpolar regions. Maternal child services can
include treatment for HIV, nutritional counselling,
vaccination programs, growth monitoring,
developmental assessments, family planning and
other health programs and interventions.
Rates of maternal and infant mortality serve as
indicators of both a nation’s wellbeing and differences
in rates demonstrate inequities between nations. A
significant number of maternal and perinatal deaths
2.6 Maternal and Child Health
can be prevented and high rates can be a marker for a
number of socioeconomic determinants in a region.
Low maternal and infant mortality rates are found in
Nordic regions which offer comprehensive support
and care in pregnancy, childbirth, the postpartum
period and first year of life. Quality of services in
proximity to woman’s place of residence is also of
importance.
Maternal child health service delivery
Maternal child health services (MCH) include
primary care and prevention programs and services
which encompass prenatal care, birthing services,
postpartum follow up of mothers and infants, family
planning and abortion services.
The Nordic countries report some of the world’s best
maternal and infant health outcomes which in part
have been attributed to well coordinated prenatal
care, birthing services and follow up. In the service
delivery system, women and infants are followed by
primary care providers who are most often midwives
and provide a broad range of treatment and
preventive services. The Scottish Executive’s Expert
Group on Acute Maternity Services reviewed selected
international models of maternity care. Included were
Finland, Sweden and Norway (Scottish Executive
2002). Some of the key findings from the report are
summarized below.
In Sweden all elements of maternity care are provided
as part of the national health system. Most care is
provided by a midwife with two visits to the
obstetrician as part of routine antenatal care. GPs are
rarely involved in providing care. 99% of women
receive their maternity care through coordinated
system of clinics for antenatal and postnatal. 99% of
births take place in hospital and home births are rare.
Much of the emphasis is placed on social issues and
multidisciplinary team work. The caesarean section
rate in 1998 was 13.4% and breastfeeding rates are
very high.
Maternity care in Finland is provided by midwifes,
public health nurses, GPs and gynaecologists.
Municipalities can employ midwives and public health
nurses to provide ante- and postnatal care. Most of the
antenatal care is provided by the midwife or public
health nurse in community based clinics; women are
then are referred to the hospital for intrapartum care.
23
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Outcomes are good, mortality and morbidity rates are
very low and breastfeeding rates are high.
Norway has 60 maternity units, the care is free and
used by over 99% of women. Most of the care for low
risk women is midwifery led, and there is close
partnership with GPs and obstetricians. At the
regional level there are several small maternity units
which are independent of hospital. The home birth
rate is <0.5%, intervention rates are approximately
25% (caesarean section and instrumental delivery)
and breastfeeding rates are over 99%.
Greenland generally follows the Nordic model in the
delivery of maternal and child health services,
although not in terms of outcomes as its infant
mortality is almost three times that of Denmark.
Children’s health is identified as one of the nine focus
areas of Inuunerita, with the emphasis on timely
intervention for prenatal care and services to at-risk
families. MCH services in Alaska is more similar to
that of southern Canada with services provided by
both public health nurses in the state system and
physicians and pediatricians in the private sector.
However, for Alaska Natives a comprehensive does
exist where MCH services are integrated with primary
health care.
Registries and data
In the Nordic regions outstanding birth registries and
maternal child cohorts are integrated with the
comprehensive service delivery systems, notably the
Medical Birth Registry of Norway, based in Bergen
and established in 1967 [www.fhi.no/eway/-
default.aspx?pid=238&trg=MainArea_5811&MainArea_5811=58
95:0:15,3320:1:0:0:::0:0] and a similar system in Finland
established 1987 [www.stakes.fi/EN/tilastot/filedescriptions/-
medicalbirthregister.htm]. Unique ID-numbers facilitate
linkage within and between these registries and other
databases maintained by the national public health
institutes. With over four decades of data collection,
the Norwegian Registry can now perform
multigenerational studies. These databases serve as a
rich resource for information on maternal and child
health, which is widely disseminated via annual
reports, research publications, and web access by the
public at no cost.
On the other hand countries such as Russia struggle
and the limited quality of data in some regions makes
24
it difficult to obtain accurate or comparable rates.
Under resourced regions can have challenges with
registration of births and standardization of diagnosis
(WHO Europe 2005). In recent years the University
of Tromsø provided technical assistance in
establishing a birth registry in Northwest Russia
(Vaktskjold et al 2004).
2.7 Determinants of Health
While most public health agencies subscribe to the
concept of the determinants of health, none actually
have an administrative division or program labelled as
such, which is understandable since the concept itself
implies that the “action” would/should occur outside
the health care system. How circumpolar public
health agencies are involved in promoting the concept
and translating it into action is discussed under 3.3
Health Disparities and Inequalities, and 3.6 Inter-
sectoral Coordination and Collaboration.
An excellent case study of the interconnectedness of
health determinants and the important health impact
of policies and events in the non-health sectors is
provided by Finland, which reduced taxes on alcohol
and abandoned import restrictions in 2004. Prices of
some spirits fell by 36%! The impact on health was
almost immediate, with increase in alcohol
consumption and alcohol-related mortality, and
exacerbated existing socioeconomic differences in
health outcomes.
Several circumpolar projects are underway to capture
on a comparable and consistent format key social,
cultural, and economic indicators which should be of
interest to health planners and researchers. The Arctic
Social Indicators project (ASI), coordinated by the
Stefansson Arctic Institute in Akureyri, Iceland
[www.svs.is/ASI/ASI.htm], intends to monitor and track
human development in the Arctic, based on a small
number of indicators falling within six domains:
» Fate control and/or ability to guide one’s own destiny;
» Cultural integrity or belonging to a viable local culture;
» Contact or close interaction with natural world;
» Material well-being;
» Education;
» Health and population.
Part 2 Public Health Programs
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada

Statistics Norway produced Economy of the North

(Glomsrød and Aslaksen 2009), updating an earlier
extensive review of economic indicators in all Arctic
regions. The Survey of Living Conditions in the Arctic
(SLICA) [www.arcticlivingconditions.org] is an international
collaborative effort that pooled data several regional
interview surveys on some 7,000 indigenous people in
Alaska, Greenland, Canada and Chukotka. A
summary of the results and some 500+ statistical
tables have been released. Statistics Canada
participated by contributing data from the 2001
Aboriginal Peoples Survey.

2.7 Determinants of Health 25

 Public Health Practice in Circumpolar Regions: Lessons for Canada

Part 3 Cross Cutting
Themes
3.1 Governance, Financing, and
Management
The Nordic model of public health is characterized by
significant decentralization, down to the municipality
level, with a high degree of autonomy, both political
and fiscal. Municipal services, including health care,
are financed by municipal taxes and central
government subsidies, which are not all “tied” to
specific programs. In the case of Finland, the share of
central government funding at the municipal level had
been reduced in the last decade. The “clout” of the
central government lies in legislative power,
information guidance, and “ideological” steering.
Influence is exerted through developmental project
funding (Palosuo et al 2008).
Figure 5 provides an example of the organization of
public health programs that is quite typical of the
Nordic countries, and not unlike that of Canada,
which is a combination of decision making powers
vested in the national health ministry while
implementation and expert advice is in the hands of
subsidiary agencies such as national institutes of
public health and advisory bodies.

Figure 5. Example of public health program management: the national immunization program in Finland
Reproduced from Rapola (2007); KTL refers to the Finnish National Institute of Public Health.

International comparison of health expenditures is
fraught with difficulties. Agencies such as OECD
annually provide data on most of the circumpolar
countries (excluding Russia and Greenland), but not
regions within countries. While adherence to the
International Classification of Health Accounts allows
the separation of prevention and public health
services [HC.6] from personal health services [HC.1-
HC.5], it should be noted that some public health
services cannot be disaggregated from primary health
care, especially in countries where such services are
closely integrated. Countries where “public health” is

26 Part 3 Cross Cutting Themes

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada

more centralized and more easily identifiable in
national accounts tend to show higher expenditures.
With such caveat, Canada ranks first in terms of the
per capita expenditures on public health and
prevention and has the highest share of total health
expenditures devoted to public health (Figure 6).
Unfortunately breakdown of total health expenditures
into public health and other types of use at the
territorial level is currently not available from the
Canadian Institute of Health Information’s National
Health Expenditures database.

Figure 6. Public health and preventive services: per capita expenditures in US$ purchasing power parities
and as share of total health expenditures
Source: OECD Health Data 2009, based on 2007 data.

next 10 years. It sets the agenda for a healthier

3.2 Policy and Planning
Canada’s northern territories have produced their
own strategic plans for public health or health care –
Nunavut’s Developing Healthy Communities (2008)
and NWT’s Foundation for Change (2009). While
Yukon has not produced a similar document, its
Health Care Review (2008), while focusing on funding
issues, did propose enhanced activities in health
promotion. National public health strategies
developed in the Nordic countries tend to have a
longer view and subscribe strongly to the social
determinants of health model.
Norway’s White Paper (2002–2003), Prescriptions for
a Healthier Norway: A Broad Policy for Public Health,
outlines the national public health strategies for the
Norway, achieved through a policy that contributes to
more years of healthy life for the population as a
whole and a reduction in health inequalities between
social classes, ethnic groups and genders.
Sweden’s Public Health Objective Bill, which was
passed by parliament in 2003, is an example of a
comprehensive coordinated policy. It has 11
“domains of objectives”, representing a mix of
upstream and downstream approaches. Rather than
focusing on health and disease, the objectives deal
with health determinants on different levels. Six
domains concern structural causes of social
inequalities – participation and influence in society,
economic and social security, secure domestic
environment during childhood, healthy working life,

27
 Public Health Practice in Circumpolar Regions: Lessons for Canada
healthy and safe environment, and a health promotion
oriented health service. The remaining five are
directed at health-related behaviours such as hygiene,
safe sex, physical activity, diet, and use of tobacco,
alcohol and drugs. Instead of quantifiable goals, a
desirable direction is suggested and progress is to be
measured with selected indicators.
Finland’s Health 2015 Programme was adopted in
2001 and contains 8 specific targets related to child
health; tobacco, alcohol and drugs; injuries; working
life; functional capacity of the elderly; increase in
overall life expectancy by 2 years; increase in
satisfaction with the health services; and reduction in
health inequalities.
Greenland’s public health program for 2007-2012,
called Inuuneritta, was made into an act of parliament
which was passed in 2006. In that sense the strategy
has the force of law and not just a bureaucratic
instrument, an approach that is also undertaken by
other Nordic countries. The areas of focus reflect
Greenland’s epidemiologic situation: alcohol and
drugs; violence, rape and sexual assault; suicide; diet
28 Part 3
and physical exercise; smoking; children and youth;
elderly; and dental health. It had few quantifiable
goals although part of the strategy was to develop
measurable indicators.
The Alaska state health department initiated an
Alaska Public Health Improvement Process with wide
participation from community partners and funded by
a grant from the Robert Wood Johnson Foundation.
It produced in 2001 Healthy Alaskans 2010 as a
“roadmap” to guide public health policies. It was
adapted from the national Healthy People 2010 and
consists of 26 “focus areas” grouped under health
promotion, health protection, preventive services and
access to care, and public health infrastructure. As a
planning document, it is well organized and
informative, outlining for the focus areas the issues
and trends for Alaska, current strategies and resources,
and data needs.
Within the State health department, the Division of
Public Health’s “strategic map” for 2007-2009 offers a
glimpse of how it sets its priorities and plans its
activities (Figure 7).
Cross Cutting Themes
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada

Figure 7. Strategic map of the

Alaska State Department of Health and Social Services, Division of Public Health

etc., but it is not possible to distinguish them on the

3.3 Public Health Human
Resources and Capacity
It is very difficult to separate out “public health”
human resources from overall health services human
resources, especially in the regional context. For many
jurisdictions it is only possible to determine the
distribution of physicians, nurses, midwives, dentists,
basis of their public health role. Many individuals in
fact, especially in jurisdictions where public health and
primary care are integrated, perform both functions.
A separate study with full access to primary
administrative and personnel data is needed to truly
describe and analyse public health human resources
and capacity in the circumpolar countries and regions.
There does not appear to be a published study on this

3.3 Public Health Human Resources and Capacity 29

 Public Health Practice in Circumpolar Regions: Lessons for Canada
topic. It is also not clear if there is any international
comparative framework that establishes equivalency
in job titles and job descriptions as they relate to
public health.
In the absence of public health-specific data, the issue
of whether the North is relatively over- or under-
served can be gauged indirectly in terms of health
human resources in general. Data on physicians and
nurses are the best documented for all regions. While
Canada’s northern territories and Greenland have far
lower rates of physicians than Canada and Denmark,
this is not the case in the Nordic countries or Russia,
where some northern regions actually exceed the
Figure 8. Employment retention of three categories of health staff in four Alaska Native health regions
Source: Fischer et al (2003)
This study shows that community health aides, mostly
recruited from among the communities where they
serve, had better retention record than either
physicians or nurses, whose median length of stay was
less than 2 years. The study did not investigate
provider or other characteristics that might predict
longer stays. There is a dearth of rigorous evaluative
literature on recruitment and retention strategies in
the Arctic, although descriptions of programs in
30 Part 3
national norms. For nurses, the rate in the Canadian
North is substantially higher than that for Canada
nationally because of the nature of the system that is
predominantly nurse-based, with nurses practising in
the expanded role of nurse-practitioners. For the
other regions, there is no consistency in terms of a
northern deficit or excess.
Retention of health staff is a major problem in remote
areas. A study in four remote Alaska Native health
regions computed “survival” curves for three
categories of staff — community health aides/
practitioners, physicians and nurses (Figure 8).
various jurisdictions, especially for nurses, have been a
perennial favourite topic in the circumpolar health
congresses.
While public health staff working in the North
normally obtain their training anywhere in the
country, there are some northern-oriented public
health training programs that are located in the North.
The Nordic School of Public Health in Göteborg,
Sweden [www.nhv.se] offers Diploma, Master’s and
Cross Cutting Themes
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
Doctor of Public Health degrees. While it is located in
a circumpolar country, it is not in a northern region as
defined in this review. As with many Nordic
institutions, this school has an international outlook
and does not particularly focus on training people for
service in the North. Three programs that are located
within the North and have a specific mandate for the
North:
» International Master of Circumpolar Health,
University of Oulu, Finland [arctichealth.oulu.fi/suomi/-
maisterikoulu.html]
» MPH program, University of Alaska Anchorage
[health.uaa.alaska.edu/mph/]
» International School of Public Health, Northern State
Medical University, Arkhangelsk, Russia [www.ispha.ru]
A major constraint in the formal graduate training of
public health staff is the difficulty of existing (but
under-qualified) staff to take time off for formal
courses leading up to the MPH or higher. This is by
no means unique to the North but is clearly
exacerbated by geographic distance. Distance learning
is thus the most appropriate approach to engage and
attract students from the North and educational
technology is now fully capable to delivering such
programs effectively.
3.4 Health Disparities and
Inequalities
Equity is an explicit objective of the Scandinavian
countries’ health systems, reflected in specific policies,
strategies, or agencies. These initiatives have their
origins from the 1980s under WHO’s Health for All
2000 banner. With their well established welfare
states, social inequalities are actually much less acute
than other “rich countries” such as Canada and the
USA. It is interesting that in the make-up of their
health ministry, the agencies responsible for standards
and quality in health care are generally also tasked
with ensuring equity.
Norway produced in 2006 a white paper called
National Strategy to Reduce Social Inequalities in Health
which called for the reduction of inequalities by
addressing the distribution of health determinants,
especially “upstream” ones. It has the slogan “equity is
3.4 Health Disparities and Inequalities
good public health policy”. The strategy focuses on
four areas:
(1) Reduce social inequalities in income, childhood
conditions, education, employment, and working
environment;
(2) Reduce social inequalities in health-related
behaviours such as nutrition, physical activity,
smoking, and substance abuse, as well as health
care utilization;
(3) Targeted initiatives to promote social inclusion;
(4) Develop knowledge and cross-sectoral tools.
This strategy is noteworthy in its practicality and
feasibility, balancing both societal response and
individual responsibility.
Finland’s Government Resolution on Health 2015,
promulgated in 2001, defined reducing health
disparities among population subgroups as a central
goal. Reflecting the country’s homogeneous
population, the focus was on stages of the life course,
gender and occupational groups rather than ethnicity.
It was innovative in establishing targets for reducing
mortality differentials by 20% in 15 years. However,
according to an evaluation of welfare and health
promotion in Finnish municipalities, less than a third
of municipal managers reported that reducing
inequalities was part of their municipal action plans
(cited in Palosuo et al 2008). It was also pointed out
that much research on health inequalities has focused
on their level and extent and what factors were
responsible for them, but not so much on specific
interventions that could actually reduce inequalities.
This is by no means unique to Finland.
Finland has adopted a universalistic policy approach,
that by ensuring equal access to services and benefits
for all citizens regardless of their social background
and geographical location, inequalities will be
reduced. According to one critic, not much attention
has been paid to see if such services and benefits
actually reach all subgroups equally, and that they
produce equal results (Palosuo 2008).
In 2008 Finland released the National Action Plan to
Reduce Health Inequalities for the next three years
(within the term of office of the current government).
It proposes three priority areas in social policy
(addressing income security, education, employment
31
 Public Health Practice in Circumpolar Regions: Lessons for Canada
and housing); healthy lifestyles especially in
disadvantaged groups; and equal access to good
quality social and health services. The focus on service
delivery appears to be unique to Finland and not
shared by the other Nordic countries.
Norway’s approach to inequalities appears to have
shifted over the years. In a review of policy documents
in the 1990s, inequality was mainly perceived of in
terms of disadvantaged, vulnerable, or marginalized
groups and individuals – e.g., low income families,
immigrants, mentally ill, drug addicts, homeless, etc,
rather than as something that occurs across the social
gradient, and is thus relevant to the entire population
(Dahl 2002). As a follow-up to the White Paper on
Public Health of 2003 and the subsequent national
strategy to reduce social inequalities, there was a shift
in focus away from targeting only the poorest groups
to addressing the social gradient in the population
(Fosse 2008).
Sweden’s Public Health Objective Bill seems to
embrace both the universalistic and the targeted
group approaches. It states explicitly that the national
public health goal is to “create social conditions to
ensure good health, on equal terms, for the entire
population”. At the same time, it also states that
“public health should improve the most for groups
that have the worst health status.”
Dahl (2002) applied Whitehead’s (1998) Action
Spectrum to characterize Norway’s efforts in reducing
health inequalities during the 1990s as belonging in
the lower end, consisting mostly of “measurement”,
“awareness raising” and indifference. According to
Fosse (2008), the development of the action plan has
now moved Norway up the spectrum to the middle
section, consisting of “more structured development”
and “isolated initiatives”, but still not reaching the
strongest level of commitment. These are perhaps
unnecessarily harsh critiques of the Nordic
experience, at least from the standpoint of North
America.
It is interesting that in none of the Nordic countries
are the Sami singled out for “redressing” inequalities
or identified as a group with special needs, unlike
groups such as immigrants and refugees (more so in
Sweden and Norway than Finland) which are
approaching a significant proportion of the
population, especially in the urban centres, and
32 Part 3
started to be of concern to the health system long
accustomed to a homogeneous native-born
population. This has not escaped the criticism of Sami
organizations which emphasize their need for
culturally specific health programs. The invisibility of
the Sami in national policies on health inequalities is
partly because there are basically very little disparities
in health status between the Sami and other citizens,
or between the North and South.
3.5 Performance Measurement
and Evaluation
It is difficult to gauge the extent to which public health
programs are evaluated by various governments, as
often the documentation remains internal and not
accessible. Independent researchers have focused on
specific policy issues, such as reducing health
inequalities [see Section 3.4 above].
The Nordic countries have well established registries,
databases and periodic population surveys to enable it
to evaluate broad population health policies and
specific programs. In Finland, the FINRISK, the Adult
Health Behaviour Survey, the School Health Survey,
and the Seniors Health Behaviour Survey are
conducted at regular intervals by the National Public
Health Institute. Sweden has conducted National
Public Health Surveys during 2004-2006.
Sweden has taken a first step towards formal national
evaluation of its public health policy and its effects on
changing the distribution of health determinants. The
National Institute of Public Health produced the first
Public Health Policy Report in 2005. It presented a
limited number of indicators relevant to the
overarching public health goals and objectives.
However, a limitation of such evaluation particularly
at the regional level, is the decentralized nature of the
health system, and indeed of government in general,
and the multiplicity of players involved – by virtue of
the nature of “health determinants”.
The National Institute of Public Health in
Copenhagen conducts recurrent health surveys on
behalf of the Greenland government. The Inuuneritta
program will undergo external evaluation in 2010-11
to guide the government determine its future action
and funding.
Cross Cutting Themes
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
The Healthy Alaskans 2010 process can be considered
an undertaking in health monitoring because of its
elaborate health goals, indicators and targets, and the
development of a data system to capture both the
baseline situation and to evaluate progress. Alaska is
part of the CDC’s Behavioral Risk Factors
Surveillance System [www.hss.state.ak.us/dph/chronic/hsl/-
brfss/default.htm] which conducts monthly telephone
surveys across the state asking respondents questions
relating to health-related behaviours and lifestyles. It
is the major source of health information for the state
and is used extensively in planning and evaluation.
Other data systems include the Alaska Youth Risk
Behavior Survey and the Pregnancy Risk Assessment
Monitoring System (PRAMS).
3.6 Citizen Engagement and
Public Education
Greenland’s Inuuneritta was summarized in a
brochure and distributed to all households in the two
largest towns, Nuuk and Sisimiut, and all hospitals
and health facilities in the rest of the country. As a
piece of legislation, it therefore has democratic appeal
beyond simply a government technical document.
Finland’s Ministry of Social Affairs and Health
organized a series of regional health promotion
seminars in 2006 to provide support for regional and
local activities in advancing implementation of the
Health 2015 Program.
In terms of reporting to citizens on the state of their
health, Finland’s Ministry of Social Affairs and Health
compiles a social and health report Health in Finland
every fourth year and submits it to parliament, the
most recent one being the revised English edition
published in 2006. Sweden’s National Public Health
Report is also published every fourth year. These
reports serve to highlight government initiatives but
also educate the public regarding the state of their
health, the causes of ill health, and actions that can be
taken to improve health.
Public consultations and community partnerships are
widely used in Alaska, in such endeavours as the
Alaska Public Health Improvement Process leading
up to Healthy Alaskans 2010 as well as the preparation
of various strategic plans relating to diabetes, nutrition
and physical activity.
3.6 Citizen Engagement and Public Education
3.7 Intersectoral Coordination
and Collaboration
Almost all significant public health programs in any
country call for intersectoral and multi-agency
coordination and collaboration, especially if
addressing social inequalities in the distribution of
health determinants is declared the main objective.
Again, the Nordic countries appear to lead the way in
truly engaging multiple ministries in improving
population health.
Greenland’s Inuuneritta implementation and
evaluation involves not just the relevant governmental
and nongovernmental health agencies, but also the
Church and the police, reflecting the country’s social
mores and the strategy’s focus on the social
pathologies.
In delivering primary services in municipalities,
Finland’s Oulu region has an innovative training
program in interprofessional collaboration that brings
together nurses, doctors, psychologists, social
workers, teachers and daycare workers. The program
is spread over 2 years, equivalent to 800 hours of
combined independent studies and 2 days per month
of contact time. An evaluation study among nurses
found that the program did effect attitudinal and
behavioural change but concluded that a long-term
process of education is needed (Taanila et al 2006).
3.8 Knowledge Translation
The concept of knowledge translation has
increasingly been recognized to play a critical role in
the research process. The process of knowledge
translation ensures relevant findings are accessible
and packaged so they may inform decision makers
and community stakeholders in the development of
policies, programs and inform best practices. There
are few instances where the impact of specific research
projects have been assessed in terms of their impact
on policies, programs, and practices. The Canadian
Academy of Health Sciences’ panel on “return on
investments in research” proposed a framework for
measurement (2009). Such a study is urgently needed
to examine research impacts on public health services
in the circumpolar regions.
33
 Public Health Practice in Circumpolar Regions: Lessons for Canada

As an example, Finland appears to have taken

significant steps to translate the findings of one of its
most celebrated research projects – the North Karelia
Project (1971-1997) – into national action to control
and prevent cardiovascular diseases. Over three
decades the epidemiologic profile of the country
actually changed as a result of knowledge generated
from the research. This experience has sparked
international interest and has served as a model for
community-based health promotion worldwide. The
experience of this project has been thoroughly studied
and documented over the years, which has been
conveniently summarized in book form recently
(Puska et al 2009).
Some of the vaccine trials, especially those conducted
in Alaska [see Section 2.4], have also resulted in
relatively quick policy change and implementation on
a statewide basis, with impressive reduction in
morbidity.

34 Part 3 Cross Cutting Themes

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
Part 4 Lessons for
Canada
This section explores the relevance of the circumpolar
experience in public health for Canada. For Canada to
learn from other circumpolar regions, it should be
understood at the outset that the concept of “North”
is very different in the different countries.
Understanding the northern context
A nation’s “polar identity” is a complex issue and often
subject to debate. The question that arises is – is one a
“polar nation”, or a “nation with a polar region”?
Perspectives are influenced by history, geography and
politics. For a resident in Canada’s northern
territories one’s polar identity is in the forefront in
many day to day activities, which is understood by
territorial policy makers. Examples abound, from
Sarah Palin’s famous statement about being able to
see Russia from Alaska, to children who grow up
participating in Arctic Winter Games with their peers
from Russia, Greenland, Alaska and the Nordic
countries, and residents in the Beaufort Delta who
share family ties and hunting grounds with residents
in Barrow, Alaska. In general one does not need to
explain to a resident of Inuvik, Iqaluit or Whitehorse
what is to be northern or how they may relate to a
circumpolar country. However, for many Canadians
and government agencies, “North” is a separate
jurisdiction. Thus national programs are first
developed and established, and then northern
perspectives are accommodated via the development
of specific strategies. Only in recent years, with
increased attention to changes occurring as a result of
climate change, are Canadians seeing their linkages
with the North. Thus it is not coincidental that
national agencies and governments are turning their
attention to northern strategies. Great potential lies
ahead as northern leaders, policy makers and
stakeholders are engaged in a national agenda which
incorporates Canada’s polar identity.
In general, “North” in Canada means “north of 60”,
where the total population size is small and
population density low, where there are few cities
(none of which having populations larger than
20,000) and many widely scattered small settlements
with poorly developed infrastructure. The North is
further fragmented from the rest of Canada by its
territorial status and diverse governance powers in the
regions. In Scandinavia, almost the entire country of
Finland and Norway lies north of 60, including the
capital cities with their parliaments, palaces, and grand
institutions. There is no psychological threshold when
one crosses the Arctic Circle. There are few programs
or practices in the North that are specifically
developed for the North, where national models tend
to prevail.
Alaska is similar to northern Canada in many respects,
with its federal/state structures. However, its parallel
systems for Alaska Natives and everyone else in the
State is not followed in northern Canada, where
historically it was the Aboriginal health care system
that was “open” to non-Aboriginal residents of the
territories. Today, health care is administered by
territorial governments with services at the regional
level delivered under different models in the three
territories. The federal government continues to
provide funding for non-insured health benefits for
Aboriginal groups.
Demographically and geographically Greenland could
almost be conceived of as a mirror image of Nunavut,
but Greenland is practically an independent country.
While the self-rule government is heavily subsidized
by Denmark, its health system does not have a
“higher” authority in Denmark to which it reports to,
or from which it receives program funding.
These “contextual” differences among the various
circumpolar regions thus need to be recognized
before one contemplates comparisons and selection
of best practices for emulation. Further study in this
area is warranted.
Integrating public health in the northern health
care system
It is notable that in the Nordic and Greenland models,
there are no “public health units” as such at the
regional level delivering “public health services”.
Scandinavian countries offer clear examples of how
public health can be successfully integrated with
primary care based in municipal health centres. The
lower expenditures on public health in the Nordic
countries shown in Figure 6 in fact attest to the
difficulty of separating specific “public health”
activities from primary health care rather than a lower
35
 Public Health Practice in Circumpolar Regions: Lessons for Canada

level of services. Moreover, population health best practices for service delivery in the northern
outcomes in the Scandinavian North is unsurpassed territories. Promoted is a model where decision
elsewhere in the circumpolar world. makers, practitioners and researchers work in close
partnership to evaluate, research and use results to
On paper, public health is already integrated with
improve service delivery models. These partnerships
primary care in Canada’s North, at least at the level of
put knowledge translation front and foremost in the
health centres in the communities. While there are
research process, increasing the uptake and
clear benefits for such integration, it has proven taxing
application of findings to enhance systems
to have the same individual delivering both services,
improvements. Although public health has not been a
and often primary care takes priority. The public
major focus of CHSRF in the past, with suitable
health programs within the health centres tend to be
funding partnerships with agencies such as PHAC, the
delivered by a nurse practitioner through individual
planning and evaluation of public health services in
clinics which focus on maternal child health, well
the North can be given a much needed boost.
woman care, immunizations and in some cases also
Similarly, CIHR’s Partnerships for Health System
elder care. The public health program framework was
Improvement [www.cihr-irsc.gc.ca/e/34347.html] program
developed many decades ago and has not undergone
can be tapped for designing and testing innovative
any critical evaluation or strategic renewal. Further
approaches to public health models for the North.
evaluation is required to assess the alignment of public
health programs with national and territorial
Developing public health human resources for the
strategies and establish a model with allows for the
North
maximization of roles in the delivery of public health
services. Two types of public health practitioners are needed
for the North – at the community level and at the
Nunavut’s public health strategy (2008) does call for
headquarters of regional health authorities, regional
“reconfiguring organizational structure to facilitate
government offices, and territorial health
public health teams at all levels” and the Northwest
departments. At the communities are public health
Territories (2004) has developed an integrated
nurses and CHR with special training in public health.
service delivery model which strives to improve links
Such training can be conducted within the territories
between the many service providers. Both of these are
through the colleges (Yukon College, Arctic Nunavut
examples of strategic approaches which show promise
College, and Aurora College). Baccalaureate degree
to guide a response which will allow for improvements
programs in nursing are already offered by the
in public health services delivery and specifically the
northern colleges through partnership agreements
maximization of roles. The key lies in the translation
with universities. These programs tend to be well
of strategies to system improvements on the ground.
designed and are responsive to training graduates to
It is a complex task, but not insurmountable.
work in northern settings. These programs, however,
Neither the Alaskan model of using health aides does not include any advanced or specialized training
(many with previous training or experience as in public health.
physician assistants) as primary care providers nor the
MPH-level public health professionals are needed for
Greenland model of posting physicians in small
disease surveillance and health monitoring,
hospitals are practicable in the Canadian North today.
epidemiologic analyses and data management, health
There is, however, already in existence a cadre of
planning, program design and evaluation. Specialists
health workers - the community health
in nutrition, mental health, chronic disease, injury
representatives (CHR) - who can be specifically
prevention, and infectious disease control are also
trained to perform most public health functions in the
needed.
communities under nursing supervision, and their
workload will not be affected by the fluctuating Support for masters and doctorate level training in
demands of acute care. public health has in the past come from outside the
North. However in recent years PHAC has allocated
The Canadian Health Services Research Foundation
supports for graduate students in epidemiology and
[www.chsrf.ca] has been active in promoting research on

36 Part 4 Lessons for Canada

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
public health to conduct practicum and thesis work
based in the North. Partnerships have been formed
between northern agencies, PHAC and universities.
This organizational match has been found to be an
optimal mix of strengths which allow for components
of masters level education to be based in the North.
Out of these partnerships more formal and sustainable
affiliations are being formed. The Institute for
Circumpolar Health Research (ICHR) and the
University of Toronto Dalla Lana School of Public
Health have signed institutional affiliation agreements
which recognize the shared mandate for research and
training at the graduate level in public health. Staff
members at ICHR have been appointed as faculty,
which allows for better standardization of supervision
and recognition of northern contributions. This
framework will allow for more sustainable
development of opportunities for MPH education
based in the North. Potential exists to offer a
combination of group classes in core courses in
northern locales (e.g., in summer institutes) and
distance learning options. Practicum training for 3-6
months can provide northern “context” and real-
world experience for trainees.
The University of the Arctic is touted as an “university
without walls” and uses both distance learning and
classroom settings to deliver courses. Northern
colleges are at various stages in developing their role
within this partnership. Yukon College currently
offers a course on site which is part of the Bachelor in
Circumpolar Studies program. At present the colleges
do not participate in UArctic’s health programs. The
masters in circumpolar health and wellbeing is based
at the University of Oulu and, through UArctic,
involves universities in Finland, Sweden, Denmark,
Russia and Canada. Canada’s participation in UArctic
is via universities based in the provinces and students
in Canada conduct their studies in the south. The
course work focuses on the wellness of circumpolar
residents and takes an interdisciplinary approach.
Specific courses related to public health practice have
not been developed.
An innovative educational program is Dechinta
[dechinta.ca]. It is a northern-led initiative to deliver
land-based, university credited educational
experiences led by northern leaders, experts, elders
and professors to engage northern and southern youth
in a transformative curriculum based on the needs of
Canada’s North. It will offer its first courses in 2010.
One course will focus on health promotion planning
and evaluation and will target individuals employed
by community based organizations who organize
health promotion programs. The work will be
accredited by the University of Alberta and creates an
opportunity to potentially apply work towards degree
requirement. This is an example of university
accredited opportunities in the North.
There are many other opportunities and partnerships
which exist for skills enhancement and training of
northern public health workers. Distance programs
exist for advanced training in public health such as the
MPH offered by the University of Alaska Anchorage,
Johns Hopkins, and the London School of Hygiene
and Tropical Medicine. The University of Waterloo is
the first Canadian university to offer an online MPH
[www.ahs.uwaterloo.ca/hsg/mph].
PHAC also has various skills enhancement programs
which are well subscribed by northerners. The online
program [www.phac-aspc.gc.ca/sehs-acss/index-eng.php] has
provided opportunities for training of northern
residents working in public health. Pilot studies have
been done to evaluate the needs of individuals
working within Indigenous organizations where some
public health functions occur.
The ability to obtain additional training and higher
qualification in public health without leaving the
North for extensive periods of time would be a strong
incentive for the recruitment and retention of public
health professionals in the North. Continuing
education in public health – through visiting
lectureships, videoconferencing links, and online
courses – can be developed further in partnership
between northern health agencies and southern-based
schools of public health in Canada, and indeed other
circumpolar health research and education
institutions. The intellectual environment in the
North can be improved through such linkages,
making full use of telecommunication technology to
overcome vast distances and reduce travel expenses.
Delivery of public health services is dependent on
sound organizational structure and having the best
person properly trained and in the right place to do
the job. This is also called ensuring maximization of
roles and scopes of practice. Further study is required
37
 Public Health Practice in Circumpolar Regions: Lessons for Canada

to explore role allocations in circumpolar regions and health services research; it has also been successfully
apply lessons to a Canadian context. applied to disease surveillance (such as the National
Diabetes Surveillance System). Pilot studies have
While having the proper professional qualifications
been done in the Yukon which show that algorithms
and technical skills is essential for public health
developed in some provinces can be applied to the
practice, proper cultural orientation is also important,
territorial databases for surveillance of some chronic
given that most health staff in the North are
diseases. Their utility can be further expanded
“imported” from elsewhere in Canada or overseas.
through data linkage at one end to mortality and the
While territorial health departments have had cultural
other end to health surveys capturing individual
orientation programs they tend to have limitations
behaviours and practices. Given the remote location
and only deal with topics such as traditional diets,
and sparse distribution of population centres, and the
hospital menu and interpretive services, and tend not
understaffed health care system, the use of
to get to the meat of cultural issues in relation to
administrative databases in public health needs to be
health outcomes, ie. health determinants and what
further developed, taking into account some of the
they are in the in the northern context. A project is
North’s peculiarities [e.g., nurses not submitting
being developed at the Stanton territorial health
health insurance claims for health care contacts].
authority in NWT under the aegis of the elders
council to design and inform better cultural Alaska’s participation in the national Behavioral Risk
orientation programs for staff. Factor Surveillance System has furnished it with
important health information on a regular basis. The
Cultural orientation is much less of an issue in the
Canadian North also participates in Statistics
Nordic countries, as most health staff are home
Canada’s Canadian Community Health Surveys but
grown. Even so, there are substantial pockets of
territorial health departments have not had the human
linguistic minorities in the northern regions that the
resources to exploit fully their capabilities. The
health services are becoming more sensitive to
establishment of a StatCan Research Data Centre
(Kunnas 2003). Cultural orientations are required as
based at the Institute for Circumpolar Health
long as a significant proportion of health care
Research in Yellowknife planned for 2010 will
providers are imported. However, these initiatives
enhance substantially the timely analyses of northern
must be paired with initiatives to train northerners
health data from such surveys.
and create career opportunities (and this is being
done by the colleges). There is important health information that cannot be
captured by administrative databases or surveys and
Strengthening surveillance and health information resources have to be allocated for infrastructure
system for the North development, from hardware to training.
Surveillance is the backbone of public health. Sadly, it
Adopting new technology to improve public
is underdeveloped in the Canadian North. Canada
health programming
does not have the centralized registries and databases
of the Nordic countries (e.g., the Medical Births The potential for digital technology to transmit
Registry), nor are databases systematically aligned reliable health information across vast distances to
with service providers and research programs. enable effective and safe health services has long been
Surveillance is well developed in the Scandinavian recognized in the North but surprisingly has not been
North as the North is simply part of a uniformly well- widely realized in the circumpolar regions. The
run national surveillance system for a variety of internet is increasingly utilized by researchers, health
diseases and conditions. care providers, and the public to seek health
information. The internet can also be employed by
Canada does have an advantage over the other
public health agencies as a powerful tool for public
circumpolar countries in having population-based
health messaging, but little research on the needs of
health administrative databases in all provinces and
the intended audience and how they use websites has
territories. While there are well recognized
been done.
limitations, such a system has long been used for

38 Part 4 Lessons for Canada

 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
In northern Sweden, for example, “district nurses”
(somewhat equivalent to public health nurses)
providing home care are equipped with 3G phones,
telemetric data devices, laptops and web cameras that
allow them to transmit health information back to the
health centre and retrieve patient medical records.
The technology was well accepted by the elderly
clients (Wälivaara et al 2009).
A report prepared for the Nordic Council of Ministers
(2009) examined how governmental and non-
governmental organizations use the “new media” in
their health-related communication activities,
especially in areas such as nutrition and physical
activity promotion. It found that the internet was used
mainly as channel for information. Few conducted
basic target group analyses before building and
launching their online activities; few assessments
beyond visitor traffic were done and little was known
about their effects, especially on behavioural change.
It urged health organizations to stay current and
flexible, especially if targeting young people, and also
learn marketing techniques from commercial actors
who are results-oriented.
Public health in the Canadian North can benefit from
emerging, accessible internet communication
technologies including Web-enabled videoconference
tools and electronic health record access. By
connecting primary care and public health, these
technologies can seamlessly link prevention and
treatment through publicly accessible platforms and
social networks. Such a system is suitable for
community-level health intelligence gathering for
pandemic preparedness and for the provision of
home- and community-based services. Fortunately,
there is substantial Canadian expertise in this area, led
by research groups such as the Centre for Global
eHealth Innovation in Toronto. The Canadian North
can lead with these public health innovations that can
be exported to other circumpolar regions.
We recognize that to effectively address the uptake of
telehealth tools in the North, some basic technical
conditions need to be in place (including basic
infrastructure, site-to-site compatibility, and available
technical support). Although the North is not the
technology backwoods that many Canadians assume
it to be, broadband penetration in homes is still far
below national norms, especially in small remote
communities. Moreover, young people in the North
are totally immersed in the digital age through the
schools. Social factors such as literacy and costs may
still limit access for some northerners to new
modalities in the delivery of public health services.
In 2009, the Finnish government declared 1 MB of
broadband web access a legal right for all citizens, as
an intermediate measure ultimately towards the right
to 100 MB! [news.cnet.com/8301-17939_109-10374831.html-
?part=rss&subj=news&tag=2547-1_3-0-20]. Clearly the
Canadian North still has a long way to go, although
various levels of government have trumpeted the
“information highway” as a priority.
Addressing social determinants of health
Given the small population size and the closely knit
political and bureaucratic communities in the
Canadian North, one should expect closer multi-
sectoral and multi-agency coordination than is
currently evident. The Nordic countries lead the way
in their specific government-wide strategies directed
at redressing inequalities in health through actions
outside the formal health sector. For example, as
many as 12 ministries participated in producing
Norway’s nutrition action plan. These strategies are
not just rhetorical exercises, but are accompanied by
dedicated funding and monitored by
multidimensional indicators.
It should not be difficult for each of Canada’s
northern territories to have “premier’s committees”
consisting of relevant ministers whose portfolios fall
within commonly recognized categories of health
determinants. A provincial example is Healthy Child
Manitoba [www.gov.mb.ca/healthychild/welcome.html], a
multidepartmental initiative that can be adapted for
the northern territories. Territorial health ministries
and regional health authorities cannot be expected to
simply ignore health care demands and shift resources
to housing, education, etc., but the entire government
can make serious decisions in resource allocations for
priority areas which have long-term impact on
population health.
Forging closer links between PHAC and northern
health agencies
Canada’s federal/provincial/ territorial division of
labour is unique among circumpolar countries. In the
39
 Public Health Practice in Circumpolar Regions: Lessons for Canada
North, it is the territorial governments that are the
implementing agents and federal agencies such as
PHAC can only be effective if there is a close working
relationship and mechanisms for collaboration with
territorial health departments and regional health
authorities.
PHAC is a repository of extensive public health
expertise from which the North can benefit
immensely. It is encouraging that it is contemplating a
“northern strategy”. Interestingly there is no parallel
in other circumpolar countries. Greenland, Iceland
and Faroe Islands are entirely “northern” jurisdictions
- there is no “southern” body that is planning a
northern strategy to serve their needs. Alaska does
benefit from national agencies such as the Indian
Health Service and CDC but there is no United States
federal strategy for northern health. In the Nordic
countries, if the whole country is already “northern”,
there is simply no need for any specific northern
strategy.
PHAC has begun to forge some connections with the
northern regions through the research affiliate
program which supports graduate students in public
health and the online training for public health skills.
Each program is successful because of the
commitment exhibited by PHAC and northern
partners. These partnerships need to be further
supported. Additional ways need to be explored such
that PHAC programs can be patriated to northern
jurisdictions as they now do in provincial regions.
Examples of programs include collaborating centers
and regional coordination. Currently PHAC’s
community based programs are coordinated and
administered through the northern region office in
Ottawa, and other regional tasks for Nunavut, NWT
and Yukon are carried out of regional office in
Ontario, Alberta and BC respectively. No
administrative support for PHAC programs exists in
any northern territory. This creates gaps in the ability
to coordinate and liaise with the agency on issues that
require attention at the earliest stages. Leaving aside
the lack of a collaborating centre for the North,
territorial engagement in existing collaborating
centres is minimal. While some collaborating centres
have conducted “northern consultations”, there is no
mechanism for qualified northerners to participate.
40 Part 4
It is encouraging that PHAC has recognized that there
are benefits to learning from other circumpolar
countries. Presently there are several international
partnerships which have mandates to support sharing
of information related to public health practice, for
example the Northern Dimension Partnership in
Public Health and Social Well-being [www.ndphs.org].
Through this partnership Canadian experts share
experiences and policies with European counterparts
in several areas. Canada participates in three of the
four Expert Groups: HIV/AIDS; Primary Health
Care; Prison Health; and Social Inclusion, Health
Lifestyles and Work Ability and the Strategy Working
Group [www.canadainternational.gc.ca/eu-ue/policies-politiques/-
arctic-arctique.aspx?lang=eng].
PHAC is already involved in the International
Circumpolar Surveillance project coordinated by the
CDC in Anchorage, Alaska. The Arctic Council is a
ministerial-level forum of Arctic States and indigenous
peoples’ organizations. Within its organization are
groups that are of particular relevance to PHAC – for
example, the Arctic Monitoring and Assessment
Group (AMAP) concerned with contaminants, and
the Sustainable Development Working Group
(SDWG), both of which have subsidiary human
health expert groups in which Canadians play a major
role, and to which Canadian federal government
departments such as INAC and Health Canada’s
Northern Region provide funding support and
representation.
Summary and conclusions
In general it appears that there are many common
public health themes between Canada and other
circumpolar countries, as we share similar public
health priorities, geography and demographics. To
this end there should be a concerted effort to enhance
partnerships between Canada and circumpolar
countries with an eye to sharing best practices and
building evidence-based public health in the North.
Circumpolar regions should have full partnerships in
the administration and design of public health
programs and policies which are in harmony with
their respective national public health systems.
Canada’s model of northern territories being engaged
via brokers in provincial centres creates fragmentation
and knowledge gaps. Thus, while partnerships with
Lessons for Canada
 Public Health Practice in Circumpolar Regions: Lessons for Canada
Public Health Practice in Circumpolar Regions: Lessons for Canada
other circumpolar regions are being built,
simultaneously Canada needs to look closely at how
the national public health agency can be present in
territorial jurisdictions.
Table 4 enumerates several strengths that we have
observed in circumpolar public health programs
Table 4. Summary of strengths in circumpolar regions and potential strategies for Canada
What are the strengths of public health programs in
circumpolar regions?
Integration of primary care and public health in
service delivery models
Administrative alignment of national public health
program with northern regions
Linkages and coordination of national databases
and registries with public health decision makers and
researchers.
Networks to support communication between
countries
Accessible public health education in northern regions
Well established public health research programs
addressing northern issues
which Canada can emulate. These are not
recommendations as such, but areas for further
consideration and study by PHAC as it moves forward
to enhance its northern programs and representation
in the circumpolar community.
What Canada (and PHAC) can do
Support further development by translating existing
territorial health care strategies to public health services
and system improvements.
Undertake initiatives to maximize roles in public health, to
achieve the best skill set fit for community health
representatives, midwives, nurse practitioners and MPH-
level public health professionals
Develop a presence for PHAC in the northern territories,
including leadership and administrative positions and
regional offices.
Allocate resources to support a collaborating centre based
in a territory.
Support models for shared data, programs and networks
of policy makers, public health officials and researchers.
Establish northern-based infrastructure to host offices of
complementary partners in public health (e.g., government,
academics, and health professionals).
Develop northern based resources to improve surveillance
and data management, to enhance national and
international/ circumpolar comparisons.
Evaluate Canada’s privacy laws and impacts on Canadian
participation in circumpolar comparative population health
research.
Promote and support financially participation of Canadian
public health decision makers, practitioners and
researchers in circumpolar public health forums.
Ensure formal Canadian representation in all relevant
international organizations to showcase Canada’s northern
practices.
Improve recruitment and retention of public health human
resources in the North through increased opportunities for
different levels and delivery options of public health
education.
Strengthen public health research capacity in the North,
and develop areas of special expertise such as the
analysis of research impacts, community based methods
and monitoring disease trends.
41
 Public Health Practice in Circumpolar Regions: Lessons for Canada
References Cited and
Additional Resources
Alaska Department of Health and Social Services. Safe and
Healthy Future for Alaskans. Annual Report Fiscal Year 2008.
Juneau, DHSS: 2008 [www.hss.state.ak.us/publications/-
2008_DHSS_AnnualReport.pdf]
Alaska Department of Health and Social Services. Healthy
Alaskans 2010, vol 1: Targets for Improved Health – Executive
Summary. Anchorage, DHSS, Division of Public Health:
2001 [www.hss.state.ak.us/dph/targets/ha2010/PDFs/-
ExecWeb.pdf].
Separate chapters available from: www.hss.state.ak.us/dph/-
targets/ha2010/volume_1.htm
Alaska Department of Health and Social Services. Taking Action:
Strategic Report 2003-2005. Juneau, DHSS, 2005.
Chapter on Public Health [www.hss.state.ak.us/pdf/-
Div_of_Public_Health.pdf]
Alaska Department of Health and Social Services. Public Health
Strategic Map 2007-2009. Anchorage, DHSS, Division of
Public Health, 2006. [hss.state.ak.us/dph/strategic/assets/-
StrategicMap.pdf]
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