IQALUIT, Nunavut — Midwinter darkness envelops this harsh, frozen land for most of the year, broken only by feeble midday twilight.

Temperatures plunge to 50 degrees below zero Farenheit, and during a blizzard, visibility drops to a few yards. There are no trees, but lichens and tiny flowers bloom during the short summer, when there is daylight around the clock.

This is Nunavut, nearly 775,000 square miles of frozen rock and ice the size of Mexico, straddling four time zones across Canada's vast north. On 1 April 1999, it was proclaimed a territory in its own right as part of the largest native land claims settlement in Canada's history. Until then, Nunavut had been part of the Northwest Territories (NWT) and governed from Yellowknife, some 1,500 miles to the west of Nunavut's new capital, Iqaluit.

Of the 25,000 inhabitants spread across 28 communities, 85 percent are Inuit. Inuit means people in Inuktitut, the Inuit language, and Nunavut, our land. Many still hunt caribou, seal, and walrus for food, yet live in modern housing and use computers and cellular phones. They have been called the "igloo-and-e-mail" generation. It's not unusual to see public billboards with ads for snowmobiles and dog teams next to promotions for Pentium microprocessors and exercise bicycles.

The creation of Nunavut, along with a US$ 737 million entitlement the federal government will pay over the next eight years, has been called by ABC World News "perhaps the most daring step any nation has ever taken to satisfy the political and geographical claims of its aboriginal people." The victory has brought a heady optimism to the Inuit, who feel they are finally in control after years of domination by non-Inuit southerners.

Despite the spirit of promise in the air, however, tough challenges lie ahead. Serious health concerns, many of them stemming from a difficult social situation, worry government authorities. Nunavut's Health and Social Services Minister Ed Picco calls the eastern Arctic territory "a very challenging place to deliver health care."

One reason is the isolation. Iqaluit, Nunavut's largest community (population: 4,500), is on Baffin Island, just south of the Arctic Circle. The only way in and out is by air, except for a summer sea-lift of goods. Located on an inlet surrounded by rocky hills, Iqaluit is a smattering of prefabricated buildings, with a few southern suburban-style units and one older high-rise that houses the movie theater. There are no traffic lights or parking lots. Few people own cars, but the seven local taxi services do a brisk business. There are only 25 miles of gravel roads. But no one ventures far from home when it's 50 below.

A third of the population relies on social assistance, more than three times the national rate. The population is growing three times faster than the total Canadian population.

More than half of Nunavut's residents are under 19 years of age, and 42 percent over 15 have not completed the ninth grade. The young workforce has high unemployment, low educational levels, and low average incomes.

Life is expensive here, since most day-to-day consumer goods must be flown in from the south. Housing is scarce and costly for the same reason: building materials mainly arrive during the annual sea-lift in July and August. Some 83 percent of homes have subsidized rents, and most are overcrowded: it is not uncommon for as many as 10 people of several generations to share a two-bedroom unit.

The infant mortality rate in Nunavut is twice the national average, and the teenage pregnancy rate is high. There is no stigma to unwed motherhood, and children often are raised by extended families. The territory's tuberculosis rate is eight times higher than the rest of Canada. Sexually transmitted diseases, too, are 13–20 times higher than the national average, and alcohol and substance abuse, such as gasoline-sniffing, are widespread. Some 68 percent of the adult population are smokers, compared with a Canadian average of 27 percent, despite the fact that a pack of cigarettes here costs the equivalent of US$ 6.

The suicide rate in Nunavut, at six times the national average, is Canada's highest. The reasons cited usually contain a common thread—the pressures to pursue a more modern way of life, underemployment, the waning of centuries-old customs and traditions, and the Inuit's lack of experience with living in settlements—especially under such overcrowded conditions—and the subsequent loss of self-sufficiency and identity. Whatever the reason, nearly every Inuk (the singular term for Inuit) has been touched by suicide through the loss of a relative, friend, or other loved one.

Until half a century ago, what is now Nunavut had little contact with the rest of Canada or the outside world. Then, during World War II, the U.S. Air Force built an airfield at Frobisher Bay (now Iqaluit), and with the onset of the Cold War, many Arctic communities served as radar bases for the Distant Early Warning (DEW) Line, a joint U.S.-Canadian project launched in 1955 to protect against an "over-the-Pole" attack on the North American continent by the Soviets.

During this time, southern nurses were first sent by Canada's federal government northward to provide health care in community clinics. In the 1980s, responsibility for health care, including nursing stations and hospitals, was transferred to the NWT government. Even so, the federal government, through Health Canada, continued to support some community-based programs for Inuit and First Nations peoples, particularly in the areas of prenatal nutrition; tobacco control; alcohol, drug, and solvent abuse; suicide counseling; and nursing education.

Today, the federal and NWT governments are acting as advisers to Nunavut's health department. "We are building a whole new relationship with a new set of people," says Judith Ross, of Health Canada's Medical Services Branch Northern Secretariat. "We are assisting with the recruitment of health professionals, particularly nurses, and we liaise and advocate on their behalf with other government agencies and departments."

Nunavut's new Health and Social Services Ministry is struggling to find qualified administrative staff. Halfway through 1999, it had only 23 people; its goal is 83. Some services, such as epidemiology and health statistics, are contracted back to the NWT government. Of Nunavut's budget of US$ 408.7 million for 1999, health care received US$ 78.6 million. "We have the second-highest departmental operating budget," notes Picco, with only the education sector receiving a larger share.

The biggest chunk of the health budget goes to transportation. Patients from the Baffin region are flown to Iqaluit's 34-bed hospital, while those from the Kitikmeot and Kivalliq regions travel 2,000 miles or more away to Yellowknife, Edmonton, Churchill, or Winnipeg. The Baffin region, which serves 12 of the 28 Nunavut communities, spends US$ 5.36 million a year on travel, much of it for medical evacuations by air. There are an average of 1.5 medivacs a day in this area alone. Conditions include heart failure, pneumonia, injuries, ectopic pregnancies, cesarean sections, and premature labor. Any patient requiring chemotherapy or radiology also must be flown south. Often, a family member goes with them, with the government picking up the tab.

General practitioners visit communities once a month to check on patients who are not sick enough for emergency evacuation, while other specialists fly from Ottawa, Canada's capital, to Iqaluit on a regular basis to see patients.

Telemedicine, because of its ability to close large distances, has found fertile ground in Canada's frozen tundra. Doctors thousands of miles away in Ottawa can observe patients in remote locations using satellites and video images and decide whether to airlift them south for treatment. Picco says Nunavut is "on the cutting edge" of this new technology and its effectiveness has spurred great interest on the part of other countries with similar geographical obstacles.

Iqaluit's hospital director, Dr. Chuck MacNeil, is convinced that in the future, telemedicine can help the government shave big dollars off its bloated travel budget. As examples, he cites the technology's compatibility with psychiatry, social work, dermatology, and orthopedic consultations, and its appropriateness for public health training and staff upgrading. "We can't afford to send one teacher into 12 communities to teach one nurse or even five nurses," he says. "And we can't get replacements for them so that they can come south. But we can easily do teleconferences."

The shortage of nurses, is, in fact, one of the territory's biggest headaches. Clinics have a 35–40 percent vacancy rate. Unfortunately, the nursing scarcity is nationwide, and the local government is hard-pressed to come up with the type of financial incentives that would lure nurses north.

A major crisis is the lack of Inuit healthworkers in general. Currently, there is one Inuk dental therapist, one Inuk nurse, and no Inuit doctors. Therefore, Inuit have to go south for post-secondary training, and the culture shock and loneliness have driven many to quit and return home before completing their studies.

To address this issue, a pre-entry nursing program is upgrading Inuit candidates to the necessary educational level to apply for a full training program that was launched in September 1999. "We have to train local nurses," says Picco. "This may take some years, but we need to build up capacity and provide nurses who speak the language and relate better to the clientele."

Besides making health care more culturally sensitive, Pico hopes to change attitudes toward health. "We want to take a more holistic approach and emphasize the preventive side of health," he says. "We want to get the information out and tell people 'Protect yourself.' But it's going to take five, 10, 15 years."

Picco and other local leaders see this lapse as part of the larger transition process Nunavut is going through. Over the past half century, they say, the Inuit have undergone a type of social change that took place gradually, over some 5,000 years, in other industrialized parts of the world. Only two generations ago, the Inuit were still moving with the seasons, allowing land and sea routes to guide them to the most abundant food sources. As one social worker in Iqaluit suggests, "it has all happened too fast for the Inuit to get their culture and minds wrapped around. They are still figuring out how to live in communities, after following a nomadic lifestyle for thousands of years."

The adjustment to community living is exacerbated by the territory's social problems. "What would it do to us in the south if there were three or four nuclear families living in the same home through blood relationships?" asks the social worker. "What would this do to crime, suicides, addiction, TB, STDs, other health issues, child abuse, and neglect? If there are 10 adults in a home and one is an alcoholic, everyone in the home has a problem."

Rosemary Cooper, Assistant Deputy Minister of Health and an Inuk, believes the biggest key to change is building self-esteem and pride. She predicts the suicide rate will decline as people begin to see that the Nunavut government is creating culturally sensitive programs and services for them.

Judy Watts, of the Baffin Regional Health and Social Services Board, agrees, but adds: "A lot of teaching, a lot of mentoring, and a lot of healing are needed. There's been a great deal of family and community disruption imposed on the Inuit. Few Aboriginal groups have been thrust into the 20th century so hard and so fast. In any community, when people start being master in their own home, things can get better. But it won't be simple or easy."

Although the Canadian Government's approach today toward its Aboriginal population—the First Nations, Inuit, and Métis, as defined by the Canadian Constitution—is quite progressive, this was not always the case. In the 1950s and 1960s, ignoring the traditional nomadic lifestyle of the Inuit, a well-intentioned but paternalistic federal government felt they would be better off living in permanent settlements. Schools, health and social services, and a mammoth housing program were launched as incentives to encourage Inuit cooperation. Since the models used were Westernized, and the policies imposed contained little input from the Inuit themselves, the government's goals—to provide economic opportunities and public services and alleviate starvation—were in many ways misguided, inappropriate, and therefore ineffective.

Today things are changing. Inuktitut is the official government language and is being promoted throughout the education system. There are healing circles and a single-level court system. Government departments and agencies are being decentralized to 10 communities outside the capital in an effort to spread services and job opportunities across the territory.

Yet many Inuit now in their 40s and holding high-level public positions in Nunavut were born and spent the first decade of their lives in remote camps. Mary Wilman, a 50-year-old grandmother who heads the Nunavut Social Development Council, was born in a sod house in one of these camps before the government relocated her family to Iqaluit. "I was 10 years old and that's when I started school. At 13, I went to residential school in Churchill, and then to Ottawa. A lot of us were pulled away from our families at a very early age. I didn't go back until I was 18. We were fast-tracked into the system."

She adds: "We have gone too far towards the white society. We think everything about white society works. We have gone away from breastfeeding. We have adopted the white diet. Our traditional diet is far leaner than the Western diet, but it has taken us a generation to realize this. We are in a cross-cultural environment and we need to incorporate the best of both worlds. We have to regain respect for our own world. We have to promote and educate and train our own people."

Wilman not only works with the council but also has a consulting business that provides community training in Inuit health, healing, and wellness practices. One of her partners is Leena Evic-Twerdin, an Inuk who has a second job with the Inuit organization that negotiated the Nunavut Land Claims Agreement and is now ensuring that its terms are put into effect.

Evic-Twerdin says the Inuit moral and social structure is not there as it was before. "Our parents were our teachers, judges, and doctors before anybody else. From there, the problem would go to extended family members and finally to the elders' circle." She would like to see a return to traditional belief systems. "Holistic teachings kept us healthy mentally, physically, emotionally, and spiritually," she says.

Yet she is optimistic about her people's future, pointing out that Inuit recently have been participating in political, economic, social, and educational issues "like never before." She adds: "Most Inuit didn't have a vision of our existence any more, but because of Nunavut, they now say 'Let's do this or let's do that.' It's most encouraging. Great things are happening, but it is going to take some time to resolve the problems. Come back in 20 years and see the difference."

Nunavut information director Judith Pereira echoes that sentiment. She points to Greenland, Nunavut's neighbor to the east of Baffin Island, which gained home rule from Denmark two decades ago and is now a sophisticated society with a standard of living much higher than Nunavut's. "Nuuk [the capital] was like Nunavut is today. They are now very advanced." In 20 years, she predicts, "we shall be like they are."

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Maureen Johnson, an Ottawa-based freelance writer on health and international development issues, is communications and media relations consultant to the Canadian Society for International Health, which serves as technical representative in Canada for the Pan American Health Organization.