 And we have a great array of speakers here today. I want to first of all congratulate Heather and Heather Conley and Carolyn Roloff colleagues here at CSIS for the production of this report, which I hope you've all had a chance to get and which is available electronically online. This is a terrific and very timely piece of work that brings together, as we'll hear from Heather in one place, a lot of data, a lot of analysis, situates it all in the context of what has been going on up to this time in engagement in the Arctic on the health. What do we know and what are the possibilities here in terms of concrete additional action by the U.S. government in its chairmanship of the Arctic Council over the next two years, which begins as Heather's pointed out next week. And so we're delighted that we could partner and that Heather and Carolyn could produce this really excellent piece of work. So thank you. Thank you for doing that. Congratulations. That's terrific. Senator Murkowski this morning in her speech made a very powerful point and that was that all action by the U.S. government and other governments in the Arctic need to put the human reality, the individual and the community at the center stage in discussing the future and in discussing the approaches that are going to be taken. And so I think this gives us a wide open door for talking about these issues and where we are going to go. The way we're going to do our business here today, we're going to ask Heather to give a quick synopsis of the report and what it contains. Then we're going to move in sequence. We're going to have Pamela Collins, who is a psychiatrist and an MD, director of the Office for Research on Disparities and Global Mental Health at the National Institute of Mental Health. Pamela came to us. We've known each other a little bit over the years. Roger Glass, who's with us today. Roger, thank you for joining us. Roger kindly connected us and thank you, Pamela, for coming and being with us. We'll roll through eight or 10 minutes of presentation on the work that NIMH is leading in this area. We will then move to Dr. Michael Bruce, epidemiology team leader of the Arctic Investigations Program for CDC based in Anchorage. Michael, thank you so much for taking the time to be with us today. He will walk through the CDC program in some detail as well. We're using this really as an occasion for getting these two lead U.S. agencies to tell us what they do, tell us what the major challenges and issue focus will be and what the future might look like in terms of continued work, intensified efforts in this area. Dr. Bruce is the epidemiology health leader and has put a predominant focus upon a wide range of research and studies across vaccine preventable diseases, chronic diseases, health disparities, chronic disorders. So we're thrilled that Michael's with us. Our fourth speaker is Dr. Timothy Helleniak, who is a research professor at George Washington University and a leading polar expert. He's a migration and expert and demographer who's been working on polar geography and polar environments for his entire career. He's one of the contributing authors to the newly completed and newly issued about a month ago Arctic Human Development Report, which I hope some of you have had a chance to look at. It's a very comprehensive encyclopedic 10-year study built on the 2004 study, comes out, it's full of enormous amount of insight and detail, and we were very fortunate through Heather's intervention to enlist Timothy to come down here today to be with us. So, Tim, thank you for making the journey to be with us. So with that, once we've rolled through the presentations, we'll have a bit of a conversation among ourselves, but we're going to move to you all very rapidly to get your opinions and comments. So please be ready for that. And Heather, floor is yours. Thank you so much, Steve. And it's wonderful to be able to have such a great partner. Steve and I, our offices are right beside each other. And I'll tell you how this idea came about. We were talking, and I've sort of gotten the nickname at the office, the Polar Princess, the Arctic Queen, because I do so much on the Arctic. And he goes, you know, we should do something together. We should collaborate together. How can the global health program be a part of this conversation? I said, funny, you should ask. Health is really not an issue in the policy space that we focus on as much. We know the U.S. chairmanship, one of the major themes is the economic and the livelihoods of people in the North focus on that. And we really need to pull this information together. What do we know? What is the United States doing about it? And then, of course, I said the timing is perfect because we know the Arctic Human Development Report, which first issued in 2004. So as it was issued, it was a 2014 report that was issued a little bit later in February of 2015, we'd have 10 years to see what has changed. Where is the focus that we need to do? So all of these elements came together and really encouraged us to put this report together. So many thanks to the global health program for being part of that. And of course, my colleague Caroline Roloff was absolutely instrumental in developing this report as well. I just want to, you're so sick of hearing from me today. I'm going to be extremely brief and I really want to hear from our panelists. This is part of, I'm going to take my notes and be copious. I want to learn a lot here too. But I just want to do a couple of highlights in the report. I think that the first thing that strikes me, I think it strikes anyone that doesn't know this topic and begins to read it, is the huge challenge of mental health and suicide prevention. A recent, this comes from our report, a recent study has found that every five degrees of increased northern latitude suicide rates increased by 18%. Now, just to bring this home closely for the state of Alaska and Alaska Natives, the rates of suicide have increased 500% since 1960, with rates four times higher among 10 to 19-year-old Alaska Natives than their non-native peers. This is striking and it certainly is a huge crisis. There are contributing factors, substance abuse and violence and there's just a whole issue of mental health challenges that are profound. And if there's one thing we hope this study does is reinforce that urgency and bring new focus to it. There's other pressing issues that just require continued focus. The change in food habits, food security, we're seeing increased rates of obesity, diabetes. We're also seeing a heightened impact on the food security of environmental contaminants and mercury. And some of these things is from the changes in the climate but also as the food cycle so dramatically changes. But the Arctic picture is a complex one because there is no one model. You have a very different health spectrum in the circumpolar Arctic where health indicators in northern Europe, the Nordic countries is far different from what we see in other communities. And so the challenge for the Arctic Council as it's developing its thinking is how, there's not one size fits all but how do you meet the needs and how do you bring the study, the information, the focus together. So there's lots of information in the report. Welcome you to read it. I just wanted to conclude by highlighting some recommendations and two I think are particularly, perhaps provocative to some of our State Department colleagues. I am a proponent of really rethinking the Arctic Council's governance structure in light of its 20th birthday which we will celebrate next year. It was designed in 1996 for one purpose but as we've just talked about over the last three and a half hours, so much has changed. Do we have the right alignment in our working groups? Do we have the right alignment and how the Arctic Council meets these challenges? So we very provocatively recommend that we, the Arctic Council should really think about having a working group designated for Arctic health and well-being. If people are at the center of this policy, which they are, we have a flora and fauna working group. We have the protection for the Arctic marine environment. I would like to see a very focused working group on health. If we think it's important, we put it out there. And so as I said, I know that, whoa, that's a pretty provocative recommendation but we think actually it's the one thing that could perhaps be a legacy for the US chairmanship and moving forward. The second linkage, as you've heard from Senator Murkowski through our discussion on energy resource development, what we really found in our report, there is a link between economic development and growth and mental wellness and well-being. And maybe we should be a little bit more specific about that linkage where people have livelihood, their living standards are increasing. Can we make that linkage? Can the Arctic Economic Council have a direct role in how the private sector, public-private partnerships are engaging in some of these pressing health issues for Arctic communities? And of course, as part of all of this is how do we engage traditional knowledge in working towards an improved Arctic health and well-being picture. And I think again, the working group, a new working group could bring that traditional knowledge in. We have some other recommendations. Obviously it is our hope that the US chairmanship focuses like a laser beam on these issues. We know mental health and suicide prevention is part of it. I know our colleagues are going to give us some great insights on what the work of their agencies are doing. But we wanna raise this up, we wanna highlight it and we certainly wanna impress upon policymakers that this is a critical issue that demands our full attention. Senator Murkowski talked about the young people and their enthusiasm. We can't have Arctic young people not seeing a promising future and committing suicide. So with that, Steve, thank you so much again. Thank you. Pamela? Thank you and thank you for the introduction. It's a pleasure to be here. The many opportunities and challenges we've heard discussed this morning, I'm going to focus in on one of those, which is the area of suicide and suicide prevention. Just to orient all of you, this graph, oops, I'm pressing the wrong one. This graph shows you some data on suicide rates in the United States over the last 20 years. The red line shows you homicide rates in the United States, which you can see have dropped substantially over the last 20 years. Suicide rates have increased by about 17% from 2002 to 2012. And in 2013, there were about 41,000 suicides in the U.S. And to give you a sense of when we're talking about the circumpolar communities, where do we stand? So the bottom red arrow shows the U.S. suicide rate in comparison to other countries and sub-communities in the Arctic. The top red arrow shows you the suicide rate in Alaska. And one of the main takeaways from this point is that, first of all, just to orient you, the yellow bars represent Nordic communities and regions, Nordic countries and regions. The green represents Greenland, which you can see at the very top. The blue represents Russia and regions in Russia. And the red is North America and regions. So the, as I mentioned, the bottom red bar is the United States suicide rate. The top, the red bar by the other red arrow is Alaska. So clearly, rates in Alaska are higher than the U.S. population in general. And if you, what you can also note from this slide is that as you go higher, the bars that are the higher rates represent, often represent indigenous communities compared to the country totals. So there's considerable variation across regions and variation within countries with indigenous groups, often at a much higher rate, risk for suicide. These are data from Alaska specifically. And again, just to orient you to what the lines are, the bottom line in yellow shows non-native Alaskans. And these are females, non-native females, suicide rate. The next line, that little jagged one, are Alaska native females. And then above then the brown line, non-native males in Alaska. And that top line represents Alaska native young men and men. So again, huge differences by ethnicity and certainly regional variation within Alaska too, where there are certain communities in Alaska that have higher suicide rates than others. So this is a complex problem. It's not the same everywhere. But clearly this group of men, and young men in particular are the group that are at the highest risk among Alaska natives. The conversations about, oops, thank you. The conversations about suicide prevention in the United States are happening at an opportune time. The US just published this prioritized research agenda for suicide prevention in 2014, with an ambitious goal of seeing that suicide could be reduced by 20% in the US over the next five years should the research and resultant policy and services interventions be implemented. And an ambitious goal of seeing a 40% reduction over the next 10 years in the United States. Again, given that we can implement what we know needs to happen. At the same time the WHO published earlier in 2014, its World Suicide Report. Also setting ambitious targets and looking at what are the regional differences around the world and what can we learn as a global community to address suicide. And I just wanna highlight a couple of cross-cutting themes in the US research agenda that are relevant I think to Arctic countries. One is a positive approach. So testing approaches that actually initiate and maintain healthy behaviors that can lead to reduction and risk. Testing interventions that are aimed at reducing risk factors, but also using technology to figure out how to facilitate social connections and help seeking. Using practical studies. Practical trials to determine the benefits of quality improvement in healthcare systems. So recognizing that these interventions need to happen in the context of quality mental health service delivery and quality healthcare delivery. And finally, recognizing that these are interventions that need to take place intersectionally. So adapting and testing components within other systems that are responsible for health, including housing, justice, education, et cetera. So I spent some days, a few weeks ago in Iqaluit, the Canadian Institutes of Health Research sponsored a meeting of report out on the mental wellness project that they did underneath the Canadian chairmanship. And it was a great discussion. The Canadians sponsored a couple of teams to do an environmental scan of available interventions that are being implemented in communities that communities find promising. Particularly looking to see what is it that indigenous communities in the circumpolar arctic find most important and what do they consider practices? What do they consider promising interventions? They also looked to see though what were the evidence-based interventions. And some of the lessons that came from this conversation were that solutions need to be culturally grounded. They need to be community-based and community-driven. There was a lot of discussion around the importance of intervention specificity for communities. This was important for communities to recognize that this is not a one-size-fits-all, these solutions need to be adapted for context. What's the importance of culturally appropriate shared interventions across communities? So how can one learn from simply implementing the mental health services that are needed, for example? How can we learn from intersectoral cooperation that would benefit multiple communities? Another takeaway was that the solutions, studies of these problems need to be solution-focused instead of problem-focused. So again, how do we focus on health? How do we focus on strengthening health? Even while we're trying to reduce risk and reduce bad outcomes. Communities, clinicians, governments, and others need to know what works in order to know what to implement more widely. And a number of questions arose about how do we do that? How do we make sure that communities, how do we know how communities define what works? That's not always the same as the way researchers define what works. How do decision-makers define what works and where do these different perspectives actually intersect? And finally, as I mentioned, they noted that there were few studies of interventions with a rigorous evaluation. So opportunities that we see from the U.S. perspective for building on the Canadian activities, first of all, acknowledging that these kinds of challenging problems need shared knowledge and tailored efforts. But when we're tailoring interventions, how can we also be sure that others are learning from those interventions? And if your interventions are successful, what's required for implementation? And once an intervention is implemented, how can one ensure that the intervention can be sustained? So how can the results of successful interventions be communicated to decision-makers to aid sustainability? And one answer may come in how we approach testing the efficacy of these interventions. And that includes figuring out how can we harmonize outcome measures to provide a shared language to communicate to different stakeholders? An important issue arose in the conversations in Iqaluit, and that is that if we want to think about wellness and health, there are many slices to the pie. And so focusing on the health sector alone is not sufficient. One also has to think about the economic sector, and we've talked about this today, economy, education, the physical environment, climate, and also remembering social history and how that influences the way that people respond to current challenges. So the US proposed project under the Arctic Council is called Reducing the Incidents of Suicide in Indigenous Groups, Strengths United Through Networks, or Rising Sun. And the context for this is remembering that, as I've shown you in the first slide, there's an elevated risk of suicide in these remote rural Arctic communities. We also are talking about communities with considerable cultural diversity and often very small populations. So the standard approaches that researchers tend to use to evaluate the efficacy and the effectiveness of interventions is quite challenging. So what might be a way to get around some of those things? There are also some important assumptions, and those are that efforts also have to continue, of course, beyond what's proposed under the US chairmanship and under the Sustainable Development Working Group, specifically, and that these proposed projects, like Rising Sun, can move the agenda forward, but they have to happen in concert with broader ongoing efforts for service delivery, for research, and for these other intersectoral interventions as well. So some of the questions that Rising Sun hopes to answer are, can lessons about the impact of suicide prevention interventions be learned from information across more than one Arctic community? Would this be facilitated by identifying common measures to assess the outcomes of interventions, and what are some of the underlying themes that are most frequently measured across these interventions? So what might this look like? We know that there is a big body of existing interventions out there, some of which were highlighted in Canada a few weeks ago, and those interventions target policies, some of them target health systems, some of them are clinics-based, some of them are more community-level interventions that are focusing on bringing youth in particular back in touch with their cultural traditions, and some of them are focused at individual levels. And so what we hope to do is prepare a toolkit that takes into account these various levels of intervention and meaningful outcome measures that can be used to harmonize the evaluation across sites that could enable communities to measure what's relevant to their needs and that would enable the sharing and comparing of data across studies of effectiveness. And this we hope will be able to be amenable for community use and will take into consideration what communities value in terms of outcomes that will take into consideration the kinds of data that sub-national governments are currently using and value in terms of outcomes, and that will also use the expertise of researchers who are working on methods appropriate for this kind of evaluation. Thank you. Thank you very much, Pamela. Dr. Michael Bruce, CDC. See, can we pull up the slides? Oh, there it is. Okay. Thanks very much for having me here to speak to you today about CDC's role in activities in regards to human health in the Arctic and the subarctic. So I'm going to work off a series of slides. So this is a slide that shows you sort of CDC's assets in the Arctic, and I work for the Arctic Investigations Program, 33 people total. We also have a quarantine station there focused on infectious diseases. We have the National Institute of Occupational Safety and Health Office there, and we also have an ATSDR office. So our mission at Arctic Investigations Program is to prevent infectious disease morbidity and mortality in peoples of the Arctic and the subarctic, with a special emphasis on diseases of high incidence and concern among indigenous people. Our priority areas are surveillance of infectious diseases, emerging infectious diseases, reducing health disparities, preparedness and response, and leadership in circumpolar health. So I'm going to go through some of our circumpolar activities right now. One of them is international circumpolar surveillance, and we're the headquarters for a circumpolar network looking at different infectious diseases across the Arctic. That map shows you in the darker color the countries that participate in the Invasive Bacterial Disease Surveillance Network, and we recently added TB on. So if it was a map showing TB, Russia would be included also. Some of the things that have come out of this network are we've been able to identify outbreaks of infectious diseases across the different countries. We've also been able to identify new, dangerous, emerging infections in these countries, and we've actually been working over the past decade to identify a new emerging infection called Hemophilus influenza serotype A that has a case fatality rate of about 10% in our children. And we've worked closely with the Canadians in particular where the Canadians have quite high disease rates also to work on this issue. We also work with the International Union for Circumpolar Health. I'm the former president of the union. We also work with the American Society for Circumpolar Health that I'm also the former president of, and we work mainly through a variety of different infectious disease working groups, and these working groups fall within the union's purview. We also work with the US Interagency Arctic Research Policy Committee, or IRCPIC. There's a CDC rep from our office that co-chairs that meeting, and Dr. Roger Glass, I believe also co-chairs from Fogarty and NIH, and he's here today. We also work with the Arctic Council. Particularly, we have a representative from our group that's a member of the Arctic Human Health Experts Group, and that has been Dr. Alan Parkinson, but is now gonna be Dr. Tom Hennessey, who's my boss and the director of the Arctic Investigations Program. And the AHAG advises the Sustainable Development Working Group of the Arctic Council. And then we've been working on a number of other health initiatives in Alaska. One is the Alaska Water and Sewer Challenge, and I'll tell you more about that in some subsequent slides, but one of the things that we're trying to do is to take a local Alaska-specific initiative to improve water distribution and sewer system availability to people and internationalize it and expand it to our international partners. We also work within a group called the One Health Working Group in Alaska that's led by the Alaska Native Tribal Health Consortium, and that's really looking at the intersection of human, animal, and environmental health. So I'm gonna speak just briefly about water, sanitation, and health in Alaska. In Alaska, we're pretty far behind, at least in terms of rural Alaska, in terms of the percentage of homes with complete plumbing. And if you look at this graph, you can see that on the x-axis is decade, on the y-axis is percentage of homes with complete plumbing. In the U.S., we went from about 55% in 1940 up to 100% in the lower 48 states. Alaska is pretty high, but when you look at rural Alaska, as of 2010, if you draw a line across, we're where the U.S. was in 1959 in terms of plumbing. So we're pretty far behind. And these are some pictures of a village in rural Alaska. About 25% of villages in rural Alaska have no running water or sewer. And so the picture on the upper left-hand corner is a person going to a water distribution point, filling a plastic bucket with water, and then on the upper right, he'll take that bucket back to his home and dump it in a big plastic garbage can. And that's their water source in the home. That's where they pull their water out of. Down on the lower left is the toilet. That's what we call a honey bucket. It's a bucket with a toilet seat on it. And you can see the right side picture next to it. Someone is emptying that into a receptacle. They have to carry that bucket through the village, slosh it around, spill, and dump it into the receptacle. In the winter, it gets very cold in Alaska. That freezes. They dump those frozen blocks into the sewage of the goon. In Alaska, we call those poop sickles. So if you're rationing water in the village, your priority is going to be for drinking and for cooking. And there's going to be a much lesser priority for personal hygiene, washing, clothing, and cleaning the home. When people think about waterborne disease, most people think about pathogens in the water causing illness. We think that in Alaska, waterwashed diseases are probably of greater importance. That is people rationing water. They're not washing their hands. There's lack of water for hygiene. And that allows for person-to-person transmission of a variety of different infectious diseases. And we've done a number of different studies in Alaska. This is just one slide. On the x-axis, you can see proportion of homes served with piped water. On the y-axis, you can see rates of invasive pneumococcal disease, a very, very serious illness. And that's in children less than five in Alaska. And you can see that in villages with less than 10% of running water, that the invasive pneumococcal disease rates are astronomically high, almost 400 per 100,000. But as the water service increases, the rates of disease go down. And we've seen this for a number of other diseases also. So increasing the proportion of Alaskans with access to in-home water and wastewater services is quite important to Alaskans. It's one of the 25 leading health indicators for healthy Alaskans 2020. At baseline in 2010, about 78% of rural homes had running water. Our target for 2020 is 87%. And I pulled this right off the web. That red stop sign symbol means we're not on target to reach our 87% of water distribution systems to rural homes, which is a bit alarming. One of the things that we've done in response to this that actually isn't me, it's the Department of Environmental Conservation at the state of Alaska, has put forth the Alaska Water and Sewer Challenge. And this is the website you can see listed at the bottom there if you want more information on this. But basically, this is a challenge that was put out to ask for teams to come together and propose decentralized water distribution systems for rural Alaska. There are many places in rural Alaska that will never have piped water, where the substrate is, you can't put in pipes. There are other places where it probably isn't affordable. And so we need some alternate technologies, some innovative technologies to help us with this. So these teams, the work that they do is private sector-driven. They need to be able to provide sufficient water for health. It needs to be affordable for the homeowner, feasible capital cost, long-term operability. And they need to get user input from communities. So right now they're evaluating these six teams, they're gonna hone it down to three teams. And those three teams' proposals are going to be implemented in rural villages. And we're gonna look over a period of year to see how they do in terms of health outcomes, in terms of engineering, did it work? And then in terms of acceptability within the community. And so that's actually ongoing right now. And then this is one of my last slides, is just thinking about the upcoming U.S. chairmanship of the Arctic Council and our water and sanitation initiative. I guess some of the deliverables that we have for this are we're planning on a white paper looking at water and sanitation across the Arctic, looking at populations within home water service, and looking at related health indicators and challenges and proposed solutions. We're gonna be traveling, I'm gonna be traveling in less than two months to the Finland International Congress on Circumpolar Health in which we're gonna discuss this with our international partners. And we're planning on a Circumpolar Water and Sanitation conference bringing together Circumpolar partners and sort of internationalizing the Alaska water and sewer challenge for all of the Arctic. And we're sponsoring that in Anchorage, sponsored by the state of Alaska in September of 2016, looking for innovations in water distribution for small communities. We have many partners in this effort that I have listed up here. And for the sake of time, I'll say thank you. And that's it. Thank you very much, Michael. Timothy? Yeah. The fish was that big. Oh, you got it. Oh, maybe go the other way. Go the other way. Do they load it? Oh, sorry, we need to load your slides. I may not hit the right button. There's always the technology challenge. Oh, okay. Why don't you just start your presentation and we'll catch up. Okay. Adlib. Yes. Yes, I've been asked to talk about the Arctic Human Development Report which just recently came out. As Heather said, it was, I guess it came out a couple of months ago but it's dated 2014. And this is the second Arctic Human Development Report. The first one was published in 2004. And one of the things, well, I guess I'm going through my slides already. It was put together by a number of different teams. There's some 27 lead authors, three lead editors. Very international team drawing from across the Arctic. Here we go. She took the keyboard. She's gonna bring it back. Okay, okay. Yeah, across the Arctic. And this is not a research report necessarily. It's more of a review of research that other people have done. So yeah, okay. It was done under the auspices of the Sustainable Development Working Group. We have a number of target audiences. One of them was obviously the Arctic Council, policy makers in the Arctic. Other people interested in the Arctic like yourselves. What we found is, from the first Arctic Human Development Report that the University of Arctic, other Northern colleges and universities use this report rather extensively. These are the different chapters in the Arctic Human Development Report. I'm the lead author of the chapter on Arctic populations of migration. I'll pull a little bit from that. But I'm gonna really focus on the chapter on human health and well-being by Arya Ryoto, Bjarapapal, and Q Young. We had a number of guiding questions that the authors and author teams were asked to address. One was how does the Arctic differ from the outside world, from the core of the Arctic states? Certainly to look at issues of ethnicity and indigeneity and how those affect the populations of the Arctic. Climate change was a factor also. And certainly regional variations among the different parts of the Arctic. And I'll certainly highlight some of those. And then also this last bullet point, how did the, what were the changes over roughly the first decade of the 20th century since the first Arctic Human Development Report? But focusing on health disparities or health, the issue of disparities, continuing health disparities is obviously an issue that some of the previous speakers highlighted. But this chapter, that's a trend that's highlighted in a number of different places. Disparities among countries, among regions. And certainly this disparity between indigenous and non-indigenous peoples. And then I pulled this chapter, this section from the report. And I think it's in Heather's report also, this kind of different grouping. The Nordic countries, high overall health indicators, not large disparities, not large disparities between the different peoples. And then the kind of Western North American Arctic, rather good health indicators overall. Again, these disparities between indigenous and non-indigenous peoples. Greenland and Nunavut, the two kind of Inuit regions. Again, high disparities between those places in Canada and Denmark. And then the Russian Arctic, which I'll highlight overall. Poor health indicators in general. And this is from just one short example. This is from Q. Young's Circumpolar Health Atlas. I hope you can see that. What he does is he contrasts infant mortality between Greenland and Denmark. And basically the story is Greenland is some 30 years behind Denmark in reducing infant mortality. Obviously the two lines converge rather nicely, but there's a 30-year generation gap. This is from my chapter. Again, highlighting some of these regional disparities among the 27 or so Arctic regions. You can see here there's a huge difference between the Faroe Islands, Iceland, some of these places. And then going down to Chukotka. And I, again, to make this international comparison, I put the world more developed, less developed regions. And this is according to the UN definition. But you can, like I say, there's huge difference down to Chukotka where you have a life expectancy of 58 years. Largest difference between men and women. Life expectancy for men is 53 years. And one of the factors that drives a lot of the overall disparities is the differences between men and women. On the left side are some of the Russian regions where women outlive men by over a decade. And these are some extremely large differences, possibly some of the largest in the world. And then the point is when you have roughly half of your population with a low life expectancy, you're gonna have obviously a low overall life expectancy. Infant mortality shows somewhat the same trends. The highest rates of infant mortality are in some of these predominantly indigenous regions or countries, Greenland, Nunavut, and Chukotka, going down to places like Iceland and some of the Nordic countries, which are really having among the lowest levels of infant mortality in the world. But just one thing I wanna highlight, I put the whole world and then less developed countries to show even though these are high relatively to some of these countries, I mean the Arctic regions actually exist within highly developed high income countries. So there's possibly some hope or something that can be drawn upon there. Apologize for the quality of this graph, but basically the point that this shows the trends in TB across some of the circumpolar regions. The first one is the Canadian Inuit, I guess Greenland and Alaska Natives. You can see the large declines in TB, but kind of continued disparities in TB. And this, one of the previous speakers talked about suicide. And this is from some work that Jack Hicks has done looking at suicide rates in Canada and then among the Inuit in Nunavut. And you can see the trend for Canada is relatively flat, whereas the trend for Inuit in Nunavut has continued to go up. And luckily Jack is a rather cheerful guy, this is rather depressing research to do, but he correlates this with various historical events and he also points out kind of the clustering of suicides, I mean if there's one there tends to be several. And this is from some work that I did. This shows that the sex ratio, the ratio of males to females in Russia. So this is 1989 just prior to the breakup of the Soviet Union. You can see most of the Arctic, the Northern regions have a much higher male sex ratio than the rest of the country. And this is because of the demands of industry. And Northern industry trend to draw more men and women. And as the Steve introduced, I do a lot of research on migration, so I was looking at these changing sex ratios in the Arctic. I thought, well I'll be telling a migration story that men would cope with the downsizing of the Arctic or the Northern economy by migrating out. And what happens here is you can see a declining male sex ratio, but it's not due to migration. Only about a quarter of that is due to migration. Three quarters of it is due to the fact that men are dying in much larger numbers than women in the Russian North. And if we keep going down, this male sex ratio continues to decline. And these gaps in life expectancy, Russia overall has among the highest female advantages in life expectancy. In some of these regions it's extraordinarily high. And I speculate that it's probably among the highest in the world. The first Arctic human development report really focused on health and the chapter was called health and well-being, but this one really tries to push that a little bit and look a little bit more broadly at all indicators of well-being. And I think one of the previous speakers talked about suicide intervention has to go beyond just looking at what the health or healthcare sector can do. It's probably hard to read, but the charts on the right basically show the trends in GDP and the trends in life expectancy over the first decade of the 20th century. The green shows improvement, red shows a decline. And for most of the Arctic countries there has generally been an improvement in life, or improvement in both in life expectancy and in GDP. And but there's, I won't go into detail maybe if you're interested, but there's what the Arctic human development report, there's subsequent reports to that. They take the UN human development index the three components of that, but then they try to add some others that are kind of Arctic specific, fate control, cultural identity, language retention, closest to nature, things that are kind of important specifically to people in the Arctic. So to conclude, there has been a lot of research on health and health well-being of indigenous peoples. The previous speakers talked about that in this chapter and the report talks about that. There's been a number of different research intervention efforts underway to improve the health and well-being of people in the Arctic. I mean, one of the takeaway messages in the report is that there has been considerable improvement in a lot of areas of health, I'm pointing out life expectancy and some of these others, but there are some issues, health issues in the Arctic that remain rather intractable when I showed about suicide, TB and some others, some sexually transmitted diseases, domestic violence, that just don't really show any sign of improvement. And I think the CSIS report also talked about the warming climate and how this may impact water, food security, certainly some infectious diseases and things like that. And lastly, Senator Murkowski talked about the importance of educating the next generation about the Arctic. And then I think some other speakers mentioned that as well. So I'll finish with this slide. This shows my young two-year-old daughter looking at the Arctic human development report when it came in. Notice the smile on her face and the thrill with this. She was actually born and raised kind of during my writing of this whole thing. So I'll stop there and take any questions that you may have. Thanks very much. We've heard a lot about suicide. We've heard a lot about water and sanitation, both with respect to the work underway specific to Alaska, but also work that is underway in the broader Arctic Council context. So I take that to mean from certainly the CDC and NIH perspective that these are the areas where there's the greatest promise and there's an agenda formed up and a way forward. I also took away from listening to your presentations and listening to Tim that we need to be quite realistic, that there are some significant barriers to really carrying forward that agenda or other broader infectious disease agendas. Huge variation as you've pointed out, huge variation culturally, demographically, geographically. Very significant differences across these different communities and across these different sovereign entities. We didn't talk much about what the political barriers might be in terms of getting cooperation within the council on some of these very sensitive and culturally based problems. And we didn't hear much about the questions of prioritization across the constituent governments that we're talking about. To what degree are these issues as sub-issues within a broader health spectrum? To what degree are these becoming prioritized? And to what degree is there political will and financial resources and commitments to try and move this agenda forward? So on the one hand, we have the U.S. coming into the chairmanship next week. We have this body of work out there. We have the human development purport out. There's a lot of new content to move forward. There's a lot of active, ongoing work. But what should we realistically expect in the period of the two-year chairmanship in moving the agenda forward, both at home in the state of Alaska, but on the broader context of the Arctic Council? Maybe I could ask Pamela and Michael to say a few words about sort of what your hope is given that mix of both opportunities that have arisen, all of the good work that you've done and some of the questions around what is this environment, what are we likely to see in this period? How do we set our compasses in a realistic way? Pamela, you and Michael? Well, I think one important aspect of the U.S. chairmanship is actually bringing attention to these issues. So bringing attention to the mental health needs in the Arctic and Alaska specifically, bringing attention to where the risks are, bringing attention to what resources we have to build on. So that's one important issue. From the NIH, certainly we'll continue to fund research to try to answer some of these questions in Alaska specifically and as well as in other sites as relevant. But I think that's a big one and I think the opportunity to have a mental health project as one of the Sustainable Development Working Group projects invites this collaboration across countries to address some of these issues. So as I mentioned in the presentation, the project under the Sustainable Development Working Group is one such thing, but certainly within HHS with respect to mental health interventions, the Substance Abuse of Mental Health Services Administration continues to support work on service delivery for mental health as well as for substance abuse and for suicide prevention. They in fact just released an RFA earlier this month for tribal communities on suicide prevention intervention. So to make a long story short, there are many things happening in concert, but I think this is a great platform to bring attention to an area that often does not get the kind of attention it needs in the global health context particularly and with respect to thinking about the disparities in mental health that are clearly evident. You do feel that the groundwork has been done in terms of the rising sun, consensus among the constituent governments of the Arctic Council that this framework has, there is a buy-in for this framework, a preliminary buy-in to move this forward. So when you say groundwork, so yes, this has been a proposed project that has been reviewed by the various members of the Arctic Council and that at this point we do have buy-in from countries that would like to join us in this work, so we're looking forward to that. And what is it going to take in your estimation to bring it to life and carry it forward, who do you say? So for that specific project, there will be, it will take country partners that will commit funds to move that project forward and I think we're expecting some of those kinds of commitments to occur and we'll certainly hear more about that after the US officially assumes the chairmanship. So yes, so commitment of time, commitment of funds, commitment of expertise and commitment of helping us to gain access to those networks out there that bring access not only to the experts but also to the community members who we hope to engage in this process as well. Thank you. Michael, on the Arctic Water and Sanitation Initiative, if you could say a few words about how much consensus exists today and what's it going to take to really move this forward the next two years. Sure, yeah, I guess I would second Pam's comments in terms of increasing and strengthening our collaboration with our international circumpolar partners. I've been working in the Arctic now for, it's my 16th year and when we started this circumpolar surveillance system, it brought us together focused on invasive bacterial diseases. But there's a lot more out there beyond just a narrow focus on infectious diseases. And I think broadening that with our partners is very important but with a focus on health. And so we've tried to address many of the health, a number of different health issues in Alaska but our current focus is on water and sanitation. And one of the reasons for that is that, I said a little bit about it earlier, is that we have piped water to about 78% of those rural villages, but there's a significant portion that don't have it and may never get it. So what do we do? Well, one of the interim steps that we had taken was to develop small-haul water systems into these villages. So if you have a small-haul tank in your home, you can truck water to the home and fill the tank and you can have faucets and you can have a shower and you can have some water in the home in that respect. But as it turns out, that model doesn't deliver a lot of water into the home. And so what we've learned is that homes that have honey buckets that have basically no system other than a central watering point where you go fill up buckets, they deliver about 1.5 gallons of water per person per day. If you have a small-haul system, they deliver about two and a half gallons of water per person per day. Now the WHO recommends a minimum of 13 to 15 gallons of water per person per day. And if you look at what our use is in the United States in general, we generally use about 50 gallons per person per day. So our villages in Alaska are doing extreme, extreme water rationing. And we know that this isn't just true for Alaska. There are other areas in the Arctic, some of our other neighbors in the Arctic in Northern Canada, in Greenland, in Northern Russia also have issues with remoteness and water and sanitation. And so what we're hoping to do, and we've done this with circumpolar surveillance, is we're hoping, we've learned many things from our circumpolar partners. We're hoping that this Alaska initiative on water and sanitation that I explained to you a little bit earlier, can potentially be used as a model and help in pushing that model forward to develop these technologies across the Arctic. Tim, this 10-year study, I mean, the new study for the first time in a decade, it's very comprehensive, it's encyclopedic. How is it gonna be used on the health front in your view? How is it actually going to be used by the leadership of the Arctic Council to move an agenda forward? Not exactly sure, but it's, I think one of the things we were supposed to do is to highlight some of these differences and to put this out there in front of them and say, especially since this was the second Arctic human belt and the first was really kind of a stock taking. I mean, there wasn't a lot known. And like I said, this wasn't necessarily new research. It was kind of pulling the other existing data, pulling the other from a number of scientific studies. And like I said, one of our mandates was to look at some of the trends over time and all of the chapters do that, economics chapter, my chapter, certainly the health chapter. And so I think what we've done is we've, so we've looked basically over the first decade of the 20th century since the first Arctic human development report and said, okay, we identified and hopefully I've brought some of these out. These are the areas that, there's generally been improvement. We don't necessarily have targets, but if things are getting better in certain areas, but this chapter is certainly highlighted areas where there hasn't been improvement. There hasn't been improvement in specific Arctic regions or across the Arctic. And certainly the issue of suicide and some of these others that I mentioned are kind of intractable diseases. I mean, the issue of domestic violence keeps coming up again and again. So hopefully the Arctic Council, other people, interested in the Arctic can look at this and say, okay, these areas are getting better, but there's other areas that are actually not getting better. And those are maybe the areas that we need to, there needs to be some focus on. And Heather, could you say a few words about the US calculation in this? I mean, you know the policy environment here. You know the history of US engagement on these Arctic issues. You talk all the time with the administration around these issues. What can we hope for in this next phase in terms of prioritization and leadership on these issues? And will they take up your recommendations? Well, here's hoping. You know, I think that the really disappointing thing, I guess it was about 12 or 18 months ago, it was put forward to the Office of Management and Budget to create a budget for the US chairmanship so that there would be extra funds that would be given to implementing some of these key priorities. Unfortunately, OMBE said that was not a good idea and that budget does not exist. So what is happening is we have these fantastic priorities but agencies, this is again, the theme that we raised with Senator Murkowski, they're going to have to use existing resources, try to squeak, reprioritize, and we know in this budget scarcity this is really difficult. So that was sort of step one. We missed a huge opportunity that we're, I think what the US chairmanship is going to be is a lot of really good projects, piloting projects, modeling projects that we will showcase, but quite frankly the funding will just not be sufficient to boost them. Great work being done, but boy they need some turbocharged budget. Now I never like to end on a pessimistic note. So the White House did, has a new body in place, the Arctic Executive Steering Group which has led at very senior levels. This group has been charged with doing a gap analysis. So it's, if you dared to read the White House's implementation plan for the National Strategy for the Arctic Region, short little title, we do see where in the implementation plan there are clear outlines for, and I quote, to coordinate better comprehension of the health and survival rates of Arctic indigenous peoples to facilitate improvements and wellbeing that as an objective. So I'm hoping this gap analysis says, we have, the US chairmanship theme is Arctic improvements and Arctic economic and living and wellbeing conditions. We have some great things, but there are not funding. We are going to prioritize this and we are going to put funding. I would argue as a domestic priority for the state of Alaska, it is an absolute tragedy to hear some of the figures that you've cited. It's appalling, it's unacceptable. Leadership begins at home. We need to start focusing our time and attention on Americans that are suffering from these conditions. And then exactly we need to pull this out and provide that leadership effort circumpolar. Pam, my concern about the Sustainable Development Working Group, the SDWG, it is the mother ship of the working groups. It's a monster working group. And that's where I think it gets stuck because it does so much. That's why I think it's absolutely vital that we pull this out and say, look, if we're serious about this, we're going to put those resources, we're going to hold those Arctic governments to account and say, let's put that money in. And my frustration, Tim, quite frankly, with the Arctic human development part, it's not an Arctic Council product. It's not. That's a problem because if it's not a product you go, that's a lovely report. Thank you very much. And then we can keep on going to our regular business. This is exactly what we need. These wonderful assessments and reports we need to hold governments accountable for how are they moving the measure? I love that stop sign. The Arctic Council needs that graph and those stop signs. You promise this. Ministers, you sign and you said, we agree with this but our governments have done nothing about it. Who's holding them accountable? And this is part of the Arctic Council's governance requirement, but it comes from leadership from national councils. I think we have an opportunity here and to raise public awareness, absolutely, but we must start making the tough budget choices. As Senator Ricasco said, show me, show me that money. And so far we've said it's important but we haven't reflected that it's important in our budgets. It begins with our budgets and I would encourage OMB to be much more generous. This is so easy for me to say. From CDC and NIH and Health and Human Services, we've got to start addressing these challenges. Thank you very much. Let's move to our audience. We've got 15 minutes. Let's collect several bundled together, several interventions. We have one here, one here and one there. Yes, sir. Please identify yourself, be very succinct and offer a quick comment or question. John Farrell, Arctic Research Commission. First of all, I completely support your recommendation. Heather, a blessing sister. I would take health out of SDWG as fast as I possibly could. It really does, that SDWG has too many things in it. Also structurally, it should not, in my personal opinion, beach, head of delegation should be a foreign service officer who is just brand spanking new every two years into this. That causes difficulties and the other farm industries do the same thing. So we really need to get subject matter experts on SDWG for this and specifically on health. Dr. Collins, thank you so much. I'm very pleased to see NIMH involved in this activity. It's a challenge. Part of the tyranny of focusing on suicide doubt in the North is the small numbers of people. You can have discussions in other places and they will point to the large numbers of deaths in Sub-Saharan Africa. So if you're allocating funds, you try to go where the large numbers of people are. But these are US citizens. So I'm greatly appreciative of the initiatives you're doing there. But a question for you is, you mentioned rigorous evaluations. SAMHSA funds a lot of services. Some people would argue that's really not looking at the root cause research-wise in terms of suicidality. We tried at the commission unsuccessfully to get an IOM Institute of Medicine study focusing on this. And we failed because we did not adequately engage with Alaska Native communities in developing this and explaining what an IOM study was, explaining how committees are formed and how editorial control is done. Do you think an IOM study, if we try it again, would be a useful way to do a rigorous evaluation of this issue in the North? And loaded on to that question is, very hard to get capacity. Even if you have money oriented towards these problems, hard to get capacity. There's no medical school in Alaska. There's not a lot of investigators down in the lower 48 who are capable or interested in an R01 grant in this kind of work. So an IOM, and how do we build capacity even if there is funding? Thank you, sir. And then good afternoon, Charles Newstead, State Department, and I hasten to add, I'm speaking for myself, not the department, for I find myself in the basement without a telephone. I'm very impressed, first to comment, I'm very impressed by the broad scope and expertise that this panel represents. It's truly impressive. And I'm also very impressed with the way that you and your colleagues have brought international cooperation into play in dealing with the Arctic. That's vitally important. Heather mentioned the main thing is money in the bottom line. And I found, and I think most people agree with this, that international scientific cooperation is a great multiplier on what you can do with your budget. So I applaud your efforts in that way. And now my specific question, I'm wondering if the panel could compare in their various different fields, the health situation in Russia, in various regions, compared with that in the West, with Alaska, Canada, Greenland, et cetera. And the final question is, has Mr. Putin, he's trying to become a czar again, as we all know, has he had some effect on the Arctic yet? Is that discernible? And is that good or bad? Thank you so much. There was a hand. Thank you, yes please. Hi, Linda Fernandez, Virginia Commonwealth University. I have a question for Michael Bruce, and it's largely, it's a question combined with a suggestion. You did mention a circumpolar water sanitation conference scheduled for next year, perhaps as a result of what would be a success of the Alaska Water and Sewer Challenge that's going to be magnified to the Pan Arctic. I guess I have suggestion as well as a question, are you teaming up efforts with all of the international collaborators during World Water Week that's convened in Sweden every year, has great buy-in across a lot of international countries as well as private sector organizations like Rotary International, WHO? It's clear to me that while you've made great strides in having the Arctic partners involved, some of what you're suggesting as technology developments on sanitation and water have been addressed in other settings with the Arctic partners perhaps engaged differently. So I'd make a suggestion and question whether you can in fact synchronize efforts and join in with that group. Thank you very much. Are there any other comments or questions at this time? Yes, please. Hi, I'm Michelle Lerner coming from a sort of different perspective. I work for Bread for the World Institute and we work on hunger and malnutrition advocacy. So my question is just in general, would you consider that malnutrition or food insecurity, lack of money, clearly, how do you think that's impacting the health of people in the Arctic? Thank you. Okay, so we have a question around should there be an IOM study, would that be useful? What's the comparison Russia versus the West? I think we're gonna turn to Tim on that although everyone here is gonna have something to contribute on that and what impact Putin? What about tying to Water Week in Sweden and then the food insecurity issue? Michael, why don't we start with you and just sweep down this way? Okay, I think the first question relevant to me was sort of a question from the gentleman from the State Department about the health situation in Russia versus other circumpolar nations. And I have to say that I know very little about at least in regards to water and sewer in Russia. My focus has been in infectious disease and we've had some collaborations with the Russians in Eastern Russia on a number of variety of different infectious diseases. And I know that in many of those areas there are issues with infrastructure and there's poor infrastructure. So there certainly is a great possibility that there are issues with water distribution and sewage in Russia versus the other countries but I can't tell you for sure. The next question was are we teaming up with partners at the World Water Week in Sweden? I'd like to speak to you more about the World Water Week in Sweden because I actually am not aware of that meeting and we probably should be attending. We've had some of our circumpolar partners in some discussions regarding sanitation and water and health but they haven't been formalized. They're through our international collaborations on infectious diseases. So I'd be very interested in learning more and we certainly should attend that meeting and learn from them. So thank you. And then from the woman at the Barefoot World Institute in regards to food insecurity I'm an infectious disease epidemiologist. I'm sorry, oh I'm sorry. I'm an infectious disease epidemiologist and food insecurity is not something I am a specialist and I know as an Alaskan that it is an issue particularly in rural Alaska in relation to climate change and melting of the permafrost because many of the native peoples put food and food lockers buried in the ground in the permafrost and as the permafrost melts or as there's increased erosion into the village those food lockers are failing. So food insecurity is definitely an issue in rural Alaska as well as other places in the Arctic and I think I went through the questions. Sure, so in response to you John Farrell I'll start with the research capacity because I think that's critical in places where you don't have a lot of researchers one response is to try and develop a cadre of researchers that can actually that will have some commitment and some insider understanding of the context. So we certainly do need to see more research career development in the context of Alaska. So I would certainly support that. And I think that that means a number of things that means figuring out how to establish mentoring for students that the idea of pursuing research as a career option becomes a feasible and realistic idea. It means working with institutions in order for them to develop an adequate infrastructure and base for training and sustaining young researchers and researchers throughout their career as well. So yes, I agree that that would be important particularly in the context of mental health research. Some of those efforts are underway at NIH where there are initiatives that focus on American Indian and Alaska native research capacity building and we need to continue those efforts. With respect to the IOM meeting I think I would probably ask you again that sounds like how much buy-in is there in the local context for that. So to me that seems like that would be one starting place to make sure that you've got all of your stakeholders in Alaska being of a single mind about pursuing something in that direction but certainly whatever avenues whether it's an IOM report, whether it's some other avenue to bring attention to the needs and to rigorously document where we are with respect to effective interventions in these contexts that would be it would be an interesting intervention. Well just thank you, wonderful questions. Two quick comments. First a preview of coming attractions we'll be releasing hopefully in June a major study on the Russian Arctic. To help us understand, you heard in the energy panel Russia has enormous economic stakes in the Arctic. They have a long history in writing very comprehensive and detailed strategies. Some of those strategies quite interestingly and Caitlin has been a great student of studying these strategies. They do have a very robust sustainable development component but as the Russian economy continues to experience extraordinary difficulties this is going to be a challenge for them to sustain their very ambitious strategies but we need to understand what's important, why is the Arctic so important to Russia and my thesis is that we have actually seen some significant and certainly disturbing changes in Russia's Arctic policy particularly after the Crimea annexation that we need to understand and study that more so thank you for your question coming to you soon in a comprehensive report. And just one final comment on sort of the World Water Week and I think what we're starting to see and we need to do a much more purposeful job there's an Arctic diplomacy that is starting to be formulated so countries that are working together in the IMO the International Maritime Organization were so instrumental in pushing through a new mandatory polar code. Could we're gonna see I think a similar Arctic caucus those are my words at the Paris Climate Summit at the end of this year saying how are we focusing governments because the climate change is occurring and the Arctic is occurring two to three times faster than anywhere else in the globe. Could we have in governmental agencies and bodies in water and sanitation where is the Arctic subgroup that's pushing this agenda? We have to think where issues sectorally cross and let's gather the eight Arctic Council members let's gather the observers if they have a role to play how can we caucus in these variety of international fora and say let's put the Arctic on the agenda. I think that's a development we need to push whether it's World Water Week or whether it's at these very different UN platforms where is the Arctic's voice and how can we push the agenda. Thank you, Tim. I'll address the question about the comparisons between Russia and the United States in terms of health indicators, life expectancy, et cetera. I've done a lot of research on Russian demographic issues and Russia more so than other countries seems to be extremely susceptible to economic downturns. You can correlate declines in GDP per capita with declines in life expectancy certainly after the breakup of the Soviet Union the kind of economic downturn with the transition things improved and then things got worse with the 98 ruble crisis and I haven't checked the numbers but I think there's been some increase in the death rates over the last year so with this economic downturn it's hard to say why but I mean there's it just seems to be more like I said more so than most other countries and we had our financial crisis in late 2000s and that didn't, life expectancy didn't drop by three or four years all of a sudden because of that but in Russia, especially among men I mean that seems to be a particular trend and like I highlighted here these gaps in life expectancy between men and women but overall life expectancy in these Arctic regions especially if you go further out into Siberia they're extremely low and I haven't seen anything where that's a priority of the Russian government to address some of these issues maybe around the margins but I mean they're the Institute but there was an Institute for the Arctic indigenous peoples that's been kind of abolished I just don't think it's a priority like it is in the US so I'll end on that pessimistic note. Well we've gotten to the end of our time now I think this is just in closing this is in a way a very opportune year I mean we have the arrival of the US chairmanship we have the sustainable development goals coming forward in September we have the Paris climate change at the end of the year the summit there there's going to be multiple opportunities to sort of move this forward I want to thank Tim, Pamela and Michael for bringing the enormous expertise that you have on in your respective areas around the arcade it's really been kind of astonishing to just listen and we know you had to travel a bit of a distance to get here and carve out some time and we're very grateful to you for doing that and Heather thank you so much for your leadership on all of this I mean watching you over the course of this morning has just exhausted me so congratulations and thank you all of you for your great questions and comments and your patience in sticking with us and so thank you all and we're adjourned. Thank you.