the northwest arctic region crosses the arctic circle and covers an area of about 63,000 square kilometers .
bordered by the brooks mountain range to the north and the chukchi sea to the west , the area is underlain by ice - rich permafrost and is in the transition zone between taiga forest in the south and tundra in the north .
it is also a transition zone between arctic , maritime , and continental climate regions . in the hub community of kotzebue , temperatures range from 46c to + 29c .
total annual precipitation averages 23 cm with an average annual snowfall of about 101 cm ( 7 ) . between 1949 and 2006 ,
the average annual temperature increased by 1.8c ( 8) , with the greatest increase occurring during the winter months .
a comparison of monthly average air temperatures suggests a trend of increasing temperature in every month of the year ( 9 ) .
there are a total of 12 communities in the northwest arctic region , the largest of which is kotzebue with a population of about 8,000 residents .
the region is remote and isolated with no connecting roads between communities or with the rest of the state .
eighty - five percent of residents are inupiat eskimos and many are engaged throughout the year harvesting caribou , seal , fish , whale , moose , berries , birds , and edible plants .
employment related to education , health , government , mining , transportation , fishing , and construction contribute to the economy .
the median household income is $ 45,976.00 and about 17.4% of the population is below the poverty level . in 1950 ,
life expectancy at birth for both sexes had risen to 70.3 years , largely due to decreases in mortality from infectious disease and unintentional injuries ( 10 ) .
still , mortality rates for alaska natives exceed that of  all races in the usa , for all causes except heart disease .
age - standardized rates of cancer are up by 12% , chronic obstructive pulmonary disease up by 191% , and diabetes is up by 262% .
these general trends also apply in the northwest arctic where the leading causes of death  cancer , heart disease , unintentional injuries , cerebrovascular diseases , and suicide  are all increasing ( 11 ) .
the northwest arctic region crosses the arctic circle and covers an area of about 63,000 square kilometers .
bordered by the brooks mountain range to the north and the chukchi sea to the west , the area is underlain by ice - rich permafrost and is in the transition zone between taiga forest in the south and tundra in the north .
it is also a transition zone between arctic , maritime , and continental climate regions . in the hub community of kotzebue , temperatures range from 46c to + 29c .
total annual precipitation averages 23 cm with an average annual snowfall of about 101 cm ( 7 ) . between 1949 and 2006 ,
the average annual temperature increased by 1.8c ( 8) , with the greatest increase occurring during the winter months .
a comparison of monthly average air temperatures suggests a trend of increasing temperature in every month of the year ( 9 ) .
there are a total of 12 communities in the northwest arctic region , the largest of which is kotzebue with a population of about 8,000 residents .
the region is remote and isolated with no connecting roads between communities or with the rest of the state .
eighty - five percent of residents are inupiat eskimos and many are engaged throughout the year harvesting caribou , seal , fish , whale , moose , berries , birds , and edible plants .
employment related to education , health , government , mining , transportation , fishing , and construction contribute to the economy .
the median household income is $ 45,976.00 and about 17.4% of the population is below the poverty level . in 1950 , the average life expectancy for alaska natives was 46.6 years . by 2001 ,
life expectancy at birth for both sexes had risen to 70.3 years , largely due to decreases in mortality from infectious disease and unintentional injuries ( 10 ) .
still , mortality rates for alaska natives exceed that of  all races in the usa , for all causes except heart disease .
age - standardized rates of cancer are up by 12% , chronic obstructive pulmonary disease up by 191% , and diabetes is up by 262% .
these general trends also apply in the northwest arctic where the leading causes of death  cancer , heart disease , unintentional injuries , cerebrovascular diseases , and suicide  are all increasing ( 11 ) .
extreme and unpredictable weather , altered seasons , and poor water , snow , and ice conditions are climate impacts that can cause injury .
a leading concern in the northwest is falls through ice . during the past two decades
, thick multiyear sea ice has been replaced by thinner first - year ice over large areas of the arctic ( 12 ) .
there is anecdotal evidence that sea ice conditions are increasing the risk of injury . 
 
this spring it was so bad people were falling through the ice all over the place .
( ray koonuk sr . , environmental program director ) 

 
  the ice is no good for hauling out bowhead . too thin .
this spring it was so bad people were falling through the ice all over the place .
, environmental program director ) 
  on may 8 , 2008 , three point hope whaling crews were cast adrift when shore - fast ice broke free , resulting in helicopter rescues .
northwest arctic residents rely on river ice roads to hunt , travel between communities , and transport fuel and supplies .
the kobuk river is breaking up more than a week earlier than when records began in the early 1900s resulting in ice conditions that are more unpredictable and unsafe , even in mid - winter ( 13 ) .
concerns about ice safety were expressed by residents in all of the communities surveyed . 
 
public safety officer ) 

 
  a few years ago freeze - up was late .
public safety officer ) 
  adaptation responses are merging traditional knowledge with modern technology . in point
hope , emergency response time has been improving with the distribution and broader use of personal emergency locator beacons .
the beacons are provided on loan to hunters and travelers by the local fire department .
these are tracking transmitters that aid in the detection and location of people in distress . 
 
( willard hunnicutt , fire chief ) 

 
  the storms have been very bad .
( willard hunnicutt , fire chief ) 
  the northwest arctic region has high rates of respiratory infection . in 2005 , pneumonia was the leading cause of hospitalization , accounting for over 55% of hospital discharges .
alaska native homes without running water experience far higher rates of respiratory and skin infections ( 14 ) .
climate change can indirectly increase the risk of infectious disease by damaging and disrupting water and sanitation infrastructure . 
 
when the washeteria freezes up , the number of people visiting the clinic with infections goes up  .
( isabelle booth , community health aide ) 

 
  when the washeteria freezes up , the number of people visiting the clinic with infections goes up  .
( isabelle booth , community health aide ) 
  in october 2004 , the development of shore ice in the village of kivalina was delayed because of unusually mild temperatures .
shore ice is important as it provides a buffer between powerful storm waves and the fragile arctic coastline .
storm surge that month ( see photo 1 ) caused extensive erosion and damaged the sewage drain field at the washeteria , the only facility in kivalina that provides public toilet , laundry , and shower facilities .
the damage closed the washeteria for five consecutive months in 2005 and continued to contribute to declining days of washeteria operation over the next few years .
extended periods of closure raised concerns about the potential for increased rates of skin and respiratory infection . kivalina residents build an emergency sea wall
. photo courtesy of millie hawley a preliminary review of clinical patient visit codes by the alaska native tribal health consortium suggests that increasing washeteria closure days correspond with increasing rates of skin infection . between 2004 and 2007 ,
the total number of skin disease - related clinical visits to the kivalina clinic more than tripled : from 44 visits per year in 2004 to 140 per year in 2007 .
an epidemiological evaluation has been initiated by the us centers for disease control and prevention to evaluate the potential relationship between washeteria closure and incidence of infectious disease .
adaptation activities in kivalina include the construction of a new washeteria waste water system and an engineering feasibility study to look at other possible water and sanitation improvements .
a traditional lifestyle and diet helps to prevent many chronic diseases , but climate change is decreasing access to some healthy traditional foods . in point hope and kivalina , thawing of the permafrost in traditional underground ice cellars is decreasing food security ( 15 ) .
harvested bowhead and beluga whale is stored in underground food cellars , ( see photo 2 ) .
, they typically thaw in the summer , resulting in meat and blubber that can be unsafe or inedible . 
 
we used to have frozen whale meat and maktak all year round , winter and summertime too .
( joe towksjhea , retired whaling captain ) 

 
  we used to have frozen whale meat and maktak all year round , winter and summertime too .
( joe towksjhea , retired whaling captain ) 
  kivalina resident millie hawley inspects a traditional ice cellar .
m. brubaker warming temperatures may also be increasing risk of food - borne , gastrointestinal diseases .
a review of traditional siuaqs design , construction , and methods of use is also being performed .
interdisciplinary teams , including traditional users , permafrost scientists , and engineers are meeting to identify potential adaptation options for these coastal communities .
alaska natives are experiencing stress related to rapid cultural change and the loss of social , cultural , and environmental conditions .
flooding in the fall of 2007 resulted in evacuation of the entire village of kivalina .
on - going vulnerability to storm events puts residents at higher risk for behavioral health problems .
local health workers report heightened stress , fear , and anxiety among residents during the storm season . 
  every time the waves get high , people get anxious .
( alice adams , community counselor ) 

 
  every time the waves get high , people get anxious .
( alice adams , community counselor ) 
  a preliminary review of selected clinical patient visit codes suggests that increased behavioral health visits occur during the storm season ( 2 ) .
adaptation has included the construction by the army corps of engineers of 1,000 m rock revetment wall .
climate change is a new challenge for water utilities already struggling with high operating costs .
warming and permafrost thaw is impacting water availability and water quality , and causing some surface water systems to operate outside their design parameters .
the active thaw layer of the permafrost is increasing , and even the deep permafrost is warming , as much as 2c over the past 20 years ( 17 ) .
a review of satellite imagery by the us geologic survey suggests that the size of the lakes in the vicinity of point hope is undergoing rapid change .
point hope acquires water from a small tundra lake situated on top of permafrost . from late june until early september operators work 24-hour shifts to have enough stored water to last through the winter .
but high summer temperatures in recent years has increased algae and other biological growth in the lake , decreasing water quality and fouling filters at the water plant . 

they plug up the bag filters and we have to change them every five minutes  .
( andrew frankson , water operator ) 

 
  there have been lots of mosquitoes and mosquito larvae .
they plug up the bag filters and we have to change them every five minutes  .
( andrew frankson , water operator ) 
  typically , water plant operators clean water system prefilters four times per day . in 2008 ,
the number of required cleaning events rose to as much as 50 times per day , significantly decreasing productivity .
adaptation responses have included baseline testing of water quality and active monitoring of lake water conditions .
extreme and unpredictable weather , altered seasons , and poor water , snow , and ice conditions are climate impacts that can cause injury .
a leading concern in the northwest is falls through ice . during the past two decades
, thick multiyear sea ice has been replaced by thinner first - year ice over large areas of the arctic ( 12 ) .
there is anecdotal evidence that sea ice conditions are increasing the risk of injury . 
 
this spring it was so bad people were falling through the ice all over the place .
( ray koonuk sr . , environmental program director ) 

 
  the ice is no good for hauling out bowhead . too thin .
this spring it was so bad people were falling through the ice all over the place .
, environmental program director ) 
  on may 8 , 2008 , three point hope whaling crews were cast adrift when shore - fast ice broke free , resulting in helicopter rescues .
northwest arctic residents rely on river ice roads to hunt , travel between communities , and transport fuel and supplies .
the kobuk river is breaking up more than a week earlier than when records began in the early 1900s resulting in ice conditions that are more unpredictable and unsafe , even in mid - winter ( 13 ) .
concerns about ice safety were expressed by residents in all of the communities surveyed . 
 
public safety officer ) 

 
  a few years ago freeze - up was late .
public safety officer ) 
  adaptation responses are merging traditional knowledge with modern technology . in point
hope , emergency response time has been improving with the distribution and broader use of personal emergency locator beacons .
the beacons are provided on loan to hunters and travelers by the local fire department .
these are tracking transmitters that aid in the detection and location of people in distress . 
 
( willard hunnicutt , fire chief ) 

 
  the storms have been very bad .
the northwest arctic region has high rates of respiratory infection . in 2005 , pneumonia was the leading cause of hospitalization , accounting for over 55% of hospital discharges .
alaska native homes without running water experience far higher rates of respiratory and skin infections ( 14 ) .
climate change can indirectly increase the risk of infectious disease by damaging and disrupting water and sanitation infrastructure . 
 
when the washeteria freezes up , the number of people visiting the clinic with infections goes up  .
( isabelle booth , community health aide ) 

 
  when the washeteria freezes up , the number of people visiting the clinic with infections goes up  .
( isabelle booth , community health aide ) 
  in october 2004 , the development of shore ice in the village of kivalina was delayed because of unusually mild temperatures .
shore ice is important as it provides a buffer between powerful storm waves and the fragile arctic coastline .
storm surge that month ( see photo 1 ) caused extensive erosion and damaged the sewage drain field at the washeteria , the only facility in kivalina that provides public toilet , laundry , and shower facilities .
the damage closed the washeteria for five consecutive months in 2005 and continued to contribute to declining days of washeteria operation over the next few years . extended periods of closure raised concerns about the potential for increased rates of skin and respiratory infection . kivalina residents build an emergency sea wall
. photo courtesy of millie hawley a preliminary review of clinical patient visit codes by the alaska native tribal health consortium suggests that increasing washeteria closure days correspond with increasing rates of skin infection . between 2004 and 2007 ,
the total number of skin disease - related clinical visits to the kivalina clinic more than tripled : from 44 visits per year in 2004 to 140 per year in 2007 .
an epidemiological evaluation has been initiated by the us centers for disease control and prevention to evaluate the potential relationship between washeteria closure and incidence of infectious disease .
adaptation activities in kivalina include the construction of a new washeteria waste water system and an engineering feasibility study to look at other possible water and sanitation improvements .
a traditional lifestyle and diet helps to prevent many chronic diseases , but climate change is decreasing access to some healthy traditional foods . in point
hope and kivalina , thawing of the permafrost in traditional underground ice cellars is decreasing food security ( 15 ) .
harvested bowhead and beluga whale is stored in underground food cellars , ( see photo 2 ) .
, they typically thaw in the summer , resulting in meat and blubber that can be unsafe or inedible . 
 
we used to have frozen whale meat and maktak all year round , winter and summertime too .
( joe towksjhea , retired whaling captain ) 

 
  we used to have frozen whale meat and maktak all year round , winter and summertime too .
( joe towksjhea , retired whaling captain ) 
  kivalina resident millie hawley inspects a traditional ice cellar .
m. brubaker warming temperatures may also be increasing risk of food - borne , gastrointestinal diseases .
a review of traditional siuaqs design , construction , and methods of use is also being performed .
interdisciplinary teams , including traditional users , permafrost scientists , and engineers are meeting to identify potential adaptation options for these coastal communities .
alaska natives are experiencing stress related to rapid cultural change and the loss of social , cultural , and environmental conditions .
flooding in the fall of 2007 resulted in evacuation of the entire village of kivalina .
on - going vulnerability to storm events puts residents at higher risk for behavioral health problems .
local health workers report heightened stress , fear , and anxiety among residents during the storm season . 
  every time the waves get high , people get anxious .
( alice adams , community counselor ) 

 
  every time the waves get high , people get anxious .
( alice adams , community counselor ) 
  a preliminary review of selected clinical patient visit codes suggests that increased behavioral health visits occur during the storm season ( 2 ) .
adaptation has included the construction by the army corps of engineers of 1,000 m rock revetment wall .
climate change is a new challenge for water utilities already struggling with high operating costs . warming and permafrost thaw is impacting water availability and water quality , and causing some surface water systems to operate outside their design parameters .
the active thaw layer of the permafrost is increasing , and even the deep permafrost is warming , as much as 2c over the past 20 years ( 17 ) .
a review of satellite imagery by the us geologic survey suggests that the size of the lakes in the vicinity of point hope is undergoing rapid change .
point hope acquires water from a small tundra lake situated on top of permafrost . from late june until early september operators work 24-hour shifts to have enough stored water to last through the winter .
but high summer temperatures in recent years has increased algae and other biological growth in the lake , decreasing water quality and fouling filters at the water plant . 

they plug up the bag filters and we have to change them every five minutes  .
( andrew frankson , water operator ) 

 
  there have been lots of mosquitoes and mosquito larvae .
they plug up the bag filters and we have to change them every five minutes  .
( andrew frankson , water operator ) 
  typically , water plant operators clean water system prefilters four times per day . in 2008 ,
the number of required cleaning events rose to as much as 50 times per day , significantly decreasing productivity .
adaptation responses have included baseline testing of water quality and active monitoring of lake water conditions .
in northwestern alaska , climate change is increasing vulnerability to injury , disease , mental stress , food insecurity , and water insecurity .
satellite technology is helping to reduce risk of injury by quickly locating hunters in distress .
improved shore revetment walls not only prevent erosion and protect infrastructure but also help reduce mental stress . in communities concerned with changes to source water quality , improved monitoring is helping engineers to design more resilient and condition appropriate water systems .
community - scale health impact assessment is an approach that is helping communities in northwestern alaska identify and address their local climate challenges .
understanding the connections between climate change and human health is the first step toward effective adaptation planning .
the program was supported by a special projects grant from the ihs , and by an indian general assistance program ( igap ) and special projects grant from the epa .
 this article provides examples of adverse health effects , including weather - related injury , food insecurity , mental health issues , and water infrastructure damage , and the responses to these effects that are currently being applied in two northwest alaska communities.backgroundin northwest alaska , warming is resulting in a broad range of unusual weather and environmental conditions , including delayed freeze - up , earlier breakup , storm surge , coastal erosion , and thawing permafrost . 
 these are just some of the climate impacts that are driving concerns about weather - related injury , the spread of disease , mental health issues , infrastructure damage , and food and water security . 
 local leaders are challenged to identify appropriate adaptation strategies to address climate impacts and related health effects.implementation processthe tribal health system is combining local observations , traditional knowledge , and western science to perform community - specific climate change health impact assessments . 
 local leaders are applying this information to develop adaptation responses.objectivethe alaska native tribal health consortium will describe relationships between climate impacts and health effects and provide examples of community - scaled adaptation actions currently being applied in northwest alaska.findingsclimate change is increasing vulnerability to injury , disease , mental stress , food insecurity , and water insecurity . 
 northwest communities are applying adaptation approaches that are both specific and appropriate.conclusionthe health impact assessment process is effective in raising awareness , encouraging discussion , engaging partners , and implementing adaptation planning . 
 with community - specific information , local leaders are applying health protective adaptation measures . 
Present investigation
Regional characteristics
About the people
Climate impacts, health effects, and adaptation
Injury
Infectious diseases
Food insecurity
Mental health
Community water infrastructure
Conclusion
Conflict of interest and funding