This article was originally published on Sept. 20 1992
First in a series
HOOPER BAY -- Would you like a drink of water?
You do what Melba Joseph does. You tote a white 5-gallon bucket to the little shed behind city hall. You place your bucket under an outdoor spigot and pull a cord.
The water that pours out is the color of dark tea.
Do you want to flush your toilet?
You do what Reuben Hill does. You walk into the bathroom and pick up the 5-gallon bucket with a toilet seat on top. The bucket is lined with a plastic bag, which is filled with urine and toilet paper and excrement. You tie the bag shut, and you strap the bucket on the back of your four-wheeler and drive to the fenced pond behind the school. You heave the bag into a pile of sewage and try not to get any on your boots. Some of your neighbors haven't gone to such trouble. Some of them simply dump their buckets in the weeds.
Stop by the village clinic. Margie Bell and the other health aides are busy, as usual. The waiting room is filled much of the day, mostly with children. Many of them have ear infections and noses runny for so long that red scabs have formed under their nostrils.
Some have rashes on their faces. Flu runs rampant through the village much of the year.
Talk with some of the adults. Chances are good that sometime in their lives they've had hepatitis A or some other serious infectious disease.
Step off the mail plane and walk into Hooper Bay or any of dozens of other growing communities in rural Alaska.
Step into America's Third World.
SOMETIMES PEOPLE DIE
Three decades after the federal and state governments began spending hundreds of millions of dollars to bring modern housing, health care and schools to the most far-flung reaches of the Alaska Bush, daily life in most villages has been transformed.
Gone are killer waves of infectious disease. Even the smallest villages now have roomy, modern schools. Village housing, while still overcrowded in many places, has improved vastly from the 1950s and '60s.
But the quality of drinking water and the means of disposing of human sewage in dozens of Alaska communities remains on a par with the developing world, and is as primitive as anywhere in America.
More than 100 villages in Alaska -- more than half of all rural communities -- have no running water or sewer systems, according to the Alaska Department of Environmental Conservation. People in dozens of communities haul their sewage by hand from their homes and get drinking water from lakes and melted blocks of river ice.
While many villages have drinking water and waste-water systems that function well, others function only sporadically. Many villages with piped utilities have had chronic maintenance problems, with expensive freeze-ups and breakdowns. Dozens of village water systems are run by uncertified operators with little training and by local governments on the verge of insolvency.
People in Alaska routinely get sick because of bad water and from disease that spreads because of unsafe waste disposal.
Sometimes people die.
The problems are spread across the state:
• In Hooper Bay, a sprawling Yup'ik Eskimo village of nearly 1,000 people and nearly no indoor plumbing, a 41-year-old man died and dozens of neighbors fell ill this past spring after drinking water from a village well. Dangerous levels of fluoride, intended in small doses to reduce tooth decay, were accidentally pumped into a holding tank.
The village had a long history of water and sanitation problems, and like most villages, Hooper Bay didn't have a certified water operator. Also like many villages, Hooper Bay had done a spotty job of monitoring its water for contaminants, having gone nearly two years without submitting results of water monitoring to state regulators.
• In Kotlik, a village of 450 people near the mouth of the Yukon River, almost 80 people fell ill, including more than 40 who were hospitalized, when an epidemic of viral meningitis raced through the community in July 1990. The disease is spread by contact with human waste; the outbreak occurred after sewage oozed out of full underground pits and into muddy yards where children played.
Rural health authorities believe a similar outbreak could occur in any number of other villages.
• Nearly 2,000 Alaskans across the state, the bulk of them Natives in Interior and coastal villages, contracted hepatitis A in an epidemic that lasted from 1986 to 1991. Like viral meningitis, the disease often spreads through contact with human waste. A state government survey found that hepatitis A rates in 1988 at the height of the epidemic were twice as high in villages without running water.
• The clinics in 52 villages the places where residents go to have wounds treated and sicknesses diagnosed have no running water or flush toilets. Some health aides resort to heating water in microwave ovens so they can wash between patients, while others keep caldrons of boiling water on stoves.
• In the southeast Alaska village of Angoon, levels of bacteria and other organisms in the drinking water have been so high in recent years and considered so unsafe by government agencies that residents have been under repeated orders from the state to boil their water. Earlier this summer, raw sewage was standing in a street after leaking from pipes.
During the first six months of this year, people in 34 communities in Alaska were required for a month or longer to boil water because of bacterial contamination, according to the Department of Environmental Conservation and the U.S. Environmental Protection Agency.
• In Bethel Alaska's eighth largest city with about 4,200 people firefighters arrived at the scene of a grass fire earlier this summer and were disgusted to discover a field of shin-deep human waste. It was the product of years of illegal dumping of honeybuckets by residents of Bethel's poorest neighborhood, Lousetown, who don't have flush toilets and apparently weren't willing or able to pay the $35 monthly charge to have their buckets emptied each week by a city crew.
"In mainstream America, things like safe water and adequate sewage disposal, those things are just taken for granted, " said Anne Walker, executive director of the Alaska Native Health Board, an Anchorage-based non- profit organization that represents the state's 12 regional Native health agencies.
"That sort of thing has become really the foundation for good public health. It goes back to Roman times: People wondered what was making everyone sick. It was the water. It's a basic fact today communities need clean water.
"Here in Alaska, that's not the case at all. It's an everyday issue: You carry the water, you dispose of the honeybucket. People live with these risks to health.
"We have all this amazing medical technology and access to modern health care and all of these wonderful things. But in terms of water and sanitation, a lot of villages are still trying to make it into the 20th century."
BUCKETS IN, BUCKETS OUT
Since 1960, more than $1.3 billion has been spent by government agencies to bring modern water and sewer systems to the villages, according to figures compiled by state and federal agencies.
As a result, virtually every village in Alaska today has some sort of minimal, functioning water and sewer system at least on paper.
The systems vary widely. There are the Cadillacs systems like the underground "utilidor" water and sewer system in Barrow, built for $360 million in the early 1980s with oil boom money to serve about 4,000 people. Regional hubs like Kotzebue and Bethel, and dozens of smaller villages, also have piped systems.
Many Interior villages, where soil is much dryer than in coastal areas, have septic tanks outside of homes, and wells that pump a steady supply of safe water. Many of them function well most of the time. Some villages with roads have haul systems, where trucks deliver water and pump out sewage tanks.
But in scores of communities, the bulk of them clustered in coastal areas and in the Arctic, there is no running water, nor are there flush toilets or outhouses just buckets in and buckets out.
In most of these villages, state and federal agencies have built central washeterias, each with washing machines and a well from which villagers draw water and carry it home. The water is often treated with chlorine, to kill bacteria, and fluoride, to reduce the risk of tooth decay.
In government reports describing the crudest village sewage systems, residents empty their full honeybuckets into covered containers scattered throughout the villages and city employees come around every few days to haul the full dumpsters to sewage lagoons. On paper, residents pay bills to keep the systems going. On paper, the containers don't spill as they're being carted off. On paper, children playing on village boardwalks don't have contact with sewage.
In reality, many of these systems aren't working very well, according to village residents, public health officials and other people familiar with them.
Honeybucket dumpsters fill up and spill over. They spill as they're carted off. In many villages, boardwalks and dumpsters are splattered with residue of lime, used to disinfect honeybucket spills.
Village governments hit by steady cuts in state and federal funding and often with tiny local tax bases, little administrative expertise and residents unwilling or unable to pay for services often can't afford to keep dumpsters emptied.
Sometimes village water operators turn off chemicals that make drinking water safer because residents don't like the taste.
And villages with piped utilities have problems as well.
Systems have been built, broken, then rebuilt. Some systems have broken and have only partly been replaced. In the Interior village of Venetie, an extensive, piped utility system, complete with fire hydrants, was built, then froze up in one of the first winters. It's never been fixed, and today people use their bathtubs as laundry bins.
"I think there's been a lot of systems break down and communities just walk away, " said Dennis Degross, an Anchorage public health consultant and former head of the Alaska Native Health Board.
"So many of 'em, they're just too damned expensive to operate. You build a $1 million system for a community of 400 people, but maintaining them and keeping them running is a whole other story.
"In the Midwest, the landmarks of a forgotten era are those old grain silos. Here in Alaska, I'm afraid someday it might be these water and sewer systems that are just too damn expensive to operate."
THE HEPATITIS THREAT
"As long as everything's working just right, the village water and sewer systems are functional, " said Dr. Donn Kruse, medical director of the Bethel- based Yukon-Kuskokwim Health Corp. Of the 48 villages served by the agency, 10 have piped systems, with the rest relying on honeybuckets and central watering points.
"They still require an amount of energy and activity that no one in Anchorage would tolerate. When people move from the villages into town, and then return to the village again, that's what you hear: 'It's a lot of work.' But the water coming out of the well is safe and sewage has an appropriate spot to go. It's a functional system.
"The thing is, any number of factors can knock the whole system out of whack and cause considerable public health risk. It happens pretty easily and it happens all the time."
For example, Kruse said, water is typically brought home from the village well and dumped into a 30-gallon plastic garbage pail in the kitchen enough water to last a family with several children a few days. But it doesn't stay pure for long. A thirsty child who hasn't washed his hands because there's no faucet or hot water dips a pitcher into the barrel. The barrel is contaminated.
When people live without a regular supply of clean water, or have regular contact with human sewage and can't wash their hands, chances increase dramatically that they will become sick. On this, there is little disagreement among doctors and other public health authorities.
But just how much healthier communities with modern water and sewer systems are is hard to measure. It's never really been studied in Alaska, and many infectious diseases that have plagued the Bush such as tuberculosis, hepatitis B and often-fatal bacterial meningitis have little, if anything, to do with water and sanitation. Their spread has much more to do with overcrowded living conditions.
But public health officials in Alaska believe there's at least a partial connection between primitive water and sewer systems in the Bush and high rates of other disease in some cases a direct connection.
"It's a significant, real health problem, " said Paul Hansen, health services director of the Maniilaq Association, the health agency that serves 11 mostly Native villages in northwest Alaska.
"It's hard to overstate the relationship between simply being able to wash your hands and the spread of disease. If you don't have water, it makes washing your hands very difficult. Most people just aren't going to be willing to haul 50 gallons of water a day to their house so you have enough for everyone to always be washing their hands."
The most common disease with the most direct link to bad water and sewer in Alaska is probably hepatitis A, which every few years races through pockets of the Bush. It's rarely fatal, but leaves people sick for weeks at a time, especially children. Its symptoms include fever and severe abdominal pain.
Alaska is hardly the only place in America with outbreaks of hepatitis A, but rural Alaska especially Native communities has a disproportionately high rate. In the most recent epidemic, from 1986 to '91, about 1,800 Alaskans two-thirds of them Native were diagnosed with hepatitis A. Overall, Natives make up only about 15 percent of the state population. Officials think the number of cases of hepatitis A was seriously underreported.
A person exposed to hepatitis A develops immunity that lasts a lifetime. So it comes and goes in waves, with each wave hitting a new generation of children hardest. Because so many rural Alaskans were exposed in the late 1980s, the number of cases has dropped substantially the past two years. Doctors expect another wave to begin by the mid-1990s, although they're hopeful an effective vaccine now being tested in Alaska hospitals can be developed before then.
Aside from hepatitis A, simple infections such as strep throat and colds and flu, which lead to ear infections, and skin infections like impetigo often spread faster because of a lack of sanitary conditions in villages, according to several doctors. Rural Alaska, especially the Yukon-Kuskokwim Delta, has some of the highest rates of influenza and chronic ear infections in America, studies by the U.S. Indian Health Service have shown. Giardia, an intestinal parasite spread through untreated water, has been a recurring problem in rural Alaska as well.
'NOT NEARLY AS BAD'
"People who come up from outside Alaska are shocked all the time, " said Perry Eaton, a Kodiak Native and president of the Community Enterprise Development Corp., a cooperative which works to develop business in rural Alaska.
"I've taken slides of villages out east and I ask groups of people, 'Where was this picture taken?' They say Russia or Eastern Europe, Norway, Finland, someplace like that.
"They can't believe it's America."
In a report to Congress in May, the U.S. Public Health Service said that almost 60 percent of the water and sewer needs in Native American communities nationally more than $1 billion worth of projects are in Alaska.
"There are problems like this, really, throughout Indian country, " said Gary Hartz, environmental health director for the Public Health Service in Washington, D.C.
"Alaska isn't the only place. I mean, I've been in Navajo country where people have to use horses to haul water miles to their houses, " Hartz said.
And while many Alaska water and sewer systems are not appreciably different from those in Third World nations, such as in Asia or Central America, overall environmental health conditions are far better here, according to a variety of public health authorities. Violence much of it alcohol-related along with cancer and heart disease have for the most part replaced infectious diseases as the leading killers in Alaska villages.
"You look at what's happening in rural Alaska, and it's not nearly as bad as it used to be, " said Dr. Brian McMahon, a doctor at the Alaska Native Medical Center in Anchorage and a specialist in hepatitis.
"We don't see kids in Alaska dying of diarrhea like in the developing world, for example. It's nowhere like that. I think clean water would be a great thing to have in the villages. It would make life easier and healthier, but it's not like India and Africa out there."
Still, substandard water and sewage-disposal systems continue to pose a significant public health threat in Alaska, he and others said.
"With something like hepatitis A, as long as there's not a good way for people to keep clean, you're going to see it, " McMahon said.
PROBLEM OF MAINTENANCE
"Technically, we can build a system anywhere, " said Jim Crum of the U.S. Public Health Service. "You give us enough money, and from an engineering standpoint, we can do it. It may cost 10 million bucks, but we can do it."
As the federal agency's chief of the Division of Sanitation Facilities for Alaska, Crum has overseen hundreds of millions of dollars in bush water and sewer projects.
"The question, really, is whether the mechanism is in place on a community level to keep it operating. What we have found is that in some places, the answer is yes, and in others . . . well, it hasn't worked so well."
Rural Alaska has some of the harshest physical environments in the world. Combined with widely isolated villages and low supplies of fresh ground water in many parts of the state, it makes construction expensive.
Some villagers complain that government agencies have done too little to help village residents maintain systems, or have not given them enough of a voice in designing them to be practical in the first place.
Government officials agree big mistakes have been made in the past. Such work had never been done in such harsh climates, they say, and they learned as they went along.
More and more, state and federal officials are saying that agencies cannot solve village water and sewer problems without a commitment from local communities to make systems work.
ALTERNATIVES SOUGHT
It's a complicated, expensive problem with few, if any, easy answers. A report last year by the Alaska Department of Community and Regional Affairs estimated that it will cost at least $1 billion more to fix the existing problems.
For a while, in the 1960s and '70s, there was a feeling among many government officials and Native leaders that it would only be a matter of time before every village had its own piped systems.
Today, though, government officials, health authorities and even village residents are asking whether it makes sense to build conventional systems in every village.
According to the state Department of Environmental Conservation, a typical piped village water and sewer system, once built, costs at least $100 a month per household to maintain. The cost in Anchorage is about $45. A survey by state government last year in more than 40 villages found that residents, on average, said they could afford only $55 a month, with a sizable number saying they were unable to pay anything.
Agencies and village officials are looking for alternatives. Among them are systems that involve hauling water to homes and hauling away waste from household holding tanks. Such systems are used extensively in Canada, but are expensive to operate.
"I don't think it's realistic for every village to expect to have conventional piped systems, " said Walker, director of the Native Health Board, which lobbies the legislature and Congress for increased funding of rural systems.
"What we really have to start asking in the next 10 years is: Can villages really support these systems? Are they willing to pay for it? How much are they willing to pay for it? All of us have to be asking these questions, and people in the village are going to have to answer them."