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Greenland

Myths and opinions on public health in greenland

In the 1990s, Greenlanders - and especially the women - put on weight. One consequence of this is an increased incidence of diabetes.

"No health problems that can be attributed to environmental impacts have been recorded in Greenland," says Peter Bjerregaard. "There are naturally a lot of suppositions about how such impacts affect people, but, firstly, they are only suppositions and, secondly, it is on the marginals that they affect people. It is possible, for example, that the high Persistent Organic Pollutants (POPs) impacts have some effect or other on the immune system so that people more easily acquire infectious diseases. However, it is also well-known, of course, that living in overcrowded conditions in poor housing has an enormous effect on the incidence of infectious diseases."

Peter Bjerregaard stresses that there have been no signs so far that the environmental impact with heavy metals and POPs has led to more cases of illness among the population of Greenland.

Peter Bjerregaard is a professor in arctic health working at Denmark's National Institute of Public Health (SIF).

"Then what," I ask, "about the fact that right now the population is putting on weight, guaranteeing that, within just a few years, Greenlanders will suffer from some of the diseases that we in the Western world are being warned against?" "It is reasonably well proven that the population is gaining in weight", replies Peter Bjerregaard. He has compared a survey carried out by SIF in 1993-1994 with a similar survey from 1999. The comparison showed that men had not gained in weight, but that women had put on an average of one kilo in two years. The reason is probably that people are abandoning their traditional diet and are instead eating poor quality food and drinking fizzy drinks. Moreover, they are not getting as much exercise as they used to.

Although it is clear that women are gaining in weight, there are different trends for men and women. Most of the men that are overweight are in the highest social group, whereas most of the women are in the lowest social group. The same situation has been found among Inuits in Canada. In Denmark, both men and women are generally most overweight in the lowest social group that.

Omens from Alaska

The number of hunters has fallen in recent years. Hunting is probably the most physically demanding occupation there is - and, in a cold climate, is undoubtedly one that calls for the highest calorie intake.

At the same time, it is the hunters and people out in the settlements that complain most of rheumatic pains and aching joints. That is the price paid for living in a settlement instead of a town.

The changes in lifestyle show the same trend all the way round the Ice Cap.

"The changes are not yet as pronounced in Greenland as in Alaska," says Peter Bjerregaard. "The Eskimos in Alaska are more Americanised in their lifestyle, so they spend more time in front of the television and ride round on snow scooters and all-terrain vehicles, even when they are only going into town. Incredibly, in a small settlement, people will even use a snow scooter to go a hundred metres down the road. Greenlanders walk much more, and there is also a healthier attitude to physical exercise."

However, the public health situation in Alaska can be used as a forewarning of the direction the trend can take in Greenland.

In Alaska, cases of diabetes have quadrupled in 20 years. There has also been an increase in Greenland, but not as big as in Alaska.

"In the 1960s, one saw almost no cases of diabetes in Greenland," says Peter Bjerregaard. "In the last couple of years we have been measuring the blood sugar level, which is the best way of diagnosing diabetes. We have tested about 1,000 Greenlanders and have found a high incidence of diabetes."

The tests have shown that 10% of the tested Greenlanders over the age of 35 have diabetes. This is at the same level, or higher, than in Denmark.

Thrombosis

"It is said that Greenlanders and Inuits do not suffer from cardiovascular diseases, but that is simply not so," says Peter Bjerregaard, surprisingly.

Looking at a list of cardiovascular diseases, there appears to be a very low incidence of cardiac thrombosis, but it is a different story altogether with the other forms of cardiovascular disease.

It is a bit complicated and becomes no less complicated when one looks at the historical picture.

Going slightly back in time, it seems to have been traditionally held in Canada and Greenland - all based anecdotally - that the incidence of cardiac thrombosis among Inuits is the same as in the rest of the population.

In Alaska, there used to be a different medical tradition, according to which almost no Inuits suffered from cardiac thrombosis. It is difficult at the present time to decide whether there is any real basis for either tradition. However, in the 1960s, the American tradition took over, and since then it has been said that there is a very low incidence of cardiac thrombosis. All the same, there is still nothing that substantiates this assertion.

Nowadays, few death certificates in Greenland give cardiac thrombosis as the cause of death. However, with the tradition of "knowing" that the incidence of cardiac thrombosis in Greenlanders is not very high, few doctors want to put that cause of death on a death certificate. There is a self-reducing effect at work.

The uncertainty concerning death certificates in Greenland probably has just as much to do with the fact that a post-mortem examination is not normally carried out, even in the large towns. Only in cases of murder or manslaughter is one carried out for forensic reasons. All in all, a post-mortem examination is only performed in a few per cent of cases, so the main cause of death is more or less a guess.

In short, we do not know with any certainty the extent to which cardiovascular diseases have been the cause of death.

Taking all cardiovascular diseases - in other words, not just cardiac thrombosis - we find a higher incidence among Inuits than among the populations of western Europe and the USA. There is a high incidence of cerebral thrombosis or cerebral haemorrhage, which display largely the same symptoms. There is also a high incidence of what are together called "other cardiac diseases". However, it does seem that there is a low incidence of cardiac thrombosis among Greenlanders, even though that has not been definitively proven.

Lifestyle and health

In the lifestyle studies in which Peter Bjerregaard has participated, people were asked for their own evaluation of their state of health. They were asked about illnesses and symptoms within the last 14 days, about tobacco, alcohol and cannabis, about the indoor climate, work, and occupational health and safety problems. In fact, they were asked about every conceivable thing.

Peter Bjerregaard says, "One of the most remarkable results was that hunters and people living in the settlements, who, with our rose-coloured glasses, we might imagine had a good life, actually described their own lives as worse than those of the town dwellers. They said that their health was poor and that they suffered from rheumatism and other problems with their arms, legs and back."

One sees the same picture in Denmark when comparing life in rural areas with urban life.

In stark figures, the study shows that there are an unreasonably high number of smokers in Greenland, but that smokers in Greenland smoke less than smokers in Denmark. There are fewer heavy smokers in Greenland, but a larger proportion of the population smokes. In the 1990s, around 80% of the population smoked. There are no social differences between smokers and nonsmokers.

According to the statistics, people in Greenland used to drink, on average, twice as much as people in Denmark, but alcohol consumption has now fallen considerably and is now only slightly higher than the average consumption in Denmark.

Peter Bjerregaard offers this explanation for the reduction: "It was always Danes that drank most in Greenland. So one of the reasons why alcohol consumption has fallen in Greenland is that fewer Danes are stationed there now. However, more important still is the fact that attitudes are changing in the population."

There are social differences in the pattern of drinking in Greenland. However, it is a little difficult to describe the pattern because the drinking is so spasmodic - perhaps every fortnight in the case of those paid fortnightly and perhaps every month in the case of those paid monthly. The usual methods of recording alcohol consumption in Denmark and other countries are of no use because it is not so much the average consumption over a year that is interesting, but the extremely episodic drinking.

Besides that, the answers given are very unreliable.

Another myth well and truly holed by Peter Bjerregaard is that the many alcohol problems and high alcohol consumption are caused by certain enzymatic factors and are thus genetically determined. In other words, it is supposed that Greenlanders become inebriated more quickly because they do not have the same alcohol-catabolising enzymes in the liver as, for example, Danes. There is no scientific support for this.

Quality of life

In comparisons of public health around the world, the main indicators are infant mortality and life expectancy.

Infant mortality in Greenland is high. The trend lies parallel with the corresponding Danish trend 30 years ago, displaying a handsome fall. So, infant mortality in Greenland corresponds to that in Denmark 30 years ago. In Greenland 30 years ago, it corresponded to the situation in Denmark 60 years ago.

Average life expectancy in Greenland has always been lower than in Denmark. That is because there has always been a higher proportion of accidents in Greenland than in Denmark - and in the last 30-40 years also a higher suicide rate, particularly among young people in the 15-24 year age group.

It might be thought that there would be more suicides in the wintertime, but that is not the case. Researchers have been very much on the lookout for a correlation between winter darkness and the number of suicides, but nothing at all indicates that there is one.

There is, on the other hand, a clear relationship between winter darkness and the number of hours spent in front of the television. In Greenland, people spend an incredible amount of time watching television in the wintertime, but watch it hardly at all in the summertime.

Average life expectancy in Greenland is 62 years for men and 68 years for women. For comparison, the corresponding figures for the Faroe Islands are 73 years and 80 years, respectively.

One can also record "lost good years of life", i.e. how many good years of life a 50-yearold can expect, but that easily becomes so refined that the message is difficult to understand.

There is some inherent uncertainty about what "self-assessed state of health" measures. The fact that the questions and answers are given in Greenlandic and that other factors than health are included in the assessment of quality of life does not make things any easier. As Peter Bjerregaard wryly points out, "These difficulties go some way to explaining why the preventive function in Greenland is nothing to write home about."

Public health through half a century

Until 50 years ago, the threats to health were: tuberculosis, polio, typhoid and other infectious diseases. There were also many accidents.

Then came the first period of modernisation. In the course of the 1950s, tuberculosis disappeared and the incidence of infectious diseases fell considerably (although it was in this period that the measles epidemic took hold). In this period, alcohol problems and suicides were rising.

Now - in the third period - it is lifestyle diseases that are appearing.

It is thus on these chronic diseases that researchers must concentrate in future. What does that mean in practice?

Peter Bjerregaard replies, "It means studying in detail why lifestyle diseases are beginning to appear. We know perfectly well, of course, that it is obesity, smoking and dietary habits that are triggering these diseases, but we want to try to go a step further back and look at why it is happening."

The best way of investigating this would be to seek out Greenlanders that have moved to Denmark and compare them with Greenlanders living in towns and settlements in Greenland. If one went back to the same people after 10-15 years, one would be able to describe causes for an unfortunate trend.

However, going back to the beginning, I ask whether it is not the National Institute of Public Health, rather than any other body, that must take on the role of watchdog, ready to raise the alarm when environmental impacts threaten public health in the Arctic.

"Yes, it is indeed," says Peter Bjerregaard. "The high level of heavy metals and POPs alone is a danger signal. Although that cannot be related to any specific disease, it is an undesirable situation. It cannot be healthy."

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