International circumpolar policy leaders are now paying attention to Indigenous youth suicide. In a recent report by the Arctic Council’s Sustainable Development Working Group (2015), they note the global burden of suicide, and write:
Nowhere, however, does suicide have such an impact and social burden as among indigenous populations, particularly those in circumpolar regions. Historically, Indigenous Peoples in circumpolar regions had very low rates of suicide deaths. Unfortunately, suicide rates in the Arctic are currently among the highest in the world. Youth are especially at risk (p.vi).
The high rates of Indigenous youth suicide coincide with the rapid, imposed social changes, forced settlement, rapid modernization and national policies of cultural assimilation of the past several decades (Allen, et., al., 2011; Fraser, et al., 2015; Hicks, 2007; Kral, 2012; Kvernmo & Heyerdahl, 2003). Now, Indigenous youth suicide is an all-too-common tragedy disproportionately impacting Indigenous communities across the Arctic (Ragnhild Broderstad, et al., 2011; Oliver, et al., 2012).
Although this picture is grim, Indigenous communities are responding in innovative and impactful ways. In Northwest Alaska, from 1990 to 2000, Iñupiat young people—aged 15 to 19—had a suicide rate of 185 per 100,000 (10-year average for 1990 thru 2000), significantly higher than the rate for the United States as a whole of 10.7 per 100,000 (Wexler, Hill, Bertone-Johnson, & Fenaughty, 2008). After the tribal health organization, school district, for-profit Tribal Corporation and others initiated and sustained a variety of community-based, self-determined programs and activities focused on young people, recent statewide data shows a significant drop in youth suicides in the last five years. Although the link between these programs and reduced rates of suicide is only correlational, this article briefly highlights several initiatives informed by research and led by local, predominantly tribal institutions to address suicide in Northwest Alaska over the past decade. We believe that these programs are contributing to the reduced suicide rates we now see in the region. This reduction in suicide rates is promising, and is conceptually linked by other studies documenting similarly hopeful trends after sustained and multi-level suicide prevention efforts (May, et.al., 2005). The marked drop in youth suicide rates in Northwest Alaska corresponds with these various prevention efforts, and is not found in other, similar regions, which strengthens this belief. We hope this catalogue of activities will inspire other communities to take self-determined, strategic actions to prevent and reduce suicide.
Located mostly north of the Arctic Circle, Northwest Alaska has approximately 40,000 square miles of tundra, mountains, and two main inland rivers: Noatak and Kobuk (see Figure 1). There are 11 communities with no roads connecting them, accessible by small commuter aircraft year-round, by boat in the summer months, and snow machine for 7 to 8 months of the year. The regional hub community, Kotzebue, is home to about 3,000 people, over 70% of whom are Alaska Native (State of Alaska, 2010). The outlying small villages range in population from 90 to 1000, with over 95% of the people living in these communities being Iñupiat. Alaska has a unique tribal political structure compared to other Indigenous peoples in North America. Alaska’s tribal health services have a comparatively sovereign structure, which operate under compact agreements with the U.S. federal Indian Health Service in order to provide self-determined, tribally-governed services to their beneficiaries (Warne & Frizzell, 2014).
Figure 1. Northwest Alaska.
Wellness and suicide prevention
Community-based and clinical initiatives focused on wellness, resilience and suicide prevention have been sustained in Northwest Alaska since 1999. We describe some of these recent efforts below, emphasizing two important considerations. First, local community members sought out, developed and championed these efforts, often using available resources such as research, clinical protocols, and/or community infrastructure to make them work. These endeavours reflect local sensibilities, community strengths and traditional culture, and underscore self-determination in conceptualizing and implementing community wellness initiatives. The second important element in these programs and events is that they are informed by research and engage many people and various sectors of the community in doing different levels of prevention work. In reflecting on these efforts, we believe these two aspects – local control and multiple institutional, family and individual involvements – are paramount to sustainable and effective suicide prevention in Arctic Indigenous communities.
Multiple efforts within the region and communities
Maniilaq Association, the tribal health and social service nonprofit organization serving Northwest Alaska, initiated a variety of the wellness and suicide prevention efforts occurring in the region over the last two decades. The organization developed the first-recorded tribal suicide surveillance system in an Indigenous region, starting in 1990 (Wexler, et al., 2008). This system documents suicidal behaviour and correlates, and has shaped targeted, clinical interventions, as well as sparked community programming (Hill, et al., 2007; Hagan, et al., 2007; Wexler & Graves, 2008). Supported by the federal Substance Abuse and Mental Health Administration (SAMHSA), the Indian Health Service (IHS) and the Department of Justice (DOJ) over the years, this programming includes media campaigns promoting culturally-specific messages about the importance of life, family, responsibility to tribe, and young people as valuable community members, as well as the more typical prevention message about the importance of help-seeking (and giving) (Fishbein, et al., 2002; U.S. DHHS, 2001). The universal media campaigns focused on messages of prevention and hope evolved to support a region-wide, annual Walk for Life, where community members create signs or just walk to show solidarity and commitment to wellness, suicide prevention and appreciating life. These events are supported by all of the major regional organizations with growing participation over the years.
Although turnover of health professionals continues to plague Maniilaq Association in ways that are similar to other rural and remote regions, the organization has developed several innovative approaches to suicide prevention through clinical care. Replicating Motto and Bostrom’s (2001) supportive, post-suicide crisis letter-writing campaign, Maniilaq initiated and implemented supportive correspondence between health and wellness staff members and those who attempted suicide from 2007-2010 (Wexler, 2010), and more recently, is developing a process to reach out through text messaging to those who exhibit suicidal behaviour. Maniilaq clinical staff are trained in cultural-specific risks for suicide that are based on the local surveillance system as well as cultural strengths, idioms and practices that clinicians need have in mind.
Local leadership development and self-determination of village communities is a priority in all the wellness activities. Since 2009, village leaders have attended retreats for healing, inspiration and leadership training, and they return to their communities to develop local wellness teams and initiatives. Maniilaq Association’s Wellness Program supports these village-based efforts with resources, which include regular village gatherings, community-wide potlucks, recovery support groups, and subsistence opportunities for people who do not have access to boats, camps or snow machines.
More recently, Maniilaq’s regional efforts support local facilitators who bring together representatives from local, village health, law enforcement, religious, and educational institutions to participate in learning circles to decipher “what we know” from suicide prevention research in order to assess and apply it to their local context. The program, called PC CARES (Promoting Community Conversations About Research to End Suicide), aims to translate research to strategic, locally-determined personal and collective actions for prevention (Wexler, et al., 2016; Wexler, et al., 2017). The “bite-size” research information shared in these learning circles includes findings from local research (Wexler & Goodwin, 2006) as well as general injury prevention information (e.g., lethal means restriction) (Roscoät et al., 2013) (see pc-cares.org) (Wexler, et al., 2016).
In a unique partnership, NANA Native Corporation resource technicians made up the bulk of local facilitator teams, making good on the organization’s commitment to “promoting healthy communities with decisions, actions, and behaviours inspired by our Iñupiat Ilitqusiat values consistent with our core principles.” Preliminary evaluation results from this program show participants gained knowledge and skills and increased their prevention activities on personal and professional levels (Wexler, et al., 2017).
Youth-focused programming through the years includes opportunities for reflection and self-expression through digital storytelling. Maniilaq wellness staff traveled to the 11 villages of the region plus Point Hope to offer week-long digital storytelling workshops for young people. From 2007-2014, youth crafted over 500 digital stories that highlight the multi-faceted reasons for living, cultural expression and pride, and commitment to family (Wexler, et al., 2012; Wexler, Eglinton, Gubrium, 2014). Community-wide screenings feature these digital stories. Through follow-up interviews, we know that young digital storytellers shared their stories with important adults and Elders in their lives, thus strengthening intergenerational support. Such support fosters a sense of mentorship, cultural identity and continuity: all of which are protective factors for suicide (Alcántara & Gone, 2007).
The Northwest Arctic Borough School District has also been involved in suicide prevention through a peer leadership program in the area’s schools. Begun in 2008, the Teck John Baker Youth Leaders Program takes a primary prevention approach to reduce risks of substance abuse and bullying through peer-led education and bystander training. The program also aims to increase protective factors of school attendance and engagement, academic success, and personal and cultural identity development. School personnel, community members and students tend to agree that the program is positive for those involved and for the schools in which youth leaders function. Outcomes from an evaluation of the program suggest increases in protective factors for suicide. More specifically, an evaluation of the program showed that participants believe they matter to others, feel positive about themselves, think they can make a difference in their community and school, and very rarely do drugs and drink alcohol. Additionally, they have higher grades and attendance than their peers. All of these factors are known to protect against suicide (Wexler et al., 2017).
Figure 2. The suicide rate in the Northwest Arctic Borough has decreased over the past ten years, but not in other similar regions or the state overall. * Indicates a significant difference from the previous timepoint based on a 95% confidence interval.
Independent village efforts focused on suicide prevention and wellness include hosting youth conferences that bring together Elders and young people to learn, engage in mentoring and learn leadership skills. One village, Kiana, created a group – Opt-In – which initiated a multi-village event to empower young people to take leadership within their communities (Frost, 2017). Another initiative, sponsored by the Kotzebue Tribal Council, invited young people to initiate inquiry with their Elders to learn about leadership, culture and community (Weinronk, 2017). Also, two villages in the region successfully competed for federal suicide prevention funding to create their own suicide prevention activities, which are in development now.
Figure 3. The decrease in suicides within the Northwest Arctic Borough over the past ten years has occurred primarily among youth and young adults. All rates within age groups are based on <20 occurrences which are statistically unreliable and should be used with caution.
Several village communities run traditional summer camps for youth each year, and regional camps are offered to younger and older youth. Camp Pigaaq, run by Maniilaq Wellness, is a week-long subsistence camp for young people aged 13-18 typically involving 15 at risk Iñupiat youth from the region. Camp Sivuñiġvik offers four, week-long sessions to young people ages 8-16 from the region. Aqqaluk Trust, a nonprofit foundation aimed at “empowering the Iñupiat through language, culture and education” offers this experience as well as scholarships to Iñupiat young people to go to college.
Change in suicide rates
Due to the complexity of the issue, preventing suicide takes time and multiple kinds of efforts before showing an impact (White, 2012). Although there have been concerted and strategic efforts to prevent suicide in Northwest Alaska as catalogued here, the correlated aimed-for outcomes are just now discernable. This finding offers reason to celebrate. The multifaceted efforts undertaken by Northwest Alaska seem to be having a positive impact on youth suicidal behaviour in the remote and rural, Iñupiat region. This reduction in suicide rates between these two, five-year periods stands out in marked contrast to the suicide rates of other, similar regions.
To illustrate, the State of Alaska Department of Health Analytics and Vital Records compiled age-adjusted rates of suicide per 100,000 from 1995 to 2014 in five-year periods. Northwest Arctic Borough (NAB) showed a significant reduction in suicide rates from 2005-2009 to 2010-2014 based on a 95% confidence interval (See Figure 2). This trend was compared to other rural and remote regions in Alaska with historically similar suicide rates including the Nome Census Area, North Slope Borough, and Yukon-Koyukuk Borough, combined. Our analysis found no significant differences in suicide rates between time points within similar northern regions combined or in the state overall (95% confidence interval).
Alaska Native youth under the age of 25 appears to be driving this reduction in suicides in the Northwest Arctic Borough (See Figure 3), and corresponds with the local and regional efforts outlined above. These findings contribute to a hopeful perspective that Indigenous communities, in partnership with service providers and researchers, can make a significant impact on the seemingly intractable problem of youth suicide. This recent reduction in youth suicides between these timeframes is noteworthy particularly because this age group experiences much higher rates of suicide in Indigenous circumpolar communities (Ragnhild Broderstad, et al., 2011; Oliver, et al., 2012; Lehti, et al., 2009). Continuing to monitor suicide rates will help to determine if ongoing multi-level suicide prevention efforts in Northwest Alaska are able to bring about a lasting and sustained decrease in suicide deaths over time, particularly among Alaska Native youth and young adults who are at highest risk.
Although suicide is complex and the result of a myriad of structural, historic, social and psychological issues, this regional example offers some reason for hope. Although causal assertions cannot be made, the correlation between this rural region’s reduced suicide rates and their consistent, multilevel programming and self-determined practices is promising. Standing out as a hopeful example, Northwest Alaska has sustained a myriad of evidence-informed and self-determined suicide prevention initiatives for over 10 years, and is now showing a reduction in youth suicide rates. Interestingly, similar multi-level approaches to suicide prevention in Indigenous communities elsewhere have shown decreases in suicidal behaviour (May, et al., 2005). The correlation is promising and can offer other regions a hopeful perspective to spur multi-level and self-determined efforts. We believe other Indigenous communities may find inspiration in this example, and policy makers can find evidence for sustaining support of multiple kinds of community-driven prevention and intervention programming. ◉
Lisa Wexler has been partnering with Maniilaq Association on community-engaged research for over twenty years, and is Associate Professor of Community Health Education, School of Public Health and Health Sciences at the University of Massachusetts Amherst.
Jodi Barnett is an evaluator with the Center for Behavioral Health Research and Services at the Institute of Social and Economic Research, University of Alaska Anchorage.
Lucas Trout, MA is Social Medicine Program Manager at Maniilaq Association and Lecturer on Global Health and Social Medicine at Harvard Medical School.
Roberta Moto, Inupiaq from the Native Village of Deering, Alaska, is the program manager for Maniilaq Association Wellness Program.
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