Sharing environmental health practice in the North American Arctic: a focus on water and wastewater service.

Introduction and Background

The U.S. Public Health Service (U.S. PHS) became responsible for protecting and promoting the health of Alaska Natives in 1954. U.S. PHS quickly determined infectious disease to be the leading cause of mortality and set a goal of improving health through construction of modern sanitation (i.e., water and wastewater) facilities in rural Alaskan communities, which are primarily populated by Alaska Native people. These efforts were based on the best scientific evidence of that day, which showed increased access to sanitation services to be the most important factor in prevention of enteric disease (Schliessmann, Atchley, Wilcomb, & Welch, 1958).

Great progress has been made over the past five decades. Residents of more than 170 rural Alaskan communities now have access to potable drinking water. Improvements in Alaska Native health have followed. Since the 1950s, both infant mortality and the percentage of deaths from infectious disease have declined dramatically. Alaska Native life expectancy at birth has increased by more than 20 years, substantially more than the life expectancy of the general U.S. population has increased during this same time period (Figure 1). Certainly, increased availability of potable water and safe disposal of wastewater are primary contributors to improved health.

Despite this progress, many challenges remain. The task of developing local capacity for operation and maintenance of government-provided infrastructure poses a particular challenge. The following points highlight the difficulties local communities are experiencing in providing proper operation and maintenance:

* As of April 2005, an estimated 37 percent of Alaskan Tribal water systems were classified as significant noncompliers by the U.S. Environmental Protection Agency (U.S. EPA).

* In 2000, regulated Alaskan water systems had an average of 6.4 Safe Drinking Water Act violations.

* As of July 2005, 47 percent of rural community water systems served by the State of Alaska Remote Maintenance Worker Program lacked appropriately certified water system operators.

* A 1999 survey by the Rural Utility Business Advisors (RUBA) found that 64 percent of rural utilities surveyed were not collecting enough revenue to cover basic operational costs (Black & Logan, 2000).

* The same RUBA survey found that no community had established a reserve fund to cover equipment replacement (Black & Logan, 2000).

Alaskans primarily attribute these difficulties to the combination of four factors: a harsh climate that results in high consumption of heating fuel and electricity and can damage mechanical systems, high costs for parts and consumables resulting from a lack of external road systems (see photo on page 52), a limited ability to pay for sanitation services because of underemployment or unemployment; and a reduced revenue base and limited labor pool because of small community populations. In short, sanitation operations in rural Alaska are expensive and complex; small, economically limited communities have limited financial and technical capacity to support these operations.

While establishing modern sanitation services has always been difficult in this harsh environment, Alaskans have learned to overcome the inherent challenges in order to make steady progress. Over the last half decade, however, a number of new challenges have arisen, including

* much higher heating-fuel prices;

* more complex and costly drinking-water regulations;

* reductions in the state's Power Cost Equalization subsidy;

* increased sanitation system insurance costs;

* reductions in government-provided capital projects funding;

* termination of the Municipal Revenue Sharing Program;

* a declining salmon-fishing industry that has resulted in less income for rural residents; and

* decreased Permanent Fund Dividends, on which many Alaskans rely for income.

While the cumulative effects of these new challenges have not been measured, observations suggest reason for concern. For example, the Rural Utility Cooperative (RUC), which manages six rural Alaskan sanitation utilities, recently raised user fees by as much as 75 percent. Even with this increase, some RUC utilities are expected to incur annual operating deficits.

A 2000 RUBA report discussing the challenges of financing operation and maintenance of water and sewer stated that "the future of public health in rural Alaska is tied to the ability of rural communities to deliver services" (Black & Logan, pp. 2-8). If the overall health disparity between Alaska Natives and the U.S. general population is to be eliminated, it will be necessary to identify specific practices, processes, and policies that will allow sustainable sanitation services to be established in all rural Alaskan communities. It has been suggested that learning more about the approaches used in other northern nations may help identify opportunities for improvement (Haley, 2000). One similar region is the Canadian Northwest Territories (NWT). While it has been noted that no "magic bullets" exist for the problems of high cost, remoteness, and lack of economic base (Colt, Goldsmith, & Wiita, 2003), there remains potential to improve service delivery by learning more about the NWT approach. This report discusses features of the NWT approach to providing water and wastewater services that may suggest ways of bringing about service delivery improvements in rural Alaska.

Methods

To establish a framework for comparison, the author first identified key components of water and wastewater service delivery. The components--design, support, regulations, and finance--were used to develop comprehensive descriptions of the service delivery model in each region. With the models fully described, the author identified features of interest and then considered each with an aim of identifying opportunities for improving the Alaskan approach.

Information used to complete the project was collected from January 2004 through July 2005, with NWT site visits completed in March 2005. During the site visits, the author visited the NWT communities of Yellowknife, Deline, Norman Wells, Inuvik, Aklavik, and Tuktoyaktuk, as well as two remote oil camps. The communities of interest to this project have, to varying degrees, four characteristics: small population, geographic isolation, presence of a historical culture, and limited economic base.

This work has some limitations that should be considered when it is interpreted. For example, the project was primarily focused on identifying elements of the NWT approach that could be used to improve service delivery in Alaska. Also, the project design did not allow for evaluation of intraregional differences. For the purposes of easy comparison, the regions were treated as homogenous entities. Both rural Alaska and the NWT are expansive regions with diverse populations and circumstances. Certainly, service delivery varies slightly within the regions. Lastly, differences in currencies and buying power make direct comparison of finances difficult.

Important Differences

While the regions have many similarities, they also have important differences that necessitated careful consideration when the recommendations given in this report were formed. Important differences were as follows:

* NWT communities, overall, have more favorable logistics. Most NWT communities have access to pristine water sources, are positioned on major waterways, and are located away from flood plains and swamps; many Alaskan communities lack these favorable characteristics.

* NWT soils generally have a higher gravel content, which makes it easier to construct roads and structures.

* Community populations tend to be larger in the NWT. Larger communities are typically easier to serve.

* Canadians and Americans generally hold different political and social viewpoints. The Canadians, with their collectivist culture, generally expect additional government services and are willing to pay higher taxes for them. This factor is important when such things as government subsidies for operation and maintenance are being considered.

While it was thought necessary to recognize and consider these differences during all aspects of the project, the author does not feel that they pose a substantial barrier to collaboration.

Results

A summary of important differences between the NWT and Alaskan approaches to providing water and wastewater services can be accessed on the Alaska Native Tribal Health Consortium Web site at http://www.anthc.org/cs/dehe/envhlth/ehcoordination/.

Discussion and Recommendations

Preventing Water-Washed Disease

The primary focus for Alaskans has been to provide water of high quality. While this approach has proven effective at preventing disease that is caused by drinking contaminated water (i.e., waterborne disease), it does not specifically address disease brought about by insufficiency in the quantity of water available for personal hygiene and sanitation practices (i.e., water-washed disease). Studies suggest that quantity adequate for frequent hand and body hygiene is the most important characteristic of a water supply (Cairncross & Valdmanis, 2004; Esrey, Potash, Roberts, & Shiff, 1990). Like Alaska, the government of Northwest Territories (GNWT) is also committed to ensuring water quality; evidence of commitment was found when the author reviewed NWT chemical and biological test results. The Canadians also, however, place emphasis on providing adequate water quantity for protection against water-washed disease, a practice Alaskans should emulate to further public health protection.

Many NWT and Alaskan families are served by haul systems. A haul system utilizes trucks (primarily in the NWT) or four-wheelers (mostly in rural Alaska) to provide home delivery of potable water (see photo on page 53). Wastewater is hauled away in a similar manner. The practice of hauling water is labor intensive and translates to high operational costs. A survey of four Alaskan haul systems for which cost information could be obtained showed an average cost of U.S. $0.24 per gallon ($0.06/L) of water. At this rate, families may ration water to reduce expense, a practice that has been associated with "serious negative health consequences" (Smith, Ryan, Christensen, Crum, & Heinke, 1996). Even though the NWT truck haul systems are inherently more efficient than the Alaskan small-haul version, the GNWT still subsidizes operation and maintenance costs to make rates more affordable. For the 10 NWT communities for which cost information was obtained, residential rates were approximately U.S. $0.01/gal ($0.003/L Canadian).

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It should be noted that haul systems have some advantages over piped systems. Haul systems are relatively easy to maintain, and they provide flush toilets and pressurized water for homes that may not be served by piped distribution systems. Another important advantage is that haul systems have relatively lower capital construction costs than do piped systems. The cost of constructing a haul system is often considerably less than that of constructing a piped system, sometimes by millions of dollars. If these savings could be shared with local communities to offset the high operational costs, then haul systems may provide adequate quantities of water at reasonable cost. One recommendation is to use a portion of capital cost savings to establish an endowment that would create an enduring source of revenue used to subsidize operation and maintenance and thus allow for greater protection against water-washed disease.

Regulatory Flexibility

Drinking water is a territorial function in the NWT, as opposed to a federal function in Alaska. Territorial control over regulatory functions provides the GNWT the flexibility to promulgate only those drinking-water regulations that are necessary to protect public health. In particular, this flexibility allows for consideration of how a new regulation would influence operation and maintenance. This authority is particularly valuable in small communities with little economic base--places where additional cost and operational complexity could threaten the viability of sanitation operations as a whole.

In the Alaskan regulatory scheme, there is less flexibility; most standards must be met, even if the additional operation-and-maintenance burden exceeds community capacity. Percival, Schroeder, Miller, and Leape (2003) have noted the challenges posed by a rigid one-size-fits-all model, stating, "EPAs paradox is that it must maintain national programs and seek national consistency while simultaneously attempting to make its programs and standards fit an incredibly diverse and dynamic nation" (Percival et al., 2003, p. 103). The 1996 Safe Drinking Water Act Amendments allow variances for certain regulations that are determined unaffordable. Under current procedures, however, no regulation has met this standard. U.S. EPA is considering revisions to the current affordability determination methodology that may provide flexibility for small systems. Alaskans should advocate for the proposed revisions.

Emergency Preparedness

In Alaska, the hazard analysis critical control point (HACCP) process has primarily been utilized within the food safety sector. As Inuvik (NWT) environmental health officers suggest, the HACCP approach is also well suited for application to the water and wastewater sector. The concept of using the HACCP approach in non-food-safety applications is not entirely unprecedented. This process may be particularly useful in the Arctic, where seemingly small issues such as running out of heating fuel or inadequate inventory of spare parts could jeopardize both the public health and mechanical systems. The HACCP process could enhance the emergency preparedness of facilities in rural Alaska.

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Utility Management Support

Small labor pools, limited economies, and high employee turnover make small communities inherently prone to loss of operational capacity. To provide a measure of stability, the GNWT Department of Municipal and Community Affairs (MACA) offers "service agreements," allowing communities to temporarily contract operation and maintenance services from the government. Communities must pay cost plus a 9 percent administrative fee. Since 2002, Alaskans have introduced two utility support pilot programs, the Statewide Utility Association and the Rural Utility Cooperative. Both programs offer services similar to those provided by MACA. Perhaps administrators of the Alaskan pilot programs would benefit from lessons learned by the more established MACA program.

Service Delivery Coordination

One of the most interesting differences between the models is the number of entities involved in providing sanitation services. GNWT is ultimately responsible for construction of all public infrastructure, assisting communities with operation and maintenance tasks, and ensuring that sanitation services are provided in a manner that protects health. This streamlined structure allows GNWT to create operational efficiencies from within. For example, because MACA has responsibility for all functions, it is able to design, locate, and construct public facilities in a way that later makes it most easy to provide those facilities with sanitation services. Alaskans use a more multi-organizational structure. While this approach brings additional resources "to the table," it requires substantial coordination in order to promote efficiencies. Whereas major reorganization would be undesirable, Alaskans may benefit from strategic planning, exploring how elements of the Incident Command System could be used to better coordinate activities and, in the future, consider how each new "piece" will affect service delivery as a whole.

Dispersion of Capital Projects Funding

In both regions, local communities provide day-to-day maintenance while government programs pay for infrastructure replacement. While this process furthers community self-determination and protects public health, it may also encourage deferral of maintenance. An April 2005 Pumphouse Pipeline article discussed this issue, stating, "If you consider the concept of survival of the fittest it seems that replacing failed utility infrastructure prematurely actually represents just the opposite by rewarding failure instead of success" (Rea, 2005, p. 5). The GNWT officials have proposed termination of their project-based infrastructure replacement system in favor of a block-grants program. Local governments will receive annual payments that, if saved over a period of years, would provide for infrastructure replacement. Allowing local communities to manage their own capital funds will provide incentive to prolong system life. Alaskans should monitor this innovative program and learn from the GNWT experience.

Protection of Lower-Income Residents

To counter rising costs, Alaskans have attempted to increase revenues through improved user fee collection. Typically, this approach has meant discontinuation of services when there is nonpayment. While this practice appears to be necessary, some residents cannot pay for services, regardless of desire. The National Rural Water Association has noted that using community median household income (MHI) to determine user fees fails to protect lower-income families (Rubin, 2001). While some families are left without critical services, others may go without food, sacrifice needed medical care, fail to pay rent, or incur long-term debt in order to avoid discontinuation of utility service (Edin & Lein, 1997).

Alaskans have no way of differentiating between those who cannot pay and those who choose other financial priorities. In the NWT, the public housing program protects the unemployed and impoverished. NWT residents who cannot find adequate housing for less than 30 percent of gross household income are eligible for public housing; residents of these homes are not required to pay for sanitation services. This process allows user fees to be collected from those with adequate financial means while protecting the health of the poor. Alaskans should consider safeguards for those who truly cannot pay for sanitation services.

Financial Support for Operation and Maintenance

GNWT recognizes that certain communities cannot generate enough revenue to support proper operation and maintenance and thus offers operational subsidies in the form of general block grants. The block-grants program, combined with relatively favorable logistics, is perhaps the primary reason that GNWT is able to provide modern sanitation services for nearly all NWT families. By contrast, the Alaskan approach is based on the assumption that all communities are capable of independently supporting government-provided sanitation infrastructure. Researchers from the University of Alaska Institute of Social and Economic Research (ISER) have suggested that even with higher fees, effective collection, and good management, some rural utilities will not be self-supporting (Haley, 2000). Observations made during the project reported here further suggest that some Alaskan communities cannot adequately cover operation-and-maintenance costs given the increased challenge. Operational subsidies may be required in order to establish sustainable sanitation services in many rural Alaskan communities.

Monitoring and Surveillance Capabilities

Both regions recognize the challenge of acquiring health statistics at the local community level. Many of the same factors that complicate efforts to provide sanitation services also create barriers to monitoring and surveillance. Most Alaskan and NWT communities have a health clinic where residents receive basic medical care. Statistics on waterborne and water-washed diseases, which are often nonfatal and unreportable, are not entered into comprehensive monitoring and surveillance systems. In spite of the difficulties, enhanced monitoring and surveillance capacity would allow for more effective environmental health programs.

Health Promotion and Education

Recognizing that construction is a costly and complex method of achieving health improvements, both regions may benefit from maximizing nonconstruction health promotion efforts. While construction activities have proven to facilitate reductions in sanitation-related disease, much of the health benefit is realized not from bricks and mortar, but from accompanying changes in personal-use habits. For example, increased handwashing can reduce sanitation-related disease in the absence of capital construction (Luby et al., 2005).

Attracting Indigenous People to the Profession of Environmental Health

Both regions would benefit from attracting Indigenous people to the field of environmental health. Of the more than 50 environmental health positions that exist across Alaska and the NWT, none are held by Indigenous people, even though Indigenous people comprise the vast majority of the service populations. This is not due to oversight, however. Organizations in both regions offer Indigenous hiring preference and have attempted to recruit members of the local populations. Working with local universities to develop accredited environmental health science programs and partnering with others who specialize in this area, such as the National Council on Diversity in Environmental Health, may help attract Indigenous people to the profession.

Conclusion

The findings of this report illustrate the potential for continued collaboration between the NWT and Alaska. Completion of the project reported here should not be viewed as an end, but as a step toward further exchange of information and ideas. Environmental health professionals from other northern regions of Canada, Russia, and the Scandinavian countries also could be included. In addition, both parties are interested in a circumpolar environmental health summit that would include all regions and expand cooperation to other areas of environmental health. An obvious next step would be for Alaskans to host an NWT environmental health officer through the NEHA Sabbatical Exchange Ambassador Program. Continued collaboration would allow the Canadians to learn more about and to benefit from innovative and successful elements of the Alaskan approach. These ideas could result in the development of a broad collaborative partnership beneficial to all participants.

Acknowledgements: The author thanks NEHA and Underwriters Laboratories for providing financial support through the Sabbatical Exchange Ambassador Program; the Alaska Native Tribal Health Consortium for providing financial and program support; Dr. Suzanne Cashman for providing guidance and manuscript review; former NEHA Sabbatical participant Dr. Steven Konkel for providing guidance and manuscript review; and the residents, community leaders, and environmental health professionals of the NWT.

Disclaimer: The findings and recommendations described in this report are those of the author and do not necessarily represent the views of the Alaska Native Tribal Health Consortium, the Indian Health Service, the U.S. Public Health Service, or any other party or organization.

Corresponding Author: Troy L. Ritter, Environmental Health Coordinator, Alaska Native Tribal Health Consortium, 1901 Bragaw Street, Suite 200, Anchorage, AK 99508. E-mail: [e-mail].

REFERENCES

Black, M.L., & Logan, A.J. (2000). Financing water and sewer O & M in rural Alaska. In S. Haley (Ed.), Financing water and sewer operations and maintenance in rural Alaska (pp. 2-1-2-8). Anchorage: Institute of Social and Economic Research, University of Alaska. Retrieved January 9, 2006, from http://www.iser.uaa.alaska.edu/AkNativeandRurualStudies/FinancingWS/Ch2.pdf.

Cairncross, S., & Valdmanis, V. (2006). Water supply, sanitation, and hygiene promotion. In D.T. Jamison, J.G. Breman, A.R. Measham, G. Alleyne, M. Claeson, D.B. Evans, P. Jha, A. Mills, & P. Musgrove (Eds.), Disease control priorities in developing countries (2nd ed.) (pp 771-792). New York: Oxford University Press & The World Bank.

Colt, A., Goldsmith, S., & Wiita, A. (2003). Sustainable utilities in rural Alaska: Effective management, maintenance and operation of electric, water, sewer, bulk fuel, solid waste. Retrieved December 19, 2006, from http://www.iser.uaa.alaska.edu/Publications/sustainA.pdf.

Edin, K., & Lein, L. (1997). Making ends meet: How single mothers survive welfare and low-wage work. New York: Russell Sage Foundation.

Esrey, S.A., Potash, J.B., Roberts, L., & Shiff, C. (1990). Health benefits from improvements in water supply and sanitation: Survey and analysis of the literature on selected diseases (Technical report no. 66). Arlington, VA: Water and Sanitation for Health Project.

Haley, S. (Ed.) (2000). Financing water and sewer operations and maintenance in rural Alaska. Retrieved December 19, 2006, from http://www.iser.uaa.alaska.edu/AkNativeandRuralStudies/FinancingWS/TableOfContents.htm.

Luby, S.P., Agboatwalla, M., Feikin, D.R., Painter, J., Billhimer, W, Altaf, A., & Hoekstra, R.M. (2005). Effect of handwashing on child health: A randomized controlled trial. Lancet, 366(9481), 225-233.

Percival, R.V, Schroeder, C., Miller, A.S., & Leape, J.P. (2003). Environmental regulation: Law, science and policy (4th ed.). New York: Aspen Publishers.

Rea, B. (2005). If we build it, will it last? Pumphouse Pipeline, 25(11), 1-5.

Rubin, S. (2001). Affordability of water service. Retrieved December 19, 2006, from at http://www.nrwa.org/whitepapers/afford/general/afford05/afford05.doc.

Schliessmann, D.J., Atchley, F.O., Wilcomb, M.J., & Welch, S.F. (1958). Relationship of environmental factors to the occurrence of enteric diseases in areas of Eastern Kentucky. Public Health Monograph, 54, 1-33.

Smith, D.W., Ryan, W.L., Christensen, V., Crum, J., Heinke, G.W (1996). Cold regions utilities monograph (3rd ed.). New York: American Society of Civil Engineers.

Troy L. Ritter, R.E.H.S., M.P.H., D.A.A.S.

FIGURE 1 Life Expectancy at Birth, Alaska Natives Versus All Americans,
1950-1997

                1950  1960  1990  1997

All Americans   68.2  69.7  75.4  76.5
Alaska Natives  46.4  61.1  68.8  69.5

Sources: Alaska Native Health Service, Alaska Bureau of Vital
Statistics.