iving without running water and flushable toilets is a reality in many of Alaska’s remote communities, leading to increased health concerns for both children and adults. Fortunately, the Alaska Native Tribal Health Consortium (ANTHC) has received a grant from the Indian Health Service to build up sanitation infrastructure in these communities, and work is underway to kick off these much-needed projects.

ANTHC is a nonprofit tribal health organization with an ambitious vision statement: to make Alaska Native people the healthiest in the world. This vision serves as the guiding principle in all that ANTHC does.

“ANTHC was formed by an act of Congress through all of the regional tribal health organizations in the state coming together to create the only tribal health organization with a statewide focus,” says Shea Siegert, senior manager of external relations. “There are 229 federally recognized tribes in Alaska, and ANTHC’s board members represent all regions and tribes in the state.”

The consortium is the largest, most comprehensive tribal health organization in the United States and Alaska’s second-largest healthcare employer, with more than 3,000 employees. It jointly owns and operates, with Southcentral Foundation, the Alaska Native Medical Center in Anchorage. Outside of cities, its largest project is water and wastewater improvements for rural villages.

Tony Knowles had just been elected governor when he pledged to put the honeybucket in a museum. Nearly thirty years later, more than 3,000 households statewide are still using 5-gallon buckets as toilets, emptied into a central sewage collection.

Connecting those households to piped water and sewer remains the goal, no matter how much time and money it takes. The latest infusion of money arrived in September, when the US Indian Health Service (IHS) announced that Alaska is receiving more than $440 million to improve sanitation infrastructure.

The funding is part of the Infrastructure Investment and Jobs Act (IIJA) of 2021, making $700 million available nationwide annually from 2022 to 2026. “We are especially grateful to Senator Lisa Murkowski and the rest of the federal delegation for always championing the needs of rural Alaska—especially in the passing of the 2021 infrastructure deal,” says Charissa Williar, sanitation facilities program director for ANTHC.

Tribes and organizations like ANTHC must go through numerous steps to be awarded the funds. IHS uses the Sanitation Deficiency System: a collaborative process in which communities work with ANTHC, IHS, and other entities to identify sanitation needs, develop and agree upon solutions, and prepare required documentation for the prioritization and funding decision process by IHS.

IHS distributed $13 million from congressionally directed spending earlier in 2023 and an additional $11 million from the federal sanitation facilities construction budget, in addition to $416 million of IIJA funding.

Out of more than 200 rural Alaska communities, 32 have no running water in their homes. ANTHC has determined that access to clean water and sanitation systems has a direct connection to the economic, environmental, and physical health of individuals and communities.

“It’s proven that having running water in your home helps communities be healthier,” explains Williar. “The research data states that infants in communities without running water in the home are hospitalized with pneumonia eleven times more frequently than those with in-home running water. These infants are also five times more likely to develop lower respiratory tract infections.”

Infants aren’t the only ones affected by the lack of running water. “There’s a risk of skin infections and lower respiratory tract infections to all individuals,” adds Williar. “Without running water, all community members are at higher risk for skin infections including MRSA [Methicilin-resistant Staphylococcus aureus], a staph infection that can get into a skin injury, such as a cut, bite, burn, or scrape, and lead to hospitalization.”

In addition to the 32 unserved communities, federal sanitation funds will benefit other communities with infrastructure needs. “Within the 200-plus communities exists a wide range of different sanitation needs,” explains Williar. “While the 32 unserved communities have the biggest deficiency, other communities deal with an aging infrastructure dating back as far as the ‘70s or even earlier. This is a once-in-a-lifetime opportunity to correct these issues, and we’re doing everything we can to take advantage of it.”

While ANTHC is excited to work with communities in all phases, from planning and construction to training and implementation, each community drives its own project.

“Local knowledge and community engagement is a vital component every time we evaluate and begin these significant projects,” explains Siegert. “Our Division of Environmental Health and Engineering is looking at infrastructure projects being installed in communities which experience some of the harshest weather conditions in the country, if not the world. The residents and community leaders have the knowledge and experience to make the right decisions for the communities, and they are engaged in every step of the planning process, from identifying deficiencies to discussing the solutions to selecting the preferred project. We also need to be aware of local priorities, including things like the location of culturally significant sites and how the land changes from season to season.”

All of these projects are substantial. “In the thirty-two unserved communities, we are looking at expanding wastewater lagoons, establishing water supply resources, and building the actual pipes required for each home to establish plumbing,” explains Williar, adding that two years of design are often necessary after the funding is received from IHS.

“After receiving funding from IHS, it takes a few months to set up cooperative agreements with the communities and get those signed and executed. Then projects go into the design and construction queue. They fall behind the Fiscal Year 2022 projects because we also have to meet our commitments to other projects funded in prior years,” says Williar.

ANTHC’s vision remains focused on its goal to use this opportunity for improved sanitation infrastructure to ensure every home has running water on a more day-to-day basis. “We’re working hard to do the required planning, earning the approvals from IHS, and—once the funding is there—completing the design and applying for the permits far in advance of the construction season due to our limited window for construction each year,” shares Williar.

Supply chain difficulties add an additional layer to the challenges of sanitation projects slated for these communities. For example, barge season in Western Alaska only runs from May through October, leaving a very narrow window of time to bring in the necessary supplies.

“As we prepare to begin hands-on work on the sanitation projects, we consolidate all the required materials in our shipping and receiving yard,” explains Williar. “Some of our communities only have one scheduled barge per year, and we strive to make that schedule.”

Despite the obstacles, Williar has confidence in the ANTHC logistics team. “We’ve been doing this for a long time and our logistics team is well-versed in what is required, which includes getting everything lined up ahead of time, ordering the parts, consolidating the parts upon receipt, and making arrangements to transport everything to the communities.”

While ANTHC initially anticipated a time frame of three to five years for this batch of projects, the true timeline is uncertain. “It is yet to be seen exactly how the resource constraints will draw those timelines out even further,” explains Williar. “Suppliers and vendors are already experiencing supply chain disruptions and delays, and there are only so many barges to the communities each year to be able to deliver the required materials to the project sites.”

The starting phase of each sanitation project also entails training and employing local teams.

“At ANTHC we have over 200 employees working in the Division of Environmental Health and Engineering,” says Williar. “In the early stages of the projects, our engineers and project management teams work with the communities to identify deficiencies and obtain the funding.” Those team members continue to be involved with the projects from start to finish.

Once the planning is completed and the funding is in place, the design is completed by ANTHC engineers or by consulting firms contracted by ANTHC. Once the construction drawings and specifications are completed, projects are either advertised for construction bids or planned for in-house construction by ANTHC. For in-house construction, ANTHC’s construction managers and licensed trade workers—including superintendents, electricians, heavy equipment operators, and plumbers—are added to the project teams to work with community crew members to complete the projects.

“Our construction managers and licensed trade workers work with local crew members and build local capacity throughout the project,” says Williar. “By hiring local community members to work on the building of the sanitation projects, they are receiving training about the ins and outs of the project. This provides them the capacity, understanding, and training needed to maintain and operate the infrastructure once the project is complete and ANTHC has demobilized from the community.”

Including local workers in the projects provides additional benefits for ANTHC and each community. “We will often end up hiring people onto our permanent staff, which provides home-grown workforce development while providing these individuals with secure jobs, extensive training, and the opportunity to travel to other villages to work on additional projects,” Williar adds.

As for when the last honeybucket will become a museum piece, that remains unknown. “There are only so many engineers, superintendents, licensed tradespeople, and equipment operators, and only so many construction contractors that work in these remote communities. We’ll be learning as we go as to the anticipated timeline,” says Williar.

While the completion of sanitation projects for communities in need entails a complicated time-consuming process coupled with considerable hard work for everyone involved, Williar believes it is worth it. She says, “Our goal is to keep working hard. I’ve been working in this for over twenty years, and it’s exciting to be in a place where this level of infrastructure improvement is a reality. It’s challenging but worth the hard work to witness these improvements becoming a reality for the communities who need them most.”