Monday, October 28, 2013

Alaska, USA - Isaac Benowitz, Resident in Pediatrics, Massachusetts General Hospital - Health Disparities of Alaska Natives

August 26, 2013
Greetings from America's frontier! I’m spending a month in Anchorage, Alaska, working with the CDC’s Arctic Investigations Program. I came to pursue some interests in the social determinants of health and environmental health, chasing an opportunity to work alongside CDC researchers who study health issues in Alaska Natives and other Arctic populations and to dabble in some of the diverse applied public health and epidemiology projects going on here. Alaska has a population of 700,000 people, including about 150,000 Alaska Natives, a term that describes people from several different tribes. Some people of native heritage live in urban settings and have a health status similar to others in modern cities, with relatively good access to clean water, clean air, access to healthcare. But there’s also a huge native population living in small remote rural villages where they rely on subsistence fishing and hunting and gathering, live in simple homes that often lack adequate ventilation of wood stove fumes or running water and sewage services, and have fairly poor health status. A small, cramped home makes sense way out there, despite all of the available land, when you're thinking about the heating bill for the long and harsh winters up here with prolonged stretches of sub-freezing temperatures. It’s disturbing, and amazing, to find places in the United States without abundant clean running water in homes, but there are several villages where there is no public water supply, or that supply is a pump across town, or there is an infrastructure to distribute clean water to homes but people can’t afford the bills. These villages have experienced very high rates of invasive bacterial diseases: Haemophilus influenza, meningococcus, strep pneumoniae, and skin and respiratory infections from staph aureus, as well as tuberculosis in some places, but gains in vaccination rates have turned the tide on much of this. Diets are a mix of traditional foods (think about lots of heavily-preserved fish and game meat... and the occasional whale feast!) and more modern foods brought in from outside. Transportation is a mix of boats on rivers in the warmer months and snow machines (snowmobiles) in the long winters.

I have a few projects to jump into for my time here, in addition to getting a flavor for other work in progress here. This research group at CDC works closely with the Indian Health Service, a federal agency that provides healthcare to native populations across the US, including Alaska Natives here in Alaska and American Indians elsewhere, in their own clinics and hospitals and as an insurance provider. There has been an observed rise in rates of hospitalizations in Alaska but nobody has taken a big-picture look at the IHS hospitalization data to examine trends by year and by diagnostic category, so I'll be pursuing some health services research analyzing hospital admission data. Next, there is a long-observed increased burden of skin and soft tissue infections in the Yukon-Kuskokwim Delta, a region of Southwest Alaska the size of Oregon, with 25,000 people scattered across 50 rural villages with most populations under 1,000. We know that much of this is related to poor overall health status (similar scenarios have been studied in indigenous groups in Canada, Australia, and New Zealand) but the challenge is finding workable ways to reduce the significant health burden of these skin infections. Prior field investigations and studies identified several factors that contribute to boil development, including overuse of antibiotics for respiratory conditions (leading to the development of resistant strains), poor general hygiene (many people shower once a week, with no soap) and communal steamhouses (tiny sweat lodges, build from plywood, where as many as eight people may cram into one sauna session) that allow for skin-skin contact and biofilm formation which both predispose to MRSA transmission. The regional health corporation (like the county health department for the tribal population) asked CDC to recommend ways to reduce the burden of MRSA carriage and boil development; I’ll be helping to select intervention strategies and conduct environmental testing to let us better define MRSA transmission dynamics. CDC is also pursuing several projects related to the burden of human papillomavirus (HPV) ranging from studying virus stereotypes in tissue samples to starting a vaccine effectiveness trial for HPV in native teens (the effectiveness will depend on whether the same strains are prevalent up here as in the rest of the US), looking at titer levels in teenagers over several years, and if I have time I’ll help recruit teenagers into this study designed to determine whether the three-dose vaccine series works as well in the Alaska Native ethnic group as it does in other populations where it’s been studied.

And in the time that remains, I hope to explore a few parts of Alaska. It’s gorgeous in Anchorage this time of year (August-September), a little rainy mixed with some sun, but with temperatures in the low 60s and long days with an evening glow that lingers for hours before the sun dips over the mountains around 9pm. Many people who live here love fishing in the rivers and in the ocean, hunting, boating, cross-country skiing, hiking, and running. It’s not just people in rural villages who value subsistence: one researcher here explained that it’s so easy to live off the land, so easy to fish, hunt, collect berries, and grow vegetables in a garden in the short growing season, that Alaskans consider it an indignity to go to a market for any of those foods instead of diving into their deep freezers.


 Arctic Investigations Program is CDC's outpost on the American frontier.

Every presentation from the CDC Alaska group had a picture of a moose, so here's mine.

It's gorgeous in Alaska in late August. Here's a wildflower on a hike a few hours outside Anchorage, with a high mountain stream in the background.

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