Monday, October 28, 2013

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

September 12, 2013

Access to water has been described as a basic human right. I'd heard plenty from my medical school classmates about the challenges of bringing water to poor villages scattered across Africa but I didn't realize there were places in the US with similar challenges, places where water isn't taken for granted.

I'm out in rural Alaska, "the bush," far away from the "big city" of Anchorage (which at 350,000 has half the state population). I'm in Bethel, Alaska, population 6,000 people and probably as many dogs, all-terrain vehicles, and snowmobiles (or "snowmachines" as they're called here). I've spent the past few days here working with the environmental health team of the regional native health corporation that provides for the health needs of 25,000 people, mostly Alaska Native, spread out across 50+ villages and communities in an area the size of Oregon. This is a tough place to live for the mostly poor native populations in the rural villages. They lack the oil that brings wealth to villages much farther north, and the fishing and tourism that are prevalent in many other parts of the state. Access to clean water for sanitation and cooking is one of the basic challenges out here.

Most of the villages out here historically had third-world rates of invasive bacterial diseases: pneumococcal pneumonia, haemophilus influenzae meningitis, and soft tissue infections, until not long ago. Vaccines made some headway but that's an incomplete solution. In areas where piped water has been brought in, disease rates dropped much farther. There has been a push to improve the access to basic sanitation, to provide better access to plentiful clean water and disposal of sewage, but the implementation is a persistent challenge. There's plenty of water out here at least in some places, in the rivers and lakes and the ocean, but it's expensive to treat and difficult to transport to houses. The Arctic provide some tough obstacles: the ground in this whole region is soggy and unstable and so it can't maintain water pipes, and anything above ground is incredibly expensive to keep warm when the nighttime temperature hovers in the single digits (Farenheit) for 3-4 months of the year and record cold weather dips to -45 F. Sewage disposal faces similar challenges (and freezes a lot harder than water). Supplies to the region come by cargo barge up the river, or by cargo plane, during the short summer here; in the winter, the rivers freeze solid enough that people can drive on them with snowmachines and light trucks but cargo can only come by plane. The area is rich in fish and berries but poor by most other measures. The regional health corporation is quite proactive, though, and has worked with the state and the individual cities and villages to get better sanitation to the people here. In the past, a village would have a central water distribution plant where people filled small jugs and transported them home by foot, all-terrain vehicle, or snowmachine; human waste was collected in a "honeybucket" and then dumped in each neighborhood and then towed to the village sewage lagoon.

There is an on-going initiative to bring piped water to every home in Alaska, and it faces an array of uphill battles in places like the YK Delta where many people live in villages with only a few dozen people, and the nearest real infrastructure is 20 or 50 miles away with no roads in between. Several years ago an ambitious project installed water tanks, low-flow toilets, and sinks in most of the houses in a handful of villages, using all-terrain vehicles in the summer and snowmachines in the winter to haul water to homes and haul sewage away to nearby lagoons. And they disassembled any remaining infrastructure supporting the older systems that were phased out. The system was great in principle but it has problems. The first is that over the years we've learned more about the amount of water the people use on a daily basis for what we'd consider a modern lifestyle, and we've also learned a lot out here about the economics of water utilization. And it turns out that at the price point that this water is available, and the quantities in which it's delivered, there isn't nearly enough water coming into these homes to really use water the way we all do in our homes. There's enough water to cook food. There's running water in a bathroom and a sink and a toilet, but people ration water by putting a bowl under the sink and reusing the water several times. People have simple agitation clotheswashers and it's quite common to run 5-6 loads of clothes in the same water until it turns grey or black.

I spent the last two days on a house-to-house survey of these failing water systems in a small village in the YK Delta. More recently, some of the villages with this "flush tank and haul" system have run into some serious maintenance problems that are, at some level, representative of everything wrong with these novel solutions to the water challenges out here in bush Alaska. The toilets in these homes, low-flow toilets purchased at great cost from Japan to reduce water use, are failing in simple ways, and there are no repair parts here. (Apparently the toilet flush handles were made in a factory in Japan that fell in an earthquake, and it's not clear that anyone is making more replacement parts now.) There are some repair parts floating around but people are unwilling to pay steep prices to make repairs to a system they never totally bought into in the first place. The toilets flush sewage to tanks outside the homes and workers pump out the sewage to transport to a lagoon, but the pipes that connect the homes to the tanks are falling apart. In many instances they've frozen in the winters leading to more severe damage. When people stop using this tank system, they start dumping sewage anywhere (next to their homes) which is pretty unsightly and it also means that there aren't as many fees pouring in to support the system that remains. We found all the problems that I've described above, and a village with limited means to repair a failing system. After I leave, the rest of the team will work with the village and the community to find ways to repair the system, but it's not clear where that funding will come from (this system probably cost $5 million for a village of a few hundred people, but there's no repair fund leftover) and it's not clear whether this system is viable long-term.

On a small scale, the fixes are easy in villages like the one I visited: find a repair person, find funds to pay them to get the system running again. There are other villages nearby where there's more funding, and maybe two or three people that know how to do the maintenance work, and things work better. But on a larger scale, though, the water and sewer system in that village is probably destined to fail because what made sense a decade ago no longer seems sustainable and maintainable. The state is sponsoring the "Alaska Water-Sewer Challenge," inviting bids from around Alaska, and around the world, for the next greatest system, or set of systems, to tackle the complexities of bringing adequate supplies of water, and adequate sewage removal services, to all these small remote communities. It's frustrating and disturbing to find entire communities in the US that we haven't managed to bring up to modern sanitary standards. As I head back to Anchorage and then back to Boston in a few more days, I leave with a sense of hope. There are big challenges here in Alaska, with providing basic services to these remote villages, are big challenges. But I also met a lot of highly-motivated, dedicated people, young and old, Alaskan and from elsewhere, here working to address these health disparities, and I'm hopeful that they'll persevere, with more initiatives and iterations, and see progress in our lifetime.

And as I head home, I'm incredibly grateful to all the people and organizations that made it possible for me to come out here, learn about all these challenges, and help think about how to address them. Thank you to Tom, Ros, Mike, Prabhu, and others in CDC's Arctic Investigations Program for letting me join them for the month. Thank you to Jenni at the Yukon-Kuskokwim Health Corporation for the opportunity to head into the field and learn about environmental injustices on the American frontier. Thank you to MGH Pediatrics for letting me slip away for a month. And thank you to the Partners Center of Expertise in Global and Humanitarian Health program for financial support of my travels!

With limited water coming into each home, people ration water by putting a bowl under the sink and reuse the water.
The village spigot. This village is large enough to have centralized water treatment, but with soggy ground that can't support pipes, and freezing temperatures that make above-ground pipes a recipe for freezing, they rely on ATVs and snowmobiles to carry water to each home and haul sewage away.

Going house to house to survey the state of the "flush tank and haul" systems in a small village in rural Alaska.
Heading back from a village visit, by small motorboat on one of the winding rivers in Alaska's YK Delta.


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