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
1.1 1.2 1.3 1.4 1.5 1.6

Background and Introduction ...................................................................................................... 5
Context and Objectives of Review ........................................................................................................................ 5 Methods and Data Sources ..................................................................................................................................... 5 Defining Circumpolar Regions .............................................................................................................................. 5 Population Health Status ........................................................................................................................................ 7 National Health Systems ......................................................................................................................................... 9 Organization of Public Health Services ............................................................................................................. 11

Part 2
2.1 2.2 2.3 2.4 2.5 2.6 2.7

Public Health Programs............................................................................................................. 14
Public Health Surveillance ................................................................................................................................... 14 Emergency Preparedness and Response ........................................................................................................... 16 Health Promotion .................................................................................................................................................. 17 Disease and Injury Prevention ............................................................................................................................ 19 Health Protection................................................................................................................................................... 22 Maternal and Child Health .................................................................................................................................. 23 Determinants of Health ........................................................................................................................................ 24

Part 3
3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

Cross Cutting Themes................................................................................................................. 26
Governance, Financing, and Management ....................................................................................................... 26 Policy and Planning ............................................................................................................................................... 27 Public Health Human Resources and Capacity .............................................................................................. 29 Health Disparities and Inequalities .................................................................................................................... 31 Performance Measurement and Evaluation ..................................................................................................... 32 Citizen Engagement and Public Education ...................................................................................................... 33 Intersectoral Coordination and Collaboration ................................................................................................ 33 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.

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).

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

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Public Health Practice in Circumpolar Regions: Lessons for Canada

Table 1. List of circumpolar countries and regions
[US] United States [Ak] Alaska [CA] Canada [Yk] Yukon [Nt] Northwest Territories [Nu] Nunavut [DK] Denmark [Gl] Greenland [Fo] Faroe Islands [IS] Iceland [NO] Norway [Nd] Nordland [Tr] Troms [Fm] Finnmark [SE] Sweden [Vb] Västerbotten [Nb] Norrbotten [FI] Finland [Ou] Oulu [La] Lappi [RU] Russian Federation [Mu] Murmansk Oblast [Ka] Kareliya Republic [Ar] Arkhangelsk Oblast [Ne] Nenets AO [Ko] Komi Republic [Yn] Yamalo-Nenets AO [Km] Khanty-Mansi AO [Tm] Taymyr AO [Ev] Evenki AO [Sk] Sakha Republic [Ma] Magadan Oblast [Ky] Koryak AO [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.

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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

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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
Total fertility rate 2.03
2.36

Life expectancy at birth (years) Male 74.6
74.5

Estimated population United States
Alaska

Population density 33
0.5

Female 80.0
80.1

Infant mortality rate 6.9
6.8

TB incidence 5
10

304060000
686300

Canada
Yukon Northwest Territories Nunavut

33311400
33100 43300 31500

3.7
0.07 0.04 0.02

1.52
1.60 1.96 3.04

77.2
74.9 74.6 66.6

82.2
80.1 78.8 70.9

5.3
7.4 6.0 15.3

5
5 21 108

Denmark
Greenland Faroe Islands

5489000
56300 48600

127
0.03 35

1.76
2.39 2.51

74.9
64.6 77.0

79.6
70.4 81.3

4.7
12.7 1.7

8
138 3

Iceland Norway
Nordland Troms Finnmark

319400 4768200
235200 155100 72400

3.1 16
6.5 6.2 1.6

2.00 1.81
1.82 1.80 1.91

79.0 76.6
76.7 76.5 74.6

82.6 81.7
82.0 81.5 80.6

2.6 3.6
3.9 4.0 4.7

4 6
5 6 10

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Sweden
Västerbotten Norrbotten

9219600
257700 250100

21
4.7 2.5

1.64
1.56 1.67

77.8
77.6 76.6

82.3
82.1 81.6

3.3
3.8 4.6

5
5 3

Finland
Oulu Lappi

5313400
468200 184200

18
8.2 2.0

1.74
2.15 1.84

74.8
74.3 73.7

81.6
81.6 81.1

3.3
2.7 3.8

9
9 9

Russian Federation
Murmansk Oblast Kareliya Republic Arkhangelsk Oblast Nenets AO Komi Republic Yamalo-Nenets AO Khanty-Mansi AO Taymyr AO Evenki AO Sakha Republic Magadan Oblast Koryak AO Chukotka AO

141956000
846700 689100 1267000 42000 963400 543200 1512600 37400 16600 950600 164400 21500 49900

8.3
5.8 4.0 2.2 0.2 2.3 0.7 2.9 0.0 0.0 0.3 0.4 0.1 0.1

1.27
1.20 1.25 1.31 1.95 1.30 1.61 1.56 1.91 2.01 1.82 1.27 1.81 1.63

58.8
57.6 55.1 55.9 53.8 56.6 61.8 61.3 54.2 53.6 57.9 56.6 49.9 53.6

72.1
70.5 69.6 70.5 69.0 69.5 72.2 73.0 67.5 64.6 70.4 69.4 61.7 63.7

13.3
11.0 9.7 10.1 10.1 8.6 13.4 6.9 17.3 22.5 13.4 11.8 14.7 20.3

89
72 79 92 50 90 97 104 70 172 91 98 334 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
1.5

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 quasiindependent 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

National Health Systems

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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

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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.

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,

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

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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] –

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 –

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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

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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 postSoviet 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

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 Public Health Programs

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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

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

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evaluating vaccine effectiveness in northern countries with variable dates of vaccine introduction. Further information on ICS is available from Parkinson et al (2008) and in the monograph by Zulz, Bruce and Parkinson (2009).

2.2 Emergency Preparedness and Response
Emergency preparedness has become a core public health function in most jurisdictions. Although preparing for epidemics of infectious diseases has always been a task of public health, increasingly sundry types of disasters, both natural (hurricanes, floods, earthquakes, fires) and man-made (terrorism, industrial and transportation accidents, etc) have been added to the plate. Clearly public health agencies are only one of many players in any emergency preparedness plan. In the circumpolar North, Alaska is unique in being prone to earthquakes and tsunamis, the result of plate tectonics in the circum-Pacific “ring of fire”. It actually experienced the 1964 Good Friday Earthquake, the strongest ever recorded in North America. The Nordic countries had their disaster experience being downwind from Chernobyl in 1986.

Emergency preparedness and response are approached similarly in most industrialized countries, and the circumpolar North is no exception. The aim is to protect citizens’ health and security during times of unexpected, extraordinary crisis situations, mobilizing and coordinating resources for assistance from different sectors. In Norway, for example, as is the case with its health care system, responsibility is devolved to municipalities and other local authorities, which also implement preparedness exercises. Guidance is centrally provided by the Directorate of Health of the Ministry of Health and Care Services, which is also responsible for national stockpile of selected medicines (such as antivirals for pandemic influenza) and potassium iodide against radioactive iodine, a possible contaminant from a nuclear accident. Finland has a 190-page preparedness plan, which is actually a comprehensive and informative resource handbook on all aspects of influenza and its control. All these national and regional plans have now been put to a severe test with the H1N1 pandemic. A crossnational comparative study, with special attention to the North, would be extremely instructive, in understanding how and why the epidemic behaved differently in different regions, and how and why the 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 respiratory syncytial virus infection in the Yukon-

Kuskokwim Delta in February 2008 and managed to implement its plan and prevented the spread outside Public Health Programs

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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.

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

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 20072011 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

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

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

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2.4 Disease and Injury Prevention
The circumpolar literature is substantially richer in evaluative studies on disease control programs, especially in infectious diseases and cancer. Control of infectious diseases The control of TB is of historical interest in that different approaches were used among the Inuit in Alaska, Canada and Greenland in the second half of the 20th century. In all regions, the incidence of tuberculosis had fallen quite dramatically since the 1950s, although a substantial gap still existed between the Inuit and the national rates of Canada, Denmark and United States. Tuberculosis remains a significant health threat in the Arctic. By the 1990s, the decline had slowed or even reversed, as shown in Figure 4. In Greenland in 1949, a BCG vaccination campaign was carried out on the west coast, with the aim to vaccinate all tuberculin negative children. An increasing number of patients were sent to Denmark for treatment. In 1954 Queen Ingrid’s Sanatorium in the capital Godhåb (now Nuuk) was built and by
2,500

1959 all tuberculosis patients were treated in Greenland. A hospital ship, the Misigssut, sailed along the west coast every year from 1955 to 1971 to visit all settlements and summer camps to carry out tuberculosis examinations. By 1962 the situation was firmly under control and the sanatorium was converted to a general hospital. By the 1970s the incidence was approximately 10% of that in the 1950s. Because of this reduction, Greenland abandoned routine BCG-vaccination in 1990 (Stein 1968, Soborg et al, 2001). Alaska adopted a different strategy. Following a survey in 1949-52 which showed that 25% of susceptible Yupiks in the Yukon-Kuskokwin Delta were infected each year, an intensive case finding, hospitalisation, and out-patient treatment program was initiated. In 1954 home-treatment with a combined regimen of para-amino-salicylic acid (PAS) and isoniazid (INH) was started as a trial and accepted for broad use two years later. In 1957, a field trial of INH prophylaxis was started in the Bethel area and in 1963 it was offered to all residents in the region (Comstock et al 1979, Fortuine 2005).

2,000

Canadian Inuit

TB incidence (per 100,000)

Greenland 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

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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).

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 23valent 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 vaccinetype 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 reemergence 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

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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 19982000, 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

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).

2.4

Disease and Injury Prevention

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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

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 nonintervention 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

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

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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.

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.

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

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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

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 Intersectoral 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.

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

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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

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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.1HC.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

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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.

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

next 10 years. It sets the agenda for a healthier 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,

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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

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).

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Figure 7. Strategic map of the Alaska State Department of Health and Social Services, Division of Public Health

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,

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

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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 underserved 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

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).

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

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

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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]

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

» »

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

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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

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.

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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).

3.7 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).

3.6 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

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.

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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.

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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

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level of services. Moreover, population health outcomes in the Scandinavian North is unsurpassed elsewhere in the circumpolar world. On paper, public health is already integrated with primary care in Canada’s North, at least at the level of health centres in the communities. While there are clear benefits for such integration, it has proven taxing to have the same individual delivering both services, and often primary care takes priority. The public health programs within the health centres tend to be delivered by a nurse practitioner through individual clinics which focus on maternal child health, well woman care, immunizations and in some cases also elder care. The public health program framework was developed many decades ago and has not undergone any critical evaluation or strategic renewal. Further evaluation is required to assess the alignment of public health programs with national and territorial strategies and establish a model with allows for the maximization of roles in the delivery of public health services. Nunavut’s public health strategy (2008) does call for “reconfiguring organizational structure to facilitate public health teams at all levels” and the Northwest Territories (2004) has developed an integrated service delivery model which strives to improve links between the many service providers. Both of these are examples of strategic approaches which show promise to guide a response which will allow for improvements in public health services delivery and specifically the maximization of roles. The key lies in the translation of strategies to system improvements on the ground. It is a complex task, but not insurmountable. Neither the Alaskan model of using health aides (many with previous training or experience as physician assistants) as primary care providers nor the Greenland model of posting physicians in small hospitals are practicable in the Canadian North today. There is, however, already in existence a cadre of health workers - the community health representatives (CHR) - who can be specifically trained to perform most public health functions in the communities under nursing supervision, and their workload will not be affected by the fluctuating demands of acute care. The Canadian Health Services Research Foundation [www.chsrf.ca] has been active in promoting research on

best practices for service delivery in the northern territories. Promoted is a model where decision makers, practitioners and researchers work in close partnership to evaluate, research and use results to improve service delivery models. These partnerships put knowledge translation front and foremost in the research process, increasing the uptake and application of findings to enhance systems improvements. Although public health has not been a major focus of CHSRF in the past, with suitable funding partnerships with agencies such as PHAC, the planning and evaluation of public health services in the North can be given a much needed boost. Similarly, CIHR’s Partnerships for Health System Improvement [www.cihr-irsc.gc.ca/e/34347.html] program can be tapped for designing and testing innovative approaches to public health models for the North. Developing public health human resources for the North Two types of public health practitioners are needed for the North – at the community level and at the headquarters of regional health authorities, regional government offices, and territorial health departments. At the communities are public health nurses and CHR with special training in public health. Such training can be conducted within the territories through the colleges (Yukon College, Arctic Nunavut College, and Aurora College). Baccalaureate degree programs in nursing are already offered by the northern colleges through partnership agreements with universities. These programs tend to be well designed and are responsive to training graduates to work in northern settings. These programs, however, does not include any advanced or specialized training in public health. MPH-level public health professionals are needed for disease surveillance and health monitoring, epidemiologic analyses and data management, health planning, program design and evaluation. Specialists in nutrition, mental health, chronic disease, injury prevention, and infectious disease control are also needed. Support for masters and doctorate level training in public health has in the past come from outside the North. However in recent years PHAC has allocated supports for graduate students in epidemiology and

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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 realworld 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

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to explore role allocations in circumpolar regions and apply lessons to a Canadian context. While having the proper professional qualifications and technical skills is essential for public health practice, proper cultural orientation is also important, given that most health staff in the North are “imported” from elsewhere in Canada or overseas. While territorial health departments have had cultural orientation programs they tend to have limitations and only deal with topics such as traditional diets, hospital menu and interpretive services, and tend not to get to the meat of cultural issues in relation to health outcomes, ie. health determinants and what they are in the in the northern context. A project is being developed at the Stanton territorial health authority in NWT under the aegis of the elders council to design and inform better cultural orientation programs for staff. Cultural orientation is much less of an issue in the Nordic countries, as most health staff are home grown. Even so, there are substantial pockets of linguistic minorities in the northern regions that the health services are becoming more sensitive to (Kunnas 2003). Cultural orientations are required as long as a significant proportion of health care providers are imported. However, these initiatives must be paired with initiatives to train northerners and create career opportunities (and this is being done by the colleges). Strengthening surveillance and health information system for the North Surveillance is the backbone of public health. Sadly, it is underdeveloped in the Canadian North. Canada does not have the centralized registries and databases of the Nordic countries (e.g., the Medical Births Registry), nor are databases systematically aligned with service providers and research programs. Surveillance is well developed in the Scandinavian North as the North is simply part of a uniformly wellrun national surveillance system for a variety of diseases and conditions. Canada does have an advantage over the other circumpolar countries in having population-based health administrative databases in all provinces and territories. While there are well recognized limitations, such a system has long been used for

health services research; it has also been successfully applied to disease surveillance (such as the National Diabetes Surveillance System). Pilot studies have been done in the Yukon which show that algorithms developed in some provinces can be applied to the territorial databases for surveillance of some chronic diseases. Their utility can be further expanded through data linkage at one end to mortality and the other end to health surveys capturing individual behaviours and practices. Given the remote location and sparse distribution of population centres, and the understaffed health care system, the use of administrative databases in public health needs to be further developed, taking into account some of the North’s peculiarities [e.g., nurses not submitting health insurance claims for health care contacts]. Alaska’s participation in the national Behavioral Risk Factor Surveillance System has furnished it with important health information on a regular basis. The Canadian North also participates in Statistics Canada’s Canadian Community Health Surveys but territorial health departments have not had the human resources to exploit fully their capabilities. The establishment of a StatCan Research Data Centre based at the Institute for Circumpolar Health Research in Yellowknife planned for 2010 will enhance substantially the timely analyses of northern health data from such surveys. There is important health information that cannot be captured by administrative databases or surveys and resources have to be allocated for infrastructure development, from hardware to training. Adopting new technology to improve public health programming The potential for digital technology to transmit reliable health information across vast distances to enable effective and safe health services has long been recognized in the North but surprisingly has not been widely realized in the circumpolar regions. The internet is increasingly utilized by researchers, health care providers, and the public to seek health information. The internet can also be employed by public health agencies as a powerful tool for public health messaging, but little research on the needs of the intended audience and how they use websites has been done.

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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 nongovernmental 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 multisectoral 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

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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.

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

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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

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.

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

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 MPHlevel 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.

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

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