In terms of public health, the new Canadian territory of Nunavut has more in common with the developing world than the industrialized nation of which it's a part, according to Dr. Konia Trouton, M.P.H.'94. "Almost every health or illness indicator that you would look at is the worst in Canada," she says of the region, which was formally established a little over a year ago. "We've got two times the infant mortality rate. We've got the worst smoking rate in the country--about 65 percent of the general population smokes and about 60 percent of the population of children up to the age of 16 start smoking by age six. Our suicide rate is about ten times the national average." In addition, she notes, Nunavut has the highest tuberculosis rate in Canada and is overrun with sexually transmitted diseases like chlamydia and gonorrhea.

Consequently, in her role as director of population health for Nunavut's new government, Trouton has been faced with some formidable tasks in her quest to improve the health of its residents. "To choose where to start is very challenging," she remarks. "Almost any direction you try and start up a program, there's a glaring need." Reporting to the deputy minister of health for Nunavut, Trouton coordinates preventative health programs and services for this vast territory of just 24,730 people. She is directly responsible for ten staff members in administrative roles and indirectly supervises another 400 field workers assigned to Nunavut's 27 communities, none of which are accessible by road. She also serves as a liaison to the various organizations and committees that address health issues.

Nunavut is spread out across 1,994 million square kilometers of land in the desolate eastern and central Arctic regions of northern Canada. A family practice physician who has worked in inner-city Calgary, at the United Nations, and with Health Canada, Trouton was drawn to this inhospitable area last year by the void she saw in its health expertise; Nunavut provided Trouton with an opportunity to apply her work experience with the national health system in both health care delivery and government to the development of policies and systems for a new administration. Like many of the people recruited to Nunavut from south of the 60th parallel, Trouton also serves as a mentor to less-experienced, aboriginal health workers to build capacity in this new territory.

Nunavut is the only Canadian province or territory with a majority--85 percent--aboriginal population, all Inuit. The Inuit people are not First Nation (native North Americans); rather, they are closely linked to tribes in northern Alaska, Siberia, and northern Finland and have an active circum-polar link. Officially, the Inuit in Nunavut use one language, Inuktutit, and have a more cohesive cultural identity than those of First Nations. Trouton notes, "This year, we [Canada] had a separate Inuit health policy forum and a separate First Nations policy forum" to reflect those differences.

What Trouton finds most re-warding about her work is ensuring that the public health programs she develops succeed within Nunavut's unique culture. She is accustomed to developing disease prevention and health promotion programs in an "academic" way, examining evidence to determine what works and what doesn't. "Up here, there's an eclectic approachÉnot everyone has been trained from the same book." Many of the people with whom Trouton works are Inuit with little education or training, and others are mavericks from other parts of Canada or the world who are drawn to Nunavut by its remoteness and lack of traditional structure and restrictions. Trouton says what results is a discussion style of decision-making that blends several cultures. Many meetings start with an elder coming in and telling a story. "Out of the stories comes a clearer path of what we are going to do next," Trouton explains.

The diversity of individuals working in Nunavut also adds challenge to Trouton's work. "It's hard to get us all moving in the same direction with the same vision," she says. In addition to the variations in training and background, Trouton has found that some people just don't want to work in a team. "They're up here because you can be one of a kind, you can be different," she reflects. The fact that Nunavut has a third language (in addition to the Canadian languages of English and French) only compounds the problem. "So we're trying to merge this traditional way of doing things and explaining things in Inuktutit with the evidence-based approach of intersectorial action and sustainability," says Trouton. For instance, a health promotion poster might feature a health message in Inuktutit, a drawing made by one of the children, and a story from one of the elders--with the aim of appealing both to older traditionalists and to younger people who may not identify as strongly with their cultural heritage.

Cultural challenges are exacerbated by environmental challenges. Living in Nunavut is not for the timid. This past April, there were still blizzards, and the temperature outdoors was -20ûF. Says Trouton, "You can't go out for a run. You can't go skiing. We have winds right now that are 40 miles an hour. This goes on for six months of the year." The only reprieve is an ice melt that comes for six weeks each summer, during which four sea-lifts bring in a year's supply of food in cans, tins, and boxes. In addition, the communities are small, ranging in size from 100 to 400 people, and are geographically isolated. "There are no roads between the communities--the distances are too far," Trouton notes. This makes communication with her colleagues in the field no mean feat; only four have email, and interpreters are often needed for translation.

It also means that getting out of the territory or traveling between communities requires airplane flights costing $1,000 and up. Although each community has a nursing station, with a staff nurse supported by a doctor on call, Nunavut has only one hospital, located in the capital city of Iqaluit. If patients are too ill to stay overnight at the nursing station, they are evacuated to the nearest hospital, either in Iqaluit or another closer province--often a pricey proposition: "We spend in a year at least $20 million flying people out for service," Trouton notes. "That's $1,000 per person."

In light of the living conditions, the turnover rate is high for southern Canadians recruited to get the new government up and running. Many find it difficult to establish a professional network and feel intellectually isolated. Moreover, the work demands are huge and exhausting. Trouton adds that true Northerners who want to stay in Nunavut--and who show promise in their positions--quickly move up through the ranks, leaving a void in the communities they originally served.

But Nunavut is making progress with the help of experts like Trouton, who approaches her work with a pragmatic philosophy. "What I've started to do is to try and look at what determines health and then at what the community is ready to address," she says. For example, she notes that there is strong resistance to family planning in Nunavut, so she has targeted tobacco use and activities promoting general self-esteem, optimism, and a sense of belonging in the community.

For tobacco use, Trouton has started to assemble a strategic framework incorporating a public education campaign in the schools and communities, along with a set of radio and media campaigns reminiscent of those used against smoking 20 or 30 years ago in the United States. As for the general wellness strategy, Trouton has been working with focus groups and building interdepartmental collaborations to set up workshops or events within the communities. She comments that such "intersectorial" work is unusual within the Canadian government, and she finds it very gratifying.

In considering her experiences over the past year, Trouton reflects, "Nunavut's challenges are probably the closest we have in Canada to those faced by many developing regions and countries that are geographically remote. Working here, people have the image of the global north, the political reality of democracy, and the economic options of the wealthiest nations. We have to be optimistic that there will be enough social will, trust, and partnership to make their vision a reality."

Kimberley Spire-Oh