A deadly respiratory virus gripped the entire world. Tens of millions of people died, and no corner of the globe was left untouched after two years of the pandemic.

It was the influenza pandemic of 1918–19, and it has remained seared in the memories of survivors and their descendants for the past century. Perhaps nowhere is it better remembered than in the Arctic, where entire villages were wiped out and children were left orphaned. In Nome, Alaska, a monument to those lost to the flu was established in 2018—one hundred years after the start of the influenza pandemic, and one year before SARS-CoV-2 began spreading.

The Arctic has long struggled against devastating infectious diseases brought in over the centuries—not just historic epidemics like influenza or smallpox, but also ongoing battles against tuberculosis, respiratory syncytial virus (RSV), and other deadly pathogens. And it is one of the harshest, most remote regions in the world, with limited health care, poor connectivity, a lack of running water and sanitation, crowded housing, and higher rates of preexisting conditions.

Yet the Arctic has fared better in the COVID-19 pandemic than Southern regions. Why—and what can the rest of the world learn from it?

The Arctic—known for its sweeping, icy landscapes, uncompromising conditions, and, above all the resilience of its people—has held the key to understanding previous pandemics. Now, the North holds lessons for dealing with this and future outbreaks, across the globe.

These conditions have been true across the circumpolar North, and this piece will tell that story through examples of challenges and triumphs mostly from the Alaskan Arctic.

A Historic—and Present—Devastation

Part of the Arctic’s success in containing COVID-19 lies in its historical and present experiences with diseases.

“The Spanish flu pandemic very much affected those communities,” said Andrey Petrov, director of the ARCTICenter at the University of Northern Iowa and lead author of a recent study on lessons from the pandemic in the Arctic. “I was surprised how vivid this memory apparently was.”

There are frequent, sometimes visual reminders of the flu’s devastation. As the ground of the Arctic shifted and coastlines were reshaped over the years, the caskets and bodies buried in that long-ago outbreak have resurfaced.

The 1918 flu and COVID-19 followed similar patterns in the North. “It was a delayed arrival, and then it was very devastating when it actually came. So this memory is there, and it's been a guideline” for action now, Petrov said.

Other deadly pathogens have also been carried to the North through centuries of commerce and colonization, including the introduction of tuberculosis in the 1700s. Alaska still has the highest rate of tuberculosis in the United States, a pattern that holds true throughout the Arctic. 

More recent experiences with diseases like this helped residents take the virus seriously. Leaders were able to mount quick, effective responses because they understood the dangers posed by this threat, and the responses were most successful when residents felt a strong need to protect the community.

Many communities were able to combine public health measures quickly and effectively by restricting travel, closing schools, mandating masks, limiting public (and sometimes private) gatherings, physically distancing, and highlighting the value of interventions like handwashing.

Arctic communities showed how viruses like this can be contained and, moving forward, could help us understand the properties of the virus. The Arctic’s conditions helped scientists understand the 1918–19 pandemic decades later, when they unearthed graves from the permafrost in Alaska and Svalbard and sampled frozen tissue with preserved traces of the virus. The scientists then sequenced the virus and understood its source: it had crossed into human populations from birds, a threat that continues today with the prospect of future avian influenza outbreaks.

The Benefits of Isolation

The Arctic faced innumerable challenges, particularly in distance and resources, in the fight against COVID.

“The average Alaskan travels 147 miles one way to access care, and we have many communities that are not accessible by anything besides airplanes,” said Dr. Anne Zink, Chief Medical Officer for the state of Alaska. “We also have weather that becomes a huge challenge.”

At the same time, the North's very isolation and distance helped give communities time to put preventative measures and response plans in place quickly.

Limited health services and a lack of supplies like ventilators or ECMO life support are additional challenges. “We have had, unfortunately, people pass away because we've been unable to get them out from some of our villages, unable to get oxygen there,” Dr. Zink said. 

Infrastructure, including running water and sanitation and housing, is limited in some remote communities.

“It's one thing to say ‘wash your hands.’ It’s another thing if you don't have running water or sewers to wash your hands,” Zink said. “If you’ve got seven, 10 people living in a three-bedroom house, you can't simply separate out. Food is an issue, heating oil’s an issue.”

Testing was also a huge challenge, with samples traveling on two or three planes and delays in getting results that could extend 10 to 14 days.

At the same time, however, the North's very isolation and distance helped give communities time to put preventative measures and response plans in place quickly.

“We're used to being isolated from everyone else, we're used to doing things our way. [It] proved to be a premium asset in responding to the pandemic,” said Jared Kosin, CEO and President of the Alaska State Hospital and Nursing Home Association.

Communities were able to “delay, prepare, and respond,” Petrov said. “It will come eventually, but it will come when we know more about it and our communities will be more prepared.”

In places that relaxed restrictions too soon, or didn't implement effective measures, illness and death was markedly higher. Some of the highest numbers were seen in Russia and Alaska, and some of the lowest in Greenland and the Canadian Arctic.

“COVID came later than in other places, and some of them used it to prepare and some didn't. And that really made a difference at the end of the day,” Petrov said.

Communities around the world could learn from these lessons by setting precautions in place before the next wave or outbreak arrives, he said, using the advance warning time to “try to prepare for the eventual coming and not be relaxing too early.”

Immunization, from Iditarod Onward

Present-day reminders of the fight against infectious disease are widespread in other ways. The Iditarod, a dog-sled race from Anchorage to Nome, Alaska, mirrors the 1925 race to deliver lifesaving antitoxin to battle a diptheria outbreak in Nome.

Despite its sprawling and remote populations, Alaska was able to mount an incredibly fast and focused immunization campaign against the coronavirus as well. 

“When it came to coming up with a complex vaccine rollout, we're talking about the vast majority of our state is not on the road system, just geographically speaking. Even our healthcare system—21 percent of our acute care beds are not accessible from the road system,” Kosin said. “We have challenges that others don't.”

“But we were able to work together,” he said. “It was pretty incredible, really efficient. It happened really fast and it worked really well, too.”

Zink pointed to existing community partnerships as “absolutely fundamental to getting vaccines across the state, particularly in our beautiful, wild Arctic regions.”

Airlines would touch down on tarmacs in remote towns, where community leaders would be ready to unload the thawing vaccines and distribute them quickly. Some health workers would hold vaccine clinics right there on the tarmac, while others roared off on snow machines or even employed dogsleds to bring the shots door-to-door.

In fact, the remote vaccination campaigns went even smoother and faster than rollouts in urban areas, Zink said. “It's communities working super closely together and figuring it out. You don't have to worry about an online system to schedule your appointment. It's kind of one place for communication. Many of our rural areas, they have essentially a universal health care system.”

Alaska was particularly effective at prioritizing elders. It was one of the first states to open vaccine eligibility  to people over the age of 65, which they deemed as one of the highest-risk categories for getting severe COVID-19.

Arctic Innovation and Indigenous Knowledge

The 1918 flu and other epidemics hit Indigenous communities in the Arctic particularly hard, with worse rates of disease and death. In some places, Indigenous peoples lived in forced settlements that were crowded, inadequate, and far from medical care—all factors that proved deadly in outbreaks.

But Indigenous knowledge has played a key role in addressing and suppressing outbreaks, including the Saami management of smallpox in the past.

Another Arctic innovation has been telehealth, advances in which several experts called an unexpected silver lining amid the tragedies of the pandemic.

More recently, Indigenous knowledge and subsistence traditions helped address the coronavirus itself and its ripple effects. For instance, going out on the land during the COVID pandemic helped with distancing, mental wellness, and food security, especially during supply shortages.

“Spending time on land, for instance, or engaging in traditional health healing practices and psychological healing practice” was also key, Petrov said. Long, remote hunting trips helped with food security and physical distancing, as well as providing mental health benefits. “Being on the land, being connected to the land, is healthy,” he said.  

Regions with native health services frequently encountered advantages over the virus, Petrov said. “If there is an element of sovereignty and self-determination in public health care provision, that actually may provide additional strength to the response.”

Another Arctic innovation has been telehealth, advances in which several experts called an unexpected silver lining amid the tragedies of the pandemic. “The notion that it is the most important service came back to light again,” Petrov said. “If nothing else, it's brought up telehealth again to the forefront of the discussion and it reignited the appreciation of it.”

Despite limited connectivity, telehealth expanded rapidly and successfully, showing promise for remote Arctic communities with limited health care access.

“We were already at the forefront of telehealth in the country,” Kosin said. The pandemic “really allowed us to just unleash telehealth and take it to the next level.”

These changes may become permanent, helping to ease limitations of health care in remote areas. “It’s something that we want to see forever,” Kosin said. “It doesn't make sense to go back to old technology and fixed places and have all these restrictions when we found the need to be able to get to each other quickly with effective medical care through platforms that can work for everybody.”

There are issues with internet capacity and connection in the North that still need to be addressed. “You really can't have effective telehealth without reliable internet,” Kosin said. But those issues could be fixed in the next few years, Petrov said, as long as improved connections are prioritized.

Addressing intersecting factors like climate change will be inescapable for strengthening health systems and even preventing future outbreaks, wherever and whenever they emerge. The very permafrost that preserved the 1918 influenza is now thawing and releasing ancient pathogens, including anthrax bacteria.

Moving Forward 

Learning from previous outbreaks will be key to preparing for the next ones. As the COVID-19 pandemic continues, and scientists monitor other infectious diseases for pandemic potential, it will be crucial to include Arctic perspectives, especially Indigenous communities, in pandemic planning.

Building a sense of community, especially with a reliance on Indigenous knowledge and ways of interacting, is also key for battling newly emerging threats, like misinformation and disinformation.

“What has made us work so well in Alaska has been the ability of knowing each other, trusting each other and responding, even though our geographic size is so big,” Kosin said. “We've done a lot of good, but I also think there's a lot of challenges that we could have avoided had we just built on that working-together mentality.”

Improving water and sanitation, as well as strategies around how fly-in work takes place, will also be key to strengthening Northern responses to disease outbreaks.

Addressing intersecting factors like climate change will be inescapable for strengthening health systems and even preventing future outbreaks, wherever and whenever they emerge. The very permafrost that preserved the 1918 influenza is now thawing and releasing ancient pathogens, including anthrax bacteria. Preventing the permafrost from thawing further may be vital to containing such pathogens.

The lessons Arctic communities have learned from the coronavirus pandemic can inform future responses, as the influenza pandemic informed responses to COVID-19. The same efforts that helped keep the coronavirus in check also helped reduce other infectious diseases in some Arctic communities, and such precautions and measures could continue addressing illness outbreaks even after this pandemic has receded.

 “This is how we take care of each other,” Zink said.

 As one community health worker in rural Alaska put it: “You just keep going, and you try to do the best you can with what you’ve got.”

Melody Schreiber (@m_scribe) is a journalist and editor of What We Didn’t Expect: Personal Stories About Premature Birth.

Cover photo courtesy Tanana Chiefs Conference.