ARCTIC HEALTH WORKSHOP
17-18 April 2013
Venue: Lakeside Lecture Theatres, Wilhelm Meyers Allé, 8000 Aarhus C
Merete Barker Aud. (bldg. 1253, room 211)
DAY 1
9.00 – 9.30
REGISTRATION + COFFEE AND ROLLS
9:30 – 9:40
Allan Flyvbjerg, Dean of Faculty of Health, Aarhus University
Welcome
Jesper Madsen, Aarhus University
Introduction to Arctic Research Centre (ARC)
Eva C. Bonefeld-Jørgensen, Aarhus University
Background & purpose of the Arctic Health Workshop + Introduction to Day 1
9:40 – 9:50
9:50 – 10:00
10:00 – 10:15
10:15 – 10:30
10:30 – 10:45
10:45 – 11:00
11:00 – 11:15
11.15 – 11.30
11.30 – 12:00
Peter Bjerregaard, National Institute of Public Health
New wine into old bottles? Circumpolar research and international cooperation
in the 21st century. Focus on cohort studies among the Inuit
Jon Øyvind Odland, University of Tromsø
Cohorts and health in the Arctic
Pál Weihe, University of Southern Denmark
Faroese Health Research: past, present and future challenges and perspectives
Jørn Olsen, Aarhus University*
Pregnancy cohorts starting before conception, why is the Arctic area of interest?
Gunnar Toft, Aarhus University
CLEAR – Climate change, environmental contaminants and reproductive health
Eva C. Bonefeld-Jørgensen, Aarhus University
Cohort establishment, time trends, impact of environmental and life style and
breast cancer in Greenland
Chair:
Eva C. Bonefeld-Jørgensen
THEME: COHORT STUDIES & REPRODUCTION
BREAK
12.00 – 12:15
12:15 – 12:30
12:30 – 12:45
12:45 – 13:00
13:00 – 14:00
Stig Andersen, Aarhus University*
Aspects of endocrinology in the Arctic
Michael Lynge, Queen Ingrid’s Hospital, Nuuk
Addressing challenges in chronic care in the primary health care system in
Greenland - diabetes as an example
Marit Eika Jørgensen, Steno Diabetes Center
Population research of diabetes in Greenland
Torsten Lauritzen, Aarhus University
Preventive health checks and Screening for diabetes. Interventions in general
practice with huge potential for improved health
LUNCH
Chair:
Jørn Olsen
THEME: ENDOCRINOLOGY – DIABETES
14.15 – 14.30
14:30 – 14:45
14:45 – 15:00
15:00 – 15:15
Ann Birkekær Kjeldsen, Government of Greenland
Health research, health policy and research policy
Birgit Niclasen, Government of Greenland
Cooperation, communication and implementation of health research
Flemming Kleist Stenz, Government of Greenland*
Chief Medical Officer, the National Board of Health, Greenland
Lise Hounsgaard, University of Greenland & University of Southern Denmark
Suzanne Møller, University of Greenland
Activities at Institute of Nursing and Health Sciences, Ilisimatusarfik / University
of Greenland
Gert Mulvad, Centre for Primary Health Care, Nuuk
Improving knowledge, improving access to quality and sustainable health care in
Arctic communities
15:15 – 15:45
BREAK
15:45 – 16:00
Kue Young, University of Toronto
Are we getting value for money in our health care? The Circumpolar Health
Systems Review
16:00 – 16:30
DISCUSSION
16:30 – 16:45
Eva C. Bonefeld-Jørgensen, Aarhus University
Wrap-up of Day 1
18:00 –
DINNER AT RESTAURANT 16|SECHZEHN, EUROPAPLADS 16, 8000 AARHUS C
Chair:
Peter
Bjerregaard
14:00 – 14:15
Chair:
Stig Andersen
THEME: HEALTH RESEARCH & ORGANIZATION IN THE ARCTIC
DAY 2
9.00 – 9.30
COFFEE AND ROLLS
9:30 – 9:45
Eva C. Bonefeld-Jørgensen, Aarhus University
Introduction to Day 2
9:45 – 10:00
10:00 – 10:15
10:15 – 10:30
10:30 – 11:00
Patricia Martens, University of Manitoba
Seeing the big picture of northern health and healthcare of Metis and First
Nations people in Manitoba: do healthcare patterns reflect underlying need
Rachel Eni, University of Manitoba
Manitoba First Nations Strengthening Families Maternal Child Health Program
Design and Evaluation
Niels Ebbehøj, Bispebjerg Hospital*
Environmental and Occupational Medicine in Greenland
BREAK
Chair:
Torsten Lauritzen
THEME: HEALTH PROGRAMS IN MANITOBA & GREENLAND
11:00 – 11:15
11:15 – 11:30
11:30 – 11:45
11:45 – 12:00
12:00 – 12:15
12:15 – 12:30
12:30 – 13:30
Preben Homøe, University of Copenhagen
Middle-ear problems and head and neck cancer in Greenland/the Arctic
Anders Koch, Statens Serum Institut
Infectious diseases in the Arctic and international comparisons
Karin Ladefoged, Queen Ingrid’s Hospital, Nuuk*
The HIV epidemic in Greenland
Christian Wejse, Aarhus University
Lars Østergaard, Aarhus University
Clinical impact of real-time quality assurance of HIV, chronic hepatitis B, and
tuberculosis in Greenland
Mogens Kilian, Aarhus University
Microbiota in the gastrointestinal canal, upper respiratory tract and skin plays a
role in heath
Jens Christian Jensenius, Aarhus University
The innate immune defence: role in infections and significant ethnic genetic
differences
Chair:
Pál Weihe
THEME: INFECTIOUS DISEASES IN THE ARCTIC
LUNCH
13:30 – 13:45
13:45 – 14.00
Arja Rautio, University of Oulu*
The ArcRISK project
Christian Sonne, Aarhus University
14:25 – 14:30
Rune Dietz, Aarhus University
How wildlife studies can be used as risk model for human health in the Arctic
Karen Wistoft, Aarhus University
The Real Care Doll Project: evaluation of sex and parent education in secondary
school and
The Resilience project: design of cognitive mental health promotion among
children and adolescents
Introduction to plenum for new ideas and project contacts
14:30 – 15:00
BREAK
15.00 – 15.30
15:35 – 16:00
16:00 – 16:10
Mixing and new project contacts
Plenum: presentation of new project ideas
Eva C. Bonefeld-Jørgensen, Aarhus University
Wrap-up of Day 2 and closing remarks
14:00 – 14:25
*) moderator of the thematic group
Chair:
Christian Wejse
THEME: ENVIRONMENTAL IMPACTS & HEALTH; THE YOUNG ARCTIC POPULATION;
ABSTRACTS
Peter Bjerregaard, National Institute of Public Health
New wine into old bottles? Circumpolar research and international cooperation in the 21st century. Focus on cohort
studies among the Inuit
Circumpolar health research has moved a long way since the last century and it would not be appropriate to liken the situation with the
Biblical parable about putting new wine into old bottles. I shall highlight two important developments, one organizational and one of some
importance for practical research. While the International Union for Circumpolar Health has existed as a union of national societies since
1986, with Greenland/Denmark as a separate member since 2000, and the International Journal of Circumpolar Health has been in existence
under different names since 1972, 2012 saw a new development. A membership based network of circumpolar health researchers came to
life with the following goals: 1) to publish the Journal of Circumpolar Health Research; 2) to facilitate networking among members between
the triennial congresses; and 3) to recruit, train and support the next generation of researchers.
The network members have of course been networking before. Since the 1990s some of us have worked together on population health
surveys among the Inuit in Greenland and Canada, and to a more limited extent in Alaska too. During 2004-2010, the Inuit Health in
Transition study has collected information from 6750 adult Inuit in 72 communities across the Arctic from Kuummiut in East Greenland to
Aklavik in the Inuvialuit Settlement Region (Northwest Territories, Canada). The study has a broad focus ranging from child sexual abuse,
alcohol, and suicides to diabetes, environmental health and genetics. A follow up of the cohort in national disease and mortality registers
and by repeated interviews and clinical examinations is underway in both countries.
Jon Øyvind Odland, University of Tromsø
Cohorts and health in the Arctic
In 2007, the Intergovernmental Panel on Climate Change presented a report on global warming and the impact on human activities and
health. One specific focus should be on environmental contaminants and their changing behaviour with temperature change and thus
change of human exposure, which will occur to mostly in the circumpolar areas because of the well documented long range transportation of
contaminants as well as local sources. The most sensitive group of people is pregnant women and their fetuses. Considering that the first
trimester of pregnancy is a particular sensitive time period for the effects of environmental exposure, this presentation will focus on the
impacts on the maternal and newborn health. Food security is a crucial issue for the pregnant population in a changing climate. Available
food without environmental contamination can be provided through monitoring of hazardous substances in food. Very good results have
been reached through dietary advice for vulnerable people; young people and pregnant women through public health activities. The
negative health effects of prenatal exposure to contaminants seems to be modified and reduced by intake of specific dietary items during
pregnancy, clearly emphasizing the need for healthy food during pregnancy. The perspective for the next generations will be a change in
exposure patterns; decrease in organic substance exposure through global collaboration, but increased exposure to Mercury because of
increased emissions and increased biological availability. The brain development is ongoing throughout the pregnancy, leading to harmful
effects from, e.g., Mercury and Lead. As a consequence of this a systematic implementation of mother-child cohorts to discover harmful
effects on children is highly warranted. As the latest reports on trends in biological levels of POPs are promising, the scenario for the next
generations is worrying. Effects on the foetus might be prevented through detailed trend studies connected to good dietary advice for the
pregnant women. The security for the unborn child must have top priority to the interest of all people.
The ongoing circumpolar mother/child cohorts will lead to improved knowledge and public health advisories to reduce the risk of
adverse health effects for the coming generations all over the world, but especially in the Arctic. The biomonitoring programs have resulted
in public health interventions and dietary advice for the vulnerable groups. The sparsely populated areas where the studies are implemented
create special ethical challenges to avoid research fatigue in the small population groups under surveillance. The research teams have a
special responsibility to create communication strategies in close cooperation with the local authorities and build all research into a cultural
context. The presentation will give more details from the different ongoing studies, showing differences in focus, but with a common core for
compatibility and strategic planning.
Pál Weihe, University of Southern Denmark
Faroese Health Research: past, present and future challenges and perspectives
Health research in the Faroes may be of interest for the arctic region because of the relative high exposure to marine contaminants in sea
mammals. The exposure levels in the past have been in the higher end of the exposure levels in the circumpolar areas with respect to
methylmercury and persistent organic pollutants. On the other hand the Faroese society is comparable with the Scandinavia with respect to
living standard, education, health services and infrastructure. The general health standard is high with low perinatal mortality and high life
expectancy. Self destructive behavior is rare and alcohol consumption low, but tobacco smoking relative common. These settings offered
favorable epidemiological conditions to investigate the negative impact on human health of prenatal as well as postnatal exposure to marine
contaminants. Cohort studies have been established from 1986 to 2009 and the cohort participant have been continuously assessed since.
The main emphasis has been on the central nervous system. However, the immune system, the cardiovascular system, and the reproductive
system have lately been scrutinized as well. These results have been the basis for recommending the Faroese public to give up the traditional
consumption of pilot whale meat and blubber. These recommendations have been highly successful, since the exposure in pregnant women
is reduced with a factor 5 since the mid eighties – nevertheless the exposure levels in marine food are unchanged.
The present research activities include the impact of contaminants on type 2 diabetes; gene environment interaction in Parkinson’s
disease, vitamin D insufficiency and autism, the sources of perflourinated compounds in the general population and the impact of these
substances on the immune system. For the time being the Faroese health care system is creating a genetic biobank where all Faroese will be
invited to deliver blood sample for whole genome sequencing. This facility is intended to have a double function: a research facility open to
all with a project and a clinical facility for individual patient inquiry. The perspectives in environmental medicine are a far better opportunity
to study the gene-environment interaction, e.g. vulnerability to methylmercury exposure.
Jørn Olsen, Aarhus University
Pregnancy cohorts starting before conception, why is the Arctic area of interest?
The time period of fetal development is a high risk time period and unsuccessful adaption to the expected extrauterine environment may
have long lasting health consequences. This adaption probably starts before conception and the early phase of implantation may be of
particular importance. For these reasons many countries have established cohort with the aim of being able to study diseases in a life course
perspective. Most of these cohorts have been established in affluent countries with rather similar living conditions.
Greenland would offer a setting of particular high interest for this kind of research due to the special living conditions and the poor
health indicators. Furthermore, Greenland takes part in some of the Danish health monitoring systems that will permit studies with long
follow up time. Many of the early life exposures of special interest are more frequent in Greenland than in Denmark, such as infections,
social unrest and environmental exposures related to diet. Some of these exposures may also affect the biological capacity to reproduce.
For that reason a cohort should start at the time period of pregnancy planning if possible.
Gunnar Toft, Aarhus University
CLEAR – Climate change, environmental contaminants and reproductive health
This research project investigates the possible impact of global climate change on reproductive health in one Arctic and two European
populations. The key questions addressed are, first, how may climate change impact on human exposure to widespread environmental
contaminants and, second, how may contaminants impact on occurrence of reproductive disorders as sensitive indicators of health. The first
question involved identification and description of mechanisms by which a changing climate may affect the exposure of Arctic and other
human populations to contaminants through change in chemical use and emissions, delivery to the arctic ecosystem as well as processing
within the arctic physical environment and human food chain. This work relied on modelling of existing data.
To evaluate the effects of exposure on male and female reproductive health and child development, we first analyzed polybrominated
diphenylethers, perfluorinated surfactants, phthalates, bishohenol A and heavy metals in 1600 biobanked serum samples from Greenland,
Poland and Ukraine. We have initiated studies relating these exposure measurements to male and female reproductive health. Additionally,
a follow up study on child health and development was conducted on the cohort of about 1200 mother child pairs, and data are currently
analyzed. To study if specific genetic variants are more sensitive towards environmental exposures, polymorphisms in a number of male and
child genes have been evaluated. Additionally, the global methylation pattern of sperm cells was determined to evaluate if environmental
exposures could induce epigenetic effects.
Eva C. Bonefeld-Jørgensen, Aarhus University
Cohort establishment, time trends, impact of environmental and life style and breast cancer in Greenland
ACCEPT Cohort establishment: The fetal development and the early childhood is the most sensitive period being vulnerable to environmental
exposures with negative influences on e.g. central nervous system, the immune and reproductive system but the health effects may first
become manifested later in life.
The overall aims of the ACCEPT project are to establish a representative and prospective Greenlandic mother-child cohort compatible with
other circumpolar and international child cohorts as a surveillance system and to support a healthy environment for the next generation. The
specific aims are to prospectively detect and explore causative relations between health risks, life style, environmental contaminants and
climate change. To identify changes and trends in life style and contaminant related health effects in the Greenlandic population based upon
the existing knowledge obtained from cross-sectional monitoring and bio-effect programmes. To give formalised and continued information
on environmental health issues to the local communities in Greenland. To compare contaminant related health effects between populations
on a global scale with regard to differences in exposure patterns, genetics, and life style factors being feasible because the ACCEPT project is
a part of an international network of cohort studies, carried out with identical protocols. The presentation will give more details on the
ongoing study.
Breast cancer in Greenland: Breast cancer (BC) is the most common cancer for women in the western world. From very few cases an
extraordinary increase in BC was observed in the Inuit population of Greenland and Canada although still lower than in western populations.
Previous data suggest that exposure to persistent organic pollutants (POPs) might contribute to the risk of BC. Rat studies showed that
perfluorinated compounds (PFCs) cause significantly increase in mammary fibroadenomas.
Thirty-one BC cases and 115 controls were sampled during 2000-2003 from various Greenlandic districts. For the very first time a significant
association between PFC serum levels and the risk of BC in Greenlandic Inuit women was observed. The BC cases showed also a significantly
higher concentration of polychlorinated biphenyls at the highest quartile, and a POP related hormone disruption of the estrogen- and
androgen receptor function. In conclusion, the level of serum POPs, particularly PFCs, might be risk factors in the development of BC in Inuit
and hormone disruption by the combined serum POP may contribute to the risk of developing breast cancer in Inuit. The study is on-going to
improve the statistically power and further document the study conclusions.
Stig Andersen, Aarhus University
Aspects of endocrinology in the Arctic
Arctic Health Research Centre focuses on a line of areas that include monitoring of iodine nutrition, vitamin D status, skeletal health, obesity,
body build, and cold adaption, with further areas in progress. Iodine nutrition is a major determinant of the occurrence of thyroid disorders
in a population and both high and low intakes associate with an increased risk of disease. Marine diet is rich in iodine and monitoring of
iodine intake in Greenland demonstrates a decrease in iodine intake in parallel with the lowering of the intake of local foods from sufficient
to mild iodine deficiency. Monitoring of iodine intake is ongoing. Vitamin D status in a population depends on exposure to sunlight and diet.
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Some vitamin D production was demonstrated during spring and summer around 70 N though insufficient to uphold the recommended
vitamin D level during autumn and winter. The traditional Inuit diet was demonstrated to provide a vitamin D level within the recommended
range while vitamin D insufficiency prevailed with a high intake of imported foods. This may compromise skeletal health.
Bone mineral density (BMD) differs between Caucasians and some ethnic groups. Yet, we found similar BMD in Inuit and Caucasians
when adjusting for body size. This suggests similar fracture risks. Also, risk factors for fragility fractures were common in Inuit and associated
with the risk of osteoporotic fractures. Furthermore, a review of three months consecutive lateral chest radiographs demonstrated a pattern
of vertebral deformities similar to those in Caucasians. Bone development and limb length is influenced by temperature. Arctic habitat may
influence body build in man. Hence, sitting-height/height ratio, analysis of the difference in the lipids-BMI-association between Inuit and
Caucasians, and the distribution of BMI in young, healthy Inuit men support a 10% higher BMI in Inuit compared to non-Inuit.
Arctic habitat requires adaption to cold environment. Recently, the presence of brown adipose tissue was demonstrated in adult man.
It’s activation depends on sympathetic activity in complex interaction with thyroid hormones and we found high thyroid activity in cold
exposed Inuit, i.e. hunters and settlement dwellers. This needs further elaboration. The first comprehensive population based investigation
in Greenland was performed form 1962 through 1964. Some of these data were donated to Greenland and further evaluation form the basis
for unique observations and comparisons that are in progress. In conclusion, a number of areas are covered and further surveys and
evaluation are underway.
Michael Lynge, Queen Ingrid’s Hospital, Nuuk
Addressing challenges in chronic care in the primary health care system in Greenland – diabetes as an example
Fifty years ago diabetes mellitus and other chronic lifestyle related conditions were very rare in Greenland. This has changed along with
profound change in life conditions from a traditional Inuit culture to a more westernized society. The primary health care system in
Greenland faces many challenges in the management of chronic conditions: A geographically wide spread population, very small health care
units without specialists and lack of educated health care workers and others. On the other hand, the health care system has some
advantages. The population is small and the number of patients limited, the health care system in Greenland is united and all primary health
care centers use the same electronic record. Furthermore, heath care service is free to everyone (including free medicine) and the special
challenges have made the system adaptable and flexible for new solutions.
In 2008 a national diabetes programme was implemented aiming to improve the care for patients with type 2 diabetes mellitus in
Greenland. A diabetes concept based on national guidelines, systematized recording in an electronic medical record and feedback to the
clinics was used to improve the diabetes care. Along with an increasing prevalence of diagnosed type 2 diabetes mellitus the quality of
diabetes care improved from 2008 to 2010. The diabetes programme has now been replaced by a lifestyle programme aiming to maintain
the quality achieved in diabetes care, to establish organizations for care for hypertension and chronic obstructive lung disease finally to
develop health care events.
Marit Eika Jørgensen, Steno Diabetes Center
Population research of diabetes in Greenland
Type 2 diabetes is a common and serious global health problem, which, for most countries, has evolved in association with rapid cultural and
social changes, ageing populations, increasing urbanization, dietary changes, reduced physical activity and other unhealthy lifestyle and
behavioural patterns. It is recognized that it is the low- and middle income countries that face the greatest burden of diabetes and the
largest increases will take place in the regions dominated by developing economies.
While studies of the Inuit before the 1980s found a low prevalence of diabetes compared with Danish subjects and other Western
populations, recent studies of diabetes among Greenland Inuit found a notably high prevalence of diabetes (10%) and pre-diabetic stages
(20%). Contrary to most studies of the influence of urbanisation on glucose intolerance, our results indicate that the urbanisation process
among the Greenland Inuit has not been accompanied by an increase in the proportion of people with glucose intolerance.
The highest prevalence of diabetes is found in villages and small towns compared to towns in spite of lower physical activity level in the
towns. Diet, exposure to persistent organic pollutants, low birth weight and socio-economic factors may potentially explain the inverse
association with westernisation.
The presentation will give an overview of diabetes research in Greenland over the last 15 years.
Torsten Lauritzen, Aarhus University
Preventive health checks and Screening for diabetes. Interventions in general practice with huge potential for
improved health
The Ebeltoft Health Promotion study took place in 1991 and was a five year randomized controlled trial including healthy people 30 to 50
years of age. The project showed a big interest for participation (85% participated within 5 years) many of which were at risk of
cardiovascular disease. The number of people at moderate to high risk of cardiovascular was reduced by approximately 50% at 5 year in the
intervention groups compared to the control group. No measurable psychological side effects could be demonstrated. There was no increase
in health care utilization in the intervention groups. The study indicated an increase in estimated life-time without extra cost when
comparing the intervention groups with the control group. Further details can be found at www.sundhedsprojekt-ebeltoft.dk.
Anglo-Danish-Dutch study of intensive treatment of people with screen detected type 2 diabetes in primary care (The ADDITION study)
screened 395.928 people in the age of 40-69 years. For each person identified with diabetes 2 were identified with high risk of diabetes and
further 6 with high risk of cardiovascular disease without diabetes. Cardiovascular risk factors improved substantially in people with diabetes
and a non-significant 17% reduction in the first cardiovascular event was seen when comparing intensive treatment with routine care.
Simulation modelling demonstrated an approximately 50% significant reduction in the first cardiovascular when comparing intensive
treatment and routine care with “no intervention”. All-cause mortality near normalized in individuals at highest risk at screening, i.e. those
with diabetes and HbA1c≥6.5% at time of screening.
Conclusion: Preventive health checks and screening for diabetes and cardiovascular risk in general practice offers a huge potential for
improved health.
Ann Birkekær Kjeldsen, Government of Greenland
Health research, health policy and research policy
TBA
Birgit Niclasen, Government of Greenland
Cooperation, communication and implementation of health research
The presentation starts given a story that changed life's. The story is about Cholestasis Familiaris Groenlandica (CFG) and the background for
its success is discussed. Thereafter health research priorities and needs in Greenland (and the Arctic) are discussed with special focus on child
health and child public health seen with the eyes of a researcher and public servant. Making research outside one’s own social and cultural
context always raises ethical questions not least when researching among and with indigenous populations. WHO’s guidelines are
highlighted. At last the shared needs for cooperations – also regarding presentation of findings and implementation of the result are
discussed.
Flemming Kleist Stenz, Government of Greenland
Chief Medical Officer, the National Board of Health, Greenland
Greenland has by historical, legal, cultural and traditional reasons been related to Denmark and Scandinavia, and focus regarding Health
Services has naturally been directed that way. The way to run health care, health expenditures, health statistics, immunisation programs, etc.
has been aligned with or measured by Danish/Nordic standard. This has rarely been in favour of Greenland, on the contrary, it has often led
to Greenland differing significantly from the other Nordic Countries. Since the late nineties, the National Board of Health and the Health
Services began to focus on the Arctic regions, and there has then been a significant exchange of knowledge, developed cooperation projects
and established surveillance projects.
Lise Hounsgaard, University of Greenland & University of Southern Denmark
Suzanne Møller, University of Greenland
Activities at Institute of Nursing and Health Sciences, Ilisimatusarfik / University of Greenland
Educations in the institute
 Four year nursing program (Bachelor of Science in Nursing)
 Postgraduate diploma program in Arctic Specialized Nursing
 Program in Clinical Supervision
 PhD program
Scientific work and research
 The nature of nursing practice in rural and remote in Greenland
 Women's perspectives on illness in being screened for cervical cancer
 Everyday Life with Illness
 Empowering social work through action research
Network and collaborators
 National and international
Gert Mulvad, Centre for Primary Health Care, Nuuk
Improving knowledge, improving access to quality and sustainable health care in Arctic communities
Organization and logistic related to actual health problem and their possible solution present great challenges faced by the public health
system in the Arctic, some of these challenges will require more emphasis on research and education for health care professionals in order to
set proper priorities. The increasing demand for health services in all areas and especially in mental health and addictions, aging populations,
significantly poorer health and social outcomes among Aboriginal northerners; managing the health effects of rapid economic and
environmental change in the North; and managing the rapid growth in health care expenditures. The many social determinants of health
(e.g. housing, education, employment, etc.), which ones have the most significant impact on improving health outcomes and access to care,
and what strategies are needed to address them?
Improving local knowledge during research and education, based on local capacity building in Greenland Center of Health Research at
Ilisimatusarfik, University of Greenland and in collaboration with Greenland Institute of Natural Resources, other Arctic Universities and
network like Arctic Research Centre, ARC. Health research project based on improving the quality of health care, and health research project
related to education on health care professionals’ will be described. Using the electronic health care data as a study base, include child
cohort, surveillance system as examples.
Kue Young, University of Toronto
Are we getting value for money in our health care? The Circumpolar Health Systems Review
Health care for remote communities face serious organization, financial, logistical, technical and human resources challenges. Circumpolar
countries and regions have evolved different health systems and policies. Despite considerable health care resources devoted to northern
health care, substantial disparities still exist in many regions, between North and South, and between indigenous and non-indigenous
populations. Identifying, evaluating and comparing approaches, models, and best practices may lead to development of strategies to
strengthen northern health care. An international team of health system researchers was assembled in 2010-11 to review and compare the
northern health systems of the Arctic States. The findings of this review provide descriptive statistical and narrative background information.
The next step is to move towards an evaluative framework in health system performance, developing and testing metrics that are adapted
for northern conditions, especially those that are culturally relevant to indigenous populations
Patricia Martens, University of Manitoba
Seeing the big picture of northern health and healthcare of Metis and First Nations people in Manitoba: do
healthcare patterns reflect underlying need
The Manitoba Centre for Health Policy (MCHP) is a world-renowned research unit in the Faculty of Medicine at the University of Manitoba,
Canada. The Repository of data housed at MCHP links health and social services databases for the entire population of Manitoba (~1.2
million people), de-identified yet linkable at the person-level, geocoded and longitudinal (30+ years). These data have proven extremely
helpful to Aboriginal planners and policy makers in understanding health status and the health care use patterns. Dr. Patricia Martens,
Director of MCHP and a professor in the Faculty of Medicine, has collaborated with the Assembly of Manitoba Chiefs (in First Nations
research projects) and with the Manitoba Metis Federation (in Metis research projects) to produce beneficial “atlases” used by Aboriginal
policy-makers, planners and knowledge networks. This session will include a description of the Repository, the collaborations and
knowledge translation models of MCHP, as well as key findings from various research projects and implications in the provision of healthcare
service models to northern remote communities.
Rachel Eni, University of Manitoba
Manitoba First Nations Strengthening Families Maternal Child Health Program Design and Evaluation
The presentation describes the development, implementation and evaluation of the Manitoba First Nation Strengthening Families Maternal
Child Health Program. Program linkages within and between communities and inter-jurisdictional partnerships are highlighted. The linkages
and partnerships reveal a potential for health change. Over the course of programming development and implementation, obstacles and
successes have been noted, for example, the negotiation of conflicting interests between institutions/agencies in the partnership. Program
impacts are theorized and strategies for their empirical measurement are in the process of construction. Partnership issues are central to
success of health promotion programming. Further work in this area is encouraged.
Niels Ebbehøj, Bispebjerg Hospital
Environmental and Occupational Medicine in Greenland
TBA
Preben Homøe, University of Copenhagen
Middle-ear problems and head and neck cancer in Greenland/the Arctic
We have since many years known about a different pattern of otitis media in the Arctic region. The pattern is only a matter for the Inuit
population. This has triggered a long line of studies including, population surveys, longitudinal prospective population-based cohort studies
and recently long-term follow studies of infectious middle ear diseases in Greenland. Until now this has resulted in five dissertations
concerning the subject. The studies have been undertaken as single projects but also as collaboration projects between the Department of
Otolaryngology, Head Neck Surgery and Audiology at Rigshospitalet, the Department of Epidemiology Research, Statens Serum Institut and
the National Institute of Public Health, University of Southern Denmark, Section for Arctic Public Health Research. Cohort information will be
given along with some of the most important results which all have been published in internationally recognized scientific papers and at
meeting in the Danish/Greenlandic Society for Circumpolar Health where we all meet on a regular basis and exchange ideas and research
results. Also research on microbiological and immunological aspects of middle ear infections has been part of the mentioned cohort studies.
Furthermore, several cancer diseases show a very special epidemiological pattern in Inuits in the Arctic. As some of these belong to the
otorhinolaryngological specialty like cancers of the salivary glands and the nasopharynx we have also performed epidemiological and clinical
studies concerning these diseases. The very latest study was a study of human papilloma virus in oropharyngeal cancers in Greenlanders.
These studies are mainly a result of registry compilations and tissue specimen examinations as almost all Greenlanders with head and neck
cancers have been and still are treated at Rigshospitalet.
Anders Koch, Statens Serum Institut
Infectious diseases in the Arctic and international comparisons
The pattern of infectious diseases in the Arctic is characterized by a number of highly prevalent diseases with particular epidemiological
characteristics. Diseases like respiratory tract infections, otitis media, tuberculosis, sexually transmitted diseases, invasive pneumococcal
disease, hepatitis B infection, and certain viral associated cancers (nasopharyngeal carcinoma and cervical cancer) are very frequent. In
Greenland the incidence of TB is increasing in spite of a number of public health measures and is unrelated to HIV that in Greenland is
characterized by mainly occurring among heterosexually infected mid-aged persons. Chronic hepatitis B infection is frequent in Arctic
regions, yet appears to cause relatively lower morbidity than in other high incidence countries.
Greenland has unique possibilities for infectious disease research. The Department of Epidemiology Research at Statens Serum Institut
has since the 1990ies carried out infectious disease epidemiology studies in Greenland, mainly based on field work. Biological samples
collected through these studies are stored at Statens Serum Institut and comprise a biobank that has been used for a number of scientific
studies and forms a particularly valuable research resource for the future. In addition, the Department has used a number of health registers
for nation-wide studies of infectious and other diseases besides validated the Greenland Inpatient Register.
The Greenland population is small and the health system is often understaffed and overburdened. Care must therefore be taken to
assure goodwill both from the population and the health system when doing scientific studies in Greenland. To ensure this much of the
Department’s work has been carried out in collaboration with external partners. Particularly close collaborations have been established with
the Department of Otolaryngology, Head Neck Surgery and Audiology at Rigshospitalet, and the National Institute of Public Health, University
of Southern Denmark, Department for Arctic Public Health Research.
Knowledge of circumpolar health and research is shared in international foci. The International Union for Circumpolar Health (IUCH,
http://iuch.net/) is an international non-governmental organization with members, adhering bodies and affiliates throughout the
circumpolar region. Every third year the IUCH organizes circumpolar health conferences in different parts of the circumpolar world. For
infectious diseases four international circumpolar working groups hold annual meetings in September, most often in Copenhagen. All
interested persons are welcome (www.arcticinfdis.com).
Karin Ladefoged, Queen Ingrid’s Hospital, Nuuk
The HIV epidemic in Greenland
Since the first HIV case was identified in 1985, HIV has been introduced in Greenland at least 9 times, but only one of these introductions
gave rise to an epidemic accounting for 76% of the cases. The incidence of sexually transmitted diseases was high in Greenland and an
uncontrolled epidemic was feared. However, the HIV incidence has remained relatively low (8-10 per 100.000 per year) with a slight decline
in recent years. Until September 2011 a total of 171 HIV infected adults, 112 males and 59 females, have been reported. Seventy-four per
cent were infected through heterosexual contact, 18% through homosexual contact and 2% through intravenous drug abuse. Six per cent
had other or unknown routes of transmission. Most patients were middle-aged at the time of diagnosis (median 46, range 20-82 years)
reflecting late infection rather than late diagnosis. Most patients lived in the two main cities Nuuk and Sisimiut and most were infected
locally. Treatment of HIV in Greenland commenced later and was implemented at a slower pace with a lower therapeutic effectiveness than
in Denmark. Compliance has been a big problem poor compliance being related to young age and living in districts outside Nuuk. However,
considerable improvements have been observed in recent years. AIDS related deaths have declined and median age at death has increased
in HIV patients.
Conclusion: The HIV epidemic in Greenland is apparently under control but it is a continuing challenge to avoid spread of the infection.
Although improved treatment outcome is still suboptimal mainly due to poor compliance.
Christian Wejse, Aarhus University
Lars Østergaard, Aarhus University
Clinical impact of real-time quality assurance of HIV, chronic hepatitis B, and tuberculosis in Greenland
Background: Quality assurance of health care management is important in order to provide optimal medical care. In a collaboration with the
Swedish provider of InfCare (Health Care Solutions), we have developed computer based systems that provides "real-time" quality assurance
database programs for control and treatment of HIV, chronic hepatitis B, and tuberculosis. which are existing in endemic proportions in
Greenland. A "real-time" quality assurance allows clinical outcomes for at patient level, in addition to overall clinic level, to be assessed on a
day-to-day basis. Such a system should provide better results compared with the conventional clinical quality database commonly hampered
by a considerable delay in data registration, causing inconsistence in data outcome analysis and reporting. However, the clinical impact of
real-time quality assurance has never been estimated.
Proposed study: In order to assess the clinical impact of real-time quality assurance at a patient level, we aim to assess this in a
randomized trial. We will allocate patients to InfCare monitored health care versus receiving health care by allready existing standard.. As
we have already introduced HIV-InfCare in in Greenland we will focus on patients with chronic hepatitis B and tuberculosis in the study.
Timely performed diagnostic procedures as well as clinical treatment endpoints will serve as outcome measures.
The presentation will focus on chronic hepatitis B and tuberculosis prevalence, the InfCare system, and the proposed research study on
the impact of real-time quality assurance.
Mogens Kilian, Aarhus University
Microbiota in the gastrointestinal canal, upper respiratory tract and skin plays a role in heath
Emerging insight at the molecular level supports the new paradigm that the human body and its commensal microbiota constitute a highly
integrated “superorganism”, which is the result of coevolution for millions of years. The benefits for both the microbiota and the host are
substantial and multifaceted and build on a state of mutual tolerance. In return for the shelter provided for the microbiota, the human host
benefits from the microbial synthesis of vitamins and other contributions to metabolic handling of the complex molecules found in our diet.
In addition, activation and fine-tuning of the reaction patterns of the immune system, and cell to cell cross-talk with multiple physiological
implications are part of this intimate relationship. Several recent studies suggest that obesity and many chronic inflammatory conditions,
including autoimmune diseases and allergies, are results of dysbiosis within the superorganism. Moreover, there are strong indications that
the long-term genetic diversification of both the human host and its microbiota has resulted in disease susceptibilities that may vary
considerably between different ethnic groups. The prospects for significant changes in the life style of the arctic population conceivably will
have a significant impact on their commensal microbiota and ensuing disease predilections.
Jens Christian Jensenius, Aarhus University
The innate immune defence: role in infections and significant ethnic genetic differences
A number of pattern recognition molecules (PRMs) participate in the defence against infections. In contrast to antibodies and T-cell antigen
receptors, the recognition structures of PRMs are genetically encoded and recognize so-called Pathogen Associated Molecular Patterns,
PAMPs, representing conserved structures on microorganisms. We are investigating the biological function and clinical role of soluble PRMs.
The PRMs comprise mannan-binding lectin (MBL) and the three ficolins, H-, L- and M-ficolin. Upon binding to ligands they activate
complement through sekvential activation of the associated enzymes, MASP-1 and MASP-2. Deficiencies of MBL have been found associated
with increased risk of infections, and are determined by mutations or allotypes, which differ in frequency among different ethnic groups.
Examination of the levels and the allotypes in Greenland may provide insights in the role of these proteins for infections among inuits.
Arja Rautio, University of Oulu
The ArcRISK project
Human health and wellbeing are the result of complex interactions between genetic, social and environmental factors. Global climate change
has the potential to remobilize toxic metals and other environmental contaminants, and also to alter contaminant transport pathways, fate
and routes of exposure in humans. The multidisciplinary ArcRisk project (FP-ENV-2008-1, 2009-2014) has its focus on human health, and aims
to determine how climate-mediated changes in the environmental fate of contaminants affect the exposure of human populations in the
Arctic and selected areas in Europe. The project coordinator is AMAP Secretariat, and there are altogether 20 partners from Denmark,
Norway, Sweden, Finland, Russia, Canada, Spain, Germany, Switzerland, Slovenia, the Czech Republic and United Kingdom.
The research group in the University of Oulu has focused on contaminant exposure – health outcome relationships based on
epidemiological and other published studies, reports and reviews. Putative relationships between exposure levels and health outcomes are
evaluated by using meta-analyses and other statistical methods aiming to estimate exposure levels (cut-off-points of exposure) beyond
which adverse health effects are more likely in the exposed populations. A search from article databases (Medline, Scopus, Web of Science)
constitutes an essential tool for the study. The effects of the exposure during pregnancy is the most important for the whole lifetime, hence
sex-ratio, birth weight and child development have been selected as primary health outcomes to be studied. In the review of PCBs and sexratio no correlation was found. Classical meta-analysis was impossible due to difficulties to harmonize studies according to statistical
standards. The main problems in having the evidence between the exposure of populations and the health outcomes are unhomogeneity of
sample populations, statistical methods used in ublications or the results are documented unclearly way. An analysis of the relationship
between birth weight of newborns and maternal PCB levels indicated a weak negative correlation. The review on dioxins and breast cancer
and child development and Hg are on-going. Our results show that the harmonization of the study protocols and more careful publishing will
be needed. Of the experimental part in the ArcRisk project, human placental perfusion and cell line studies on fetal exposure for toxic metals
and PFOS/PFOA have been done. We have also worked with quantitative risk characterization calculation which is based on backward
calculation of average and life-long average daily doses using population pharmacokinetic models.
One important result of the ArcRisk project will be the comparisons of the present and future situations in the Arctic to those in the
selected parts of Europe, which will provide a good source of information for the development of policies to reduce levels of contaminants.
We are now in the synthesis process of integrating the information of two case studies, PCBs and Hg.
Christian Sonne, Aarhus University
Rune Dietz, Aarhus University
How wildlife studies can be used as risk model for human health in the Arctic
The challenge is to link wildlife and human health studies if the on-going anthropogenic pressures from multiple stressors are to be
understood in the Arctic. This task is important since human health and wildlife studies complement each other given the different sampling
opportunities and subsequent opportunities for analyses. Another important linkage between human health and wildlife studies is the case
of hunters and their intake of high trophic prey. This relationship means, that humans are exposed to environmental contaminants (e.g.
mercury, persistent organohalogenated pollutants and perflourinated compounds) and zoonotic diseases, meanwhile the hunters also
benefit from nutrients including fatty acids, vitamins and elements all know to be important for health. Recently, climate change has also
been recognized as jeopardizing health parameter not least because there seem to be a synergy between energetic needs during changing
temperatures and biotopes and the biomagnification of pollutants and their endocrine disrupting effects. In addition to this, changes toward
a modern way of living also put the Arctic populations in an increased risk for life style diseases. Further, climate change may alter the
composition of environmental contaminants in wildlife and humans and may also change the composition of micro-pathogens and parasites.
In Greenland there is a unique opportunity to combine invasive wildlife samples from Inuit harvest with human (non/semi-invasive)
samples. In the Arctic, human health research has a specific focus of end-point lifestyle diseases such as immune suppression, cancer,
diabetes (I+II) and cardio-vascular diseases with one of the risk factors being mercury, persistent organic pollutants and perflourinated
compounds. The question is how do we optimize the linkages between wildlife and human health studies in order to benefit and crossfertilize from our different approaches and data collection of health endpoints? One way to look at this is to look at species that face an
extreme lifestyle. We suggest polar bears as a model species for such studies. The female polar bear is hibernating for 6 month without
getting osteoporosis, polar bears are eating over a ton of blubber without facing diabetes or cardiovascular diseases. Finally, polar bears are
exposed to endocrine disrupting chemical at very high daily doses and still it can reproduce and do not suffer from high prevalence of cancer.
Therefore, polar bears must be the ideal test organism. As polar bears are hunted by Inuit hunters we have collected, analyzed and
archived samples of different nature since 1983. These samples have enabled us to conduct various ex vivo analyses and time trend studies
of contaminant loads with linkages to climate related physical-chemical changes. Therefore an improved inter-disciplinary dialog is needed
providing answers to questions like: Can we improve the synergism between our various disciplines? What do the medical doctors want to
explore of polar bears? And how can we as vets and biologists support the on-going human health studies?
Karen Wistoft, Aarhus University
The Real Care Doll Project: evaluation of sex and parent education in secondary school
and
The Resilience project: design of cognitive mental health promotion among children and adolescents
Key words
• Teen pregnancy • baby simulants • family and sex education • prevention • intended pregnancy
Purpose of the study
The main objective is to examine how students’ overall awareness and perception of early pregnancy and parenting is affected by taking care
of baby simulants as part of a family and sex education program.
Introduction/background
The Real Care Doll Program intent to show students in Greenland the amount of responsibility involved in caring for a baby. The program
consists of sex education, competence development in relation to establishing a family and prevention of unintended pregnancy. More than
one thousands of predominantly eight- and ninth-grade students in Greenland have been provided with an experience of being the parent of
newborn infant using Real Care baby infant simulators. The program requires students to become the sole caretaker of the Real Care baby
infant simulator, whose appearance and behavior imitates a real infant. The experience is intended to demonstrate the demands of caring
for a new born baby. Throughout the 2 or 3 days, the students typically are responsible for the ‘baby’; an internal computer collects data
about the students’ performance. Accompanying education helps students explore the physical, emotional, social, and financial
consequences of parenthood. The educators are healthcare assistants, health visitors and midwives and teaching takes place in the
classroom at school. The evaluation is carried out by health education researchers from University of Aarhus.
Objective
The general objective is to determine the short-term impact of the family and sex education including evaluating the effectiveness of Real
Care Baby simulation as a strategy to influence Greenland teenagers' perceptions of pregnancy and parenting.
Evaluation methods
The study is a pre-/posttest questionnaire survey design supplemented with observations in Nuuk and at the West Coast. The sample
includes 802 answers to questionnaire from Greenland students predominantly age 13 to 16 years and 266 parental answers Classroom
observations have been supplemented by personal interviews with the educators.
Key results and conclusions
Significant gains were found on the impact of the students perception of how early parenting affects their social and emotional life, and
apprehension of the amount of responsibility involved in infant care. Parents and grandparents are to follow the students more prepared to
having ‘early children’. On a posttest measure, the students report significant differences before and after carrying the doll with regard to
the age at which they wished to have a child, their education plans and social life. There are significant differences between several
monitored parameters in Nuuk and in selected towns on the coast, as Greenland is in this area are divided into two separate parts.
Implications
The evaluation study’s results show a substantial need for further competence development among the educators.