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An interview with epidemiologist Dr. Anders Koch

Dr. Anders Koch is an infectious disease physician by training, a medical epidemiologist and a university professor in Greenland. He has done research on infectious diseases in Greenland for the past 25 years and currently wears four hats: He works as a consultant for the national epidemiologic institute of Denmark, the department of infectious diseases at the Rigshospitalet in Copenhagen, and for the Greenlandic health system, where he is an active clinician for infectious diseases and involved in planning work – being clinically nationally responsible for tuberculosis. In addition, Dr. Koch is involved in the work of the International Circumpolar Surveillance System for Infectious Diseases.

We asked him about coronavirus in the Arctic and the impact on small Arctic communities. We discussed the current situation regarding coronavirus in Greenland, the measures being put in place to flatten the curve of infections to protect Arctic communities against coronavirus and how similar infectious outbreaks have impacted Arctic communities in the past.

How are small communities in the Arctic prepared for a pandemic?

If you take the circumpolar region as a whole that is probably very varied. In large parts of the Arctic, the communities are small and scattered and health planning is hampered by the disperse geography and the scattered and limited resources compared with e.g. Denmark and Norway. Thus, you don’t have the same possibilities and means to prepare for and act on a pandemic in small communities as you do in our capitals. That is mainly due to two things: the lack of testing facilities and the difficulties associated to handling an infected person. For Greenland there are of course plans in place but they are hampered by logistic challenges and the lack of staff.

It’s important to note that the Greenlandic health system is independent from Denmark. Of course, Denmark helps Greenland – for example with laboratory testing of the coronavirus. At present, Greenland does not have its own facilities to test for the novel coronavirus. As the testing procedure is technically challenging to introduce to a lab, all samples from Greenland are being sent to Denmark at the moment. This results in a delay of one to two days or more.

There is also a continuous flow of medical staff from Denmark. At present, the number of persons coming to Greenland is highly limited, but from this weekend on, we offer corona test to all such persons going to Greenland, irrespectively of whether they have symptoms or not. The main priority is to not bring the coronavirus into the country.

What is the current situation in Greenland in relation to the coronavirus?

As of today, there are four cases. The first case appeared about two weeks ago. This case was travel related and complete contact tracing was carried out. Place of infection for the second case that was diagnosed last week was unclear, and this case might have resulted in local transmission. Therefore, a number of public health means were established inclusive of shutting down the capital Nuuk from the outside. Only selected people are allowed to travel to Nuuk and domestically. Over the weekend we had two more cases in Greenland and one of them was related to the self-rule government, so there’s a risk that the person might have infected people within the administrative system.

"If the containment policy should not work, then I think it’s likely that the virus will spread to the settlements." Dr. Anders Koch

How likely is it that the coronavirus will come into some of these small and remote communities?

This is very difficult to answer. If the containment policy should not work, then I think it’s likely that the virus will spread to the settlements. But as it is for now, cases are limited to Nuuk and have most likely been travel related. People from the settlements rarely travel, compared to people in e.g. Nuuk or Sisimiut who travel more either for work or for leisure. I think it is very likely that the coronavirus will come to the settlements if the containment measures don’t work – and we don’t know if they do yet.

How do measures in small remote communities compare or differ from measures taken in big cities and densely populated areas?

In Alaska for instance the authorities have advised people living in homes without running water how to use disinfectants. However, I am unaware of what they do regarding containment and tracing of possibly infected contacts. In regards to Greenland, the self-rule government has implemented a more aggressive strategy than we have in Denmark – which was already aggressive from the start. But I think, it is highly justifiable in Greenland at this point. To put it simple: you don’t want the virus to enter the country and you are in a position in Greenland where you can actually shut down the country, towns and settlements. You can’t do that efficiently in Denmark.

What are some of the major concerns related to an outbreak in a small Arctic community?

The reason why we are particularly concerned with Arctic communities is not that we necessarily consider their populations more susceptible to more severe courses of the diseases. The main problem is that the health systems are not geared for such a challenge. They are vulnerable, have a limited amount of staff, hospital beds and ventilators that are not spread out across the region. If you need ventilator treatment in Greenland, you have to be transferred to the capital Nuuk – and three quarters of the population live outside of Nuuk. So, the health system is not adaptive in the same ways as the Danish system.

"That is why it is highly imperative to keep the virus out of the country and to flatten out the epidemic in the Arctic." Dr. Anders Koch

How have similar international disease outbreaks affected Arctic communities in the past?

I can bring up three examples. Firstly, the Spanish flu in 1917/1918. That hit Indigenous peoples across the Arctic, particularly in Alaska hard. In the mission station in Brevig, Western Alaska, 85% of the adult population died in just five days from the disease. In fact, some years ago the gene of the virus was recovered from a buried corpse in Brevig from a woman who had died from the Spanish flu influenza virus. Secondly, a major measles epidemic reached Baffin Island and the Ungava peninsula in northern Quebec in 1952 which affected 99% of the population and killed between 2 and 7% of the population. The epidemic was traced to Inuit visitors to the Armed Forces base at Goose Bay, Labrador. Third, in recent years we have seen outbreaks from a bacterium called Haemophilus influenzae type A in Alaska, Northern Canada and other countries with Indigenous populations. This bacterium is now a significant cause of pneumonia, meningitis and infection of the joints in these populations.

Finally, in Arctic populations tuberculosis was a main health problem in the first part of the previous century. In the forties and fifties Indigenous populations of the Northern American Arctic inclusive of Greenland held world record rates of tuberculosis. We have done a lot against the disease and incidences has been reduced markedly in these populations, but you still have social and environmental conditions that favor transmission of tuberculosis and other respiratory diseases – such as the coronavirus.

What are these conditions that favor transmission?

Environmental and social factors inclusive of crowded housing conditions, poor hygienic standards and lack of running water. In fact, tuberculosis is partly considered to be a social disease that is affected by low social living conditions. Also, for common respiratory pathogens, such as the common cold, we observe that children in Greenland have very high rates, much higher than in Denmark and the rest of Scandinavia. So, there are living conditions that favor the transmission of such agents between people.

"There are living conditions that favor the transmission of such agents between people." Dr. Anders Koch

Could the elevated rate of respiratory diseases also affect the spread of covid-19?

Although the number of tuberculosis cases is relatively high in Greenland, this does not in itself predispose the population for coronavirus infection. If you have a hundred new cases of tuberculosis per 100,000 inhabitants in Greenland per year that means that you have around fifty new cases per year in a population of 56,000 persons. So, it’s not a large part of the population that is affected by tuberculosis. Thus, it is not that other infectious diseases weaken the population or the immune function, it is rather the living conditions that may make people susceptible to diseases. This may favor both disease transmission and a more severe cause of infection. The average life expectancy of Greenlanders is around ten years shorter both for males and females compared to Denmark. That doesn’t mean that they have the same health up to the moment they die, they have more co-morbidities and other factors that shorten the lifespan.

How could cooperation across the Arctic support communities to prepare for future outbreaks?

Right now, countries consider what is best for their own communities. We have not yet reached the point, where there is much collaboration across the Arctic on this particular outbreak. But I think that is one of the things that we will strengthen in the future both within our research and on a political and administrative level. I know there has been some exchange between the Greenlandic authorities with authorities in Canada and Alaska. We need to see that increasingly over the time to come, but it’s somewhat hampered by the fact that the health systems are very different.

Dr. Anders Koch is the past President of the International Union for Circumpolar Health, one of the Council’s Observers. Visit the IUCH website here.