**1. Introduction**

Over the previous decades, many studies, including those conducted in the framework of the Arctic Monitoring and Assessment Program (AMAP), have explored major aspects of public health in circumpolar communities, as well as assessed various stressors on human populations living in the North [1]. The Arctic, however, is changing rapidly in many ways. The once established patterns are transforming and bringing new potential risks to human health, such as contaminants, climate change, industrialization, urbanization, economic disruptions, and nutritional transitions. Among the current health effects, whose study is prioritized by the AMAP, are immunological, neurobehavioral, cardiovascular, metabolic, diabetogenic, developmental, reproductive, endocrine, and epigenetic [2]. To address the diversity of ongoing changes, there is a need to investigate multivariate interactions of environmental contaminants, dietary nutrients, and other factors and reveal their combined effects on health outcomes across Arctic communities [3].

Air pollution in the Arctic has been emerging as one of the threats to ecosystems and public health since the 1950s [4]. According to Arnold et al. [5], Arctic air pollution includes harmful trace gases, such as tropospheric ozone, particles, such as black carbon and sulfate, and toxic substances, such as polycyclic aromatic hydrocarbons. They are responsible for detrimental effects on human health even at low concentrations [6,7], ranging from physiological changes in pulmonary functions and the respiratory and cardiovascular systems to premature death [8]. Pope et al. [9] and Dockery et al. [10] found out that long-term exposure to fine particles and sulfur oxide-related air pollution was positively associated with death from lung cancer and cardiopulmonary. Naess et al. [11] discovered the particularly strong effects of the concentration of air pollution on chronic obstructive pulmonary disease.

Increased air pollution due to the ongoing industrialization and urbanization in the Arctic creates new challenges in relation to the quality of water, sanitation, and wastewater handling [12]. According to Dudley et al. [13] and Parkinson et al. [14], environmental disruptions in the North could spur the discharge of pathogenic microorganisms from wastewater treatment systems into marine and freshwater environments, emerging human health risks. Out of four types of water and infectious diseases categorized by White et al. [15], two are believed to be of crucial importance in the Arctic: waterborne infectious acquired by consumption of contaminated water and water-washed diseases acquired through person-to-person spread that can be interrupted by the use of water for washing [16]. Hennessy et al. [17] demonstrated a direct positive association between the lack of complete plumbing and higher incidence rates of respiratory and skin infections. The households with in-home water service have lower infant hospitalization rates for pneumonia and respiratory syncytial virus [18]. An exposure to inappropriately treated wastewater is recognized as one of the reasons for higher rates of infectious diseases in circumpolar communities, such as tuberculosis and methicillin-resistant *Staphylococcus aureus* [19,20].

The majority of previous studies on environmental impacts on health in the Arctic focused mainly on persistent organic pollutants (POPs) and metals [2,21]. Stockholm Convention recognizes that Arctic ecosystems and indigenous communities are particularly at risk because of the biomagnification of POPs [22]. However, identified threats from POPs and other contaminants have emerged public health concerns in the Arctic and reduced confidence in understanding the full picture of environmental impacts on health [23]. Apart from POPs, the Arctic environment is increasingly affected by new chemicals of emerging concern (CECs), such as current use pesticides, pharmaceuticals, and personal care products, and per- and polyfluoroalkyl substances [24], but current understanding of their health outcomes is limited. In large parts of the Arctic, for some CECs, there is a general lack of toxicological and other data that are needed to better understand health issues related to such compounds and for health risk assessments [25]. For instance, no reliable environmental data have been available from Russia, where spatial and temporal patterns of air pollutant emissions and wastewater discharge are poorly reported by the manufacturers and thus remain generally unknown. Arctic zone of Russia is one of the major centers for the production of fluoropolymers with manufacturers that have not signed on to stewardship programs to reduce long-chain perfluoroalkyl carboxylic and sulfonic acids in products [26]. For some CECs used in consumer products (siloxanes and phthalates), concentrations have been found to be higher near settlements and urban sites, particularly, in receiving waters impacted by sewage effluents [22,25].

Alongside with air and water pollution, the fact of poorer nutritional status of people in the Arctic communities of Russia compared to other parts of the country is believed to be one of the most adverse impacts on public health [27,28]. A poor-quality diet has long been associated with increasing obesity, diabetes, and glucose intolerance in many circumpolar communities [29]. In the Arctic zone of Russia, there are critical gaps in per capita consumption of milk and dairy products (about 55% below the

national average), eggs, potatoes, and bread (45% lower each), and meat and meat products (30% lower) [30]. Due to the shortages of milk and dairy products, vegetables, and fruits, there is a shift of macronutrients in the diet towards carbohydrates (an abundance of sugar, confectioneries, bread, pasta, cereals) and, therefore, a lack of almost all types of vitamins, mineral nutrients (particularly calcium, phosphorus, magnesium, potassium, iodine, zinc, fluorine, etc.), and contamination of food by pesticides, metals, antibiotics, nitrates, and biological agents.

Many studies have advocated traditional food as a premier source of healthy diets and improvement of public health parameters in indigenous communities. Kuhnlein et al. [31] and Lambden et al. [32] considered traditional food as critical for providing many essential nutrients in balanced diets and recognized the progressing transition to high-energy market food in circumpolar communities as a basis for obesity and other related health problems. However, due to climate change and environmental pollution, traditional food is becoming a less obvious solution to health problems in the North. Concentrations of some CECs are increasing in Arctic air and wildlife, indicating their potential for bioaccumulation and biomagnification, including in food webs [33]. Climate change acts through alteration of food web pathways for contaminants [34], while pollution increases the risk of disease transfer from animals to humans as a large volume of marine and terrestrial wildlife is consumed by humans in the Arctic, often raw and inadequately frozen [35]. Dudarev et al. [36,37] found that blubber of marine mammals in Chukotka was highly contaminated by POPs and some metals, which was the reason for the high exposure to those contaminants by indigenous people whose diets included marine mammals. The higher temperature of ocean water moves warmer marine species towards the northern latitudes [38]. Along with the change of the polar water habitats and the effect of ocean acidification, such migrations bring new biological threats to the health of the Arctic inhabitants (diseases and microorganisms previously not met in the North).

Along with the environmental and nutritional imbalances, northern territories report higher morbidity and incidence rates of many diseases and health disorders compared to the national average [39,40] (Figure 1).

**Figure 1.** Morbidity across the Arctic territories of Russia, cases registered per 1000 people. Source: authors' development based on the Federal Service of State Statistics of the Russian Federation [41].

The major health issues are the diseases of the respiratory, genitourinary, and digestive systems (Table 1); the extremes recorded in the Nenets and Yamal-Nenets autonomous districts.


**Table 1.** Major diseases and health disorders in the Russian Arctic, average in 1997–2017, incidence rates per 1000 people.

Note: \* In descending order of the incidence rates across the Arctic zone of Russia; \*\* 1: Murmansk region; 2: Arkhangelsk region; 3: Nenets Autonomous District; 4: Komi Republic; 5: Yamal-Nenets Autonomous District; 6: Krasnoyarsk region; 7: Republic of Sakha (Yakutia); 8: Chukotka Autonomous District. Source: authors' development based on the Federal Service of State Statistics of the Russian Federation [41].

While Schmale et al. [42], Law and Stohl [43], Shindell et al. [44], and Kuhnlein et al. [31], among others, conducted the estimates of Arctic-specific disease incidence through environmental and nutritional impacts, a question remains whether particular public health parameters might experience the effects of economic factors [45]. Chen and Kan [8] recognized the people with low socioeconomic status as high-risk subgroups in terms of proneness to respiratory, cardiovascular, and other health effects. During the times of economic and social transformations in Russia in the 1990–2000s, the environmental situation in the Arctic deteriorated substantially with by-all-means emergence of extractive industries. Larsen and Fondahl [46] expected that the industrialization and urbanization trends in the Arctic accelerate in the future. The emissions of air pollutants and wastewater discharge will increase and mostly be emitted around existing industrial sites and human settlements. Due to the environmental disruptions of traditional sources of food and water, circumpolar communities have become increasingly vulnerable to economic insecurity [47]. Morozova et al. [48], Erokhin [49], and Liefert and Liefert [50] reported degrading purchasing power of population in Russia, which resulted in the redistribution of family means in favor of food, as well as a shift to less expensive food products and more affordable sources of proteins of lower quality and nutrition value [51,52].

Another question that emerges is whether particular circumpolar territories might have health impacts different from other Arctic regions and whether populations in various environmental and economic patterns respond differently to the varying combinations of influence parameters. One of the priorities declared by the AMAP Human Health program is tailoring health-related studies in the Arctic to address local issues [2]. Adlard et al. [3] and Weihe et al. [53] made a similar recommendation to consider local specifics and allowed for better cross-territorial comparisons. Chowdhury and Dey [54] and Schmale et al. [42] found that disease incidence rates varied dramatically between Arctic countries but also between the territories within a country. As the per-territory disruptions of public health are becoming increasingly complex, identifying individual factors that affect them is crucial [55,56]. In this study, an attempt was made to capture overlapping environmental, nutritional, and economic dimensions and understand their impacts on selected diseases in different types of circumpolar territories.
