Thule Air Base is a strange place: The northernmost US Air Force base, located on top of Greenland and close to the historical settlement Dundas, which served as base camp for several famous polar explorers such as Robert E Peary and Matthew Henson as well as Knud Rasmussen who founded a trade station here and named it Thule. The original Thule trade station was moved and now serves as the museum building in the modern settlement of Qaanaaq, on the other side of the fiord. Upon establishment of the Thule Air Base in the 1950s, the original inuit population were forcefully evacuated to the present day village of Qaanaaq, causing ongoing lawsuits for decades until the matter was finally settled by the Danish Supreme Court in 2003.
Around 600 people live on the base, 150 from the US military, the remaining 450 being service personnel, mainly from Denmark and Greenland. The service contract with the Thule Air Base is with the company Greenland Contractors, who hires the doctors (in my case via an Agency). This service contract is currently (2016) the center of a major controversy.
Thule Air Base
Two doctors are permanently stationed on the base, one needs surgical skills. However, I did not have to use mine as the work is centered around general medicine including health certificates and administrative reports. There were no emergencies the month I was there. The closest was a call from a captain on a Lufthansa flight located right over the North Pole presenting a patient had abdominal pain. In the end it was decided that emergency landing at the base was not indicated. Though not part of the health care system in Greenland, Thule Air Base doctors and authorities will nevertheless assist with medical evacuations from nearby settlement Qaanaaq if needed.
My office
As a doctor you are provided with a car with a compulsory driving test at the base. I had a small apartment within the medical building/hospital ward, with no admissions during my time there. There is a small convenience store. The Top of the World Club (a bar/restaurant). And a fitness center. I was on Thule Air Base in August. The sun was never down and I covered the windows with plastic foil during the night.
Dundas
The scenery is spectacular with ~20 km road to drive on outside the base. One of these goes up to the Thule Radar. And despite many visits to Greenland, this is the only time I have actually been standing on the Inland Ice. I climbed the iconic Dundas mountain and visited the old Dundas inuit village. And lastly, I visited Alert, the Canadian base, located only 817 km from the North Pole.
At 77°47′ N , 47 km north of Qaanaaq, Siorapaluk is the northenmost settlement in Greenland as well as one of the northernmost permanently inhabited settlements in the world. 68 people live here permanently. There is a school, a church and a small library, all combined in one building. The doctor from Qaanaaq visits approximately every 3 months. Health services in these small settlements are provided by a health assistant, employed for a couple of hours a day, and with only a couple of weeks training. Thus all health issues are normally discussed either on phone or telemedicine with Qaanaaq. Siorapaluk is connected with Qaanaaq by twice-weekly helicopter flights.
It is February. Windy and around -30 °C. We travel with two snow-scooters over the frozen fiords and .bring rifles in case we encounter a polar bear. We wear special polar suits including protection glasses. In the middle of the polar winter, the sun is never up, but nevertheless there is a shimmer of light in the horizon. I have no idea about the direction we are taking and have to trust the local driver. In this hostile environment, all it takes is one wrong turn and we will never be seen again.
We leave Qaanaaq at 7am and arrive in Siorapaluk a couple of hours later. With me is an assistant nurse, who also doubles as interpreter, and the plan is to work as we possibly can in one very long day before returning. I see all the children and vaccinations are brought up to date. Dental status is checked. In fact I end up seeing most of the inhabitants and those not on the list, turn up queuing at the door once the rumor had spread of our arrival.
A tragedy struck this remote community in 2013: An old man died, presumably of food poisoning. What no one knew at the time of his death, he did indeed die from botulism, from the traditional meal kiviak. At his funeral, several of the guests ate from this sane meal, and subsequently his 46-year old daughter died and five additional guests were seriously ill. A case report on this event was later published in a forensic science journal.
On the way to Siorapaluk via the frozen Robertson fiord
A 25-year old Japanese man happened to pass by this place 40 years ago in search for extreme wilderness. He never left, and founded a family there. His reputation as a hunter is widespread and as I was looking to buy a polar fox fur, I went to see him at his storage facility in the basement of his house. He immediately apologized, he did have polar foxes, however they were brown and not white. The white were sold out as confirmation season was approaching.
So far north, the sun is permanently down between November and February, and permanently up between June and August. Temperatures in winter may drop to below minus 50°C. We are even too far north for the Northern lights. It is an arctic desert, with little, if any snow even in winter. The Qaanaaq fiord is frozen 9 of 12 months and only a couple of ships a year pass by with supplies, the last one in August. Trucks drive out on the frozen fiord to collect chunks of icebergs, which supply Qaanaaq with drinking water during the Arctic Winter. You are the only doctor here. The next settlement on the Coast is Upernavik, 1:30 hours south by plane, one plane a week.
I worked as a doctor in Qaanaaq in 2006 and again in 2013.
Qaanaaq
07:30 January. The middle of the Arctic Winter. While the sun is never up, it is not pitch dark all day, as reflections of light shimmer over the flat mountains. Some people suffer depressions in this eternal darkness. I think it is wonderful. I have an entire house at my disposition, right next to the hospital. First I empty my toilet bag (there is no cloacal system here) and place it outside the house to be collected. It is minus 35 °C. After a quick coffee I run the 200 meters to the hospital.
08:00 Morning meeting at the hospital. It is Wednesday: Surgery day. Thursday is for vaccinations, Tuesday for examining children. Today we have two abortions scheduled. If I was not able to perform them, they would have been sent down south to Upernavik or Ilullissat.
09:00 Patient consultations begin: Two patients present with a common cold. One needs his diabetes controlled. One child presents with a rash. I need an interpreter for the majority of the consultations, as especially the younger patients do not readily speak Danish. 3 patients per hour are booked. While this may not seem a lot, the lack of prior knowledge of the patients as well as the need of translation makes it appropriate.
09:30 A hunter has been out on the ice-edge, hunting for walrus. They caught one and ate some raw meat. Now he feels weird. Could it be trichinosis? I have to look it up in the text book.
10:00 I administer a paracervical blockade, and the two abortions are performed without problems.
Qaanaaq, the arrival of the sun
11:00 The consultations continue: One patient presents with tendinitis. He is a hunter, and it comes from holding the reins of the dog-sledge.
12:00 Lunch break: The nurse told me that a helicopter from Thule Air Base had just landed bringing eggs. There have not been any eggs in Qaanaaq for two weeks. I run down to the supermarket Pilersuisoq, where 15 boxes of eggs are left. I took two. I check the rest of the store out: Well stocked with mainly dry and canned foods. Dairy products and vegetables are frozen.
13:00 Visit to the retirement home. The lack of continuity is a problem, a new doctor coming in every 1-3 months. I do not know the patients, but try my best together with the leading nurse to go through and update all the prescriptions.
15:00 The visiting psychiatrist is here for her yearly visit. The secretary tries to get hold of all the villagers referred for psychiatric consultation. This includes arranging transport for those living in the smaller settlements around Qaanaaq: If they don´t make it this week, they have to wait a whole year until the next visit.
15:30 Off duty. It is minus 25 degrees Celsius now. I walk the 50 metes down the hill to the public library and shuffle through the books. There is a an interesting new book out on Knud Rasmussen, signed by the author. Knud Rasmussen is well remembered here in Qaanaaq and his sledge from the Thule expeditions can be seen in the Qaanaaq museum, the building itself being his old trade station (Thule Trade Station) moved up to Qaanaaq from Dundas.
18:00 Dinner with the visiting psychiatrist at the only hotel in town. Soup with seal is served. It tastes mainly of salt water.
21:00 A call from the police. A young man has committed suicide by hanging. He is 19. The police officer picks me up at my house and we drive to examine him and fill the necessary paper work. The suicide rate in Greenland is one of the highest in the world.
Greenland is a former Danish colony, population 56.000, now related to Denmark via a bilateral agreement. The majority of the island is covered by the Inland Ice, a massive ice cap, while villages and communities are dotted along the coastline, with no roads connecting any of them whatsovers. I have worked locums on the coast in Greenland regularly since 2004 in the following places: Qaanaaq (twice), Narsaq, Paamiut, Nanortalik and Thule Air Base.
Organization of the health care system in Greenland
Nuuk is the largest city with 17.000 inhabitants and where the only official hospital, Queen Ingrids Hospital (DIH) is located. The DIH is equivalent to a provincial hospital and provides basic functions within surgery and medicine. More specialized functions such as vascular, thoracic and neurosurgery, as well as interventional cardiology and burns treatment are transferred to Denmark.
Hospitals and health centers are spread along the West coast from Qaanaaq in the far North to Nanortalik in the far south and then up again on the East Coast to Ittoqortoormiit. Sisimiut, the second largest city has 6000 inhabitants and 4-5 doctors. Nanortalik with 1300 inhabitants has only one doctor. The smallest villages with a permanent doctor are Ittoqortoormiit (pop: 450) and Qaanaaq (pop: 635).
The doctors house in Nanortalik
The doctors on the coast are normally general practitioners, however doctors from other specialties may be employed if they have sufficient experience within general medicine. In some of the larger villages, one of the 3-4 doctors on site should have surgical skills, mainly for Cesarean sections.
As a doctor on the Coast, you perform all medical duties, the majority being within the field of general medicine. Every village has a hospital-health center, where all consultations and examinations take place and, if needed, patients are admitted. Minor surgery, such as abortions, may be performed depending on the local competences. Furthermore, smaller remote settlements in the area are visited on a regular basis. After normal day duty one of the doctors will be on call. If there is only one doctor you will then be on call all the time. The staff are generally very competent and used to dealing with most emergencies. Most emergencies during the night are related to alcohol and violence including medical examinations prior to detention placement at the request of the police.
The generalists on the Coast have a close collaboration with the specialists in Nuuk: For non-urgent cases an online referral system is established and for emergency cases a doctor is on call within each specialty. Furthermore, specialists visit the coastal communities on a regular, often yearly basis: Ophtalmologists, orthopedic surgeons, psychiatrist etc. As dental health is a major issue, dentists are present in all, but the very smallest communities.
At the coast level, basic examinations such as X-ray and standard blood analyses may be performed. Further investigations take place either in Nuuk or at the yearly specialist visit. Emergencies may be transferred to Nuuk with either a chartered or scheduled plane depending on the degree of urgency.
The doctor is either employed directly by Greenlandic authorities or via an agency. As I understand it, you need a Danish authorization to work in Greenland. For Scandinavians, the authorization is easily transferable, for others the procedure vary. However dispensations may be given. It is a major challenge for the health system to employ doctors in Greenland and many positions are covered as short-term locums. Also in Nuuk there may occasionally be a lack of certain specialists.
Qaanaaq Fiord
The challenges for a medical doctor are both medical and cultural and often a mix between the two:
Cultural considerations. The level of spoken Danish is quite low among young people, problematic in terms of education as all diplomas above primary school-level require good knowledge of Danish. A translator is needed in approximately half of all medical consultations. Now, several educations (police officer, nurse, teacher etc) are offered in Nuuk, where before travelling to Denmark was required, but still Nuuk is far away from many of the villages on the coat. In Greenland I have noted a certain tendency to live in the present, rather than by the European style of long-term planning. Thus, I have seen many young people renounce on an education preferring to stay with their families. Generally speaking, one section of the inuit population seems to stay in the small communities while the other section often moves from smaller settlements to Nuuk or even Denmark to pursue educational and/or job opportunities. This pattern leads to a depopulation of smaller settlements and contributes to social challenges. As an outsider, it is very difficult to get genuine insight into inuit, though the people are incredibly friendly.
Medical considerations The disease pattern in Greenland differs quite significantly from the European mainland as outlined below:
While the incidence of hypopharynx cancer is increased, possibly related to viral infections, lung cancer is by far the most common cancer, related to a high incidence of smokers.
Due to the relative isolation down through the centuries, certain genetic diseases are endemic such as Cholestasis familiaris Groenlandicaand propionemia. Both may now be detected via pre-natal screening. Iridocyclitis and primary angleclosure glaucoma also appear more frequently in Greenland. Greenland has one of the highest suicide rates in the world, and almost every Greenlandic citizen knows someone who took their own life. Special task forces/initiatives have been launched to resolve this issue.
Sexually transmitted diseases (STDs) are rampant, and increasing as of 2013 with 1 in 26 adult Greenlandic citizen suffering from Gonorrhea, 300 times as many as in Denmark. Syfilis is also present. The transition from traditional inuit lifestyle towards a Western lifestyle and diet predictably has led to an increase in the lifestyle-associated diseases (diabetes, cardiovascular). Lactose intolerance is relatively common.
Living conditions: As a doctor you are provided with either a house or an apartment with modern facilities, heating, kitchen, shower, hot water, television. In a few communities there are no cloacal systems so toilets are emptied via a bag system (Ittoqottormiit, Qaanaaq).
Daily amenities: All settlements have at least one supermarket with basic items, loads of canned and dry foods. Transport is by ship and in remote places only two ships pass every year. Brædtet is a place where local fishermen sell their catch.
Geographical considerations: There are no roads connecting the settlements and villages in Greenland meaning all transport is by air. Often weather prevents helicopters flying and people may get stuck on the way for days.
Around Thule Air Base
Weather: From the Arctic desert of Qaanaaq, where temperatures down to minus 40°C are not uncommon during the Arctic Winter to the milder climates in the south resembling southern Norway. The Polar Circle runs approximately through Kangerlussuaq.
Transport: The only all-year international airport is Kangerlussuaq, an old American naval base with flights to/from Copenhagen. Narsarsuaq (for southern Greenland) is open in summer. Eastern Greenland may be reached directly from Iceland. From Kangerlussuaq and Narsarasuaq a mix of planes (Dash-7 or Dash-8) or helicopters then depart to the final destination on the coast. Due to the often changing weather conditions delays are common and may last a week if not more.
Outdoor activities: The scenery is unique and spectacular every where. However I have mainly worked in villages where I was the only doctor, thus I could not venture outside the village except in exceptional circumstances.
Nanortalik is the Southern-most village in Greenland with a population of 1450. So far south of the Polar Circle, so the sun is never completely away and northern lights may even be seen. Nanortalik is located on a small rocky island and the weather on this part of the coast is very unstable, helicopters often being delayed for days. I was stranded for two days in Qaqortoq on my way there.
As a medical doctor, you are alone here and thus always on call.
07:50 I walk to the hospital. It is extremely slippery after a couple of days with a mix of rain and frost. Unsurprisingly, many patients fall and end up with ankle contusions and even fractures.
08:00 Morning meeting with handover from the night shift. A man was admitted the day before on suspicition of a broken ankle and we prepare for an X-ray.
08:30 Ward round. Two patients are currently admitted, one with pneumonia, the other under investigation for tuberculosis.
The doctors house in Nanortalik
09:00 Patient clinics begin: Three patients per hour are scheduled, which is appropriate, as many need assistance from a translator. The first three patients present with 1) control of diabetes, 2) itching skin, and 3) gradual hearing loss. Otoscopy reveals a perforation of the eardrum and the patient is electronically scheduled to be seen on the upcoming visit from the ENT specialist.
10:00 It is Tuesday morning, the day of vaccinations and scheduled examination of children. Wednesday morning is set aside for minor surgeries. Normally a nurse would perform the vaccinations, but as the nursing position is vacant I do it. Many tasks are delegated to assistant nurses such as X-ray, diagnosis and contact detection of sexually transmitted diseases, outreach psychiatric care, the laboratory as well as patient screening in the emergency room.
10:30 Lunch break. A bit early, but that´s how it is done here.
11:00 The man´s ankle was broken and there is indication for surgery. I discuss with the orthopedic surgeon in Nuuk and they will receive the patient on a socalled 1st connection (first commercial flight out of here).
11:30 Call from Aapilatoq, one of the nearby settlements. A woman has been coughing for months. Tuberculosis is suspected. We book her on the next helicopter for initial evaluation and examinations (Quantiferon, sputum tests, thoracic X-ray).
12:00 Two abortions are scheduled for tomorrow and I see both women.
Traditional house in Nanortalik
13:00 A patient has post-traumatic epilepsia and is not well-regulated on his current treatment. I email the specialist in internal medicine in Nuuk for advice.
14:00 Three young men present for health examinations prior to attending the Maritime School in Nuuk.
16:00 Groceries shopping: The two supermarkets are well-stocked, though expensive: One tomato costs almost one dollar. However there are no ducks left and there is only one week to Christmas. I am reassured that an emergency sending of ducks will arrive in a couple of days.
17:00 Home. I live in a beautiful wooden yellow house right in the middle of the village.
The churchyard in Nanortalik
18:00 Call from hospital. The police car was already waiting outside my house, they said. I look out the window and it is there, barely visible in the snowstorm. They request a medical examination of a citizen prior to placing him in detention.
20:00 The police car is parked outside my house once again. A man has been found dead in his home. We fill out the necessary paperwork and I check his medical records.
