Overview of health research in Greenland from 2001 to 2020

Introduction

Greenland is a remote island in the northern Atlantic Ocean and is part of the Danish realm, with a self-governing body. The health-care system is managed by the Greenlandic authorities. The present-day population in Greenland consists of 56,421 individuals in addition to 17,079 Greenlandic-born individuals living in Denmark. Health research in Greenland has previously been anchored in Danish research centres. Since the establishment of the Greenland Centre for Health Research (GCHR) at Ilisimatusarfik (the University of Greenland) in 2008, an increasing amount of health research has been rooted in Greenland [1]. Thus, today the research community in Greenland is based on a Greenlandic foundation including such entities as the Danish Greenlandic Society for Circumpolar Health, the International Union for Circumpolar Health, the tri-annual NUNAMED conferences in Nuuk, the journal entitled The International Journal of Circumpolar Health and the Steno Diabetes Centre Greenland [1].

The population of Greenland has a distinctive genetic heritage composed of Inuit ancestry and European admixture, and lives under extreme conditions, which leads to a unique health research potential [2,3]. Geographically isolated populations like the Greenlandic population have been found to carry genetic variants considered more likely to have a functional impact on phenotype interesting for identifying disease-associated variants [2,4]. Iceland’s human genetics research institution, deCODE, which studies the Icelandic population, has achieved considerable research impact within this discipline [5].

However, while some research from Greenland has caught much attention, for example, the association between cardiovascular diseases and marine oils, and the genetic background for types of diabetes, the full spectrum of health research in Greenland is unknown. Thus, it is not readily clear where there are gaps in knowledge regarding the health of the Greenlandic population and, therefore, which areas within health research could benefit from increased attention.

Bibliometrics is an informatic method by which it is possible to obtain quantifiable data of research landscapes [6]. As efforts are made to enhance the research communities in Greenland there is an increasing need for research overview. Questions such as the amount of research conducted, in which health fields, authors’ details and how these studies are designed and funded can aid researchers and policymakers alike. Researchers and clinicians can benefit in decisions regarding resource management, future planning and progress monitoring. Furthermore, the same overview with funding details and quantification of research within health fields can assist policymakers and funding agencies.

The aim of this study was to quantify health research in Greenland by utilizing bibliometric analyses and in particular to identify gaps in knowledge to aid researchers, policymakers and funding agencies to possibly focus future research efforts in the country.

Methods

Results

Research output and designs

During the 20-year time-period from 2001 to 2020, we identified a total of 640 peer-reviewed health research publications according to our inclusion and exclusion criteria (see Figure 1), yielding an average of 32 publications per year. The yearly average before the establishment of GCHR from 2001 to 2008 was 26.5 articles per year compared with 35.7 after the establishment from 2009 to 2020. Over the total period we found an average annual publication growth rate of 2.9%, although the output fluctuated year by year (Figure 2). We found that 82% of studies were primary studies with most being epidemiologic (66%). Clinical research studies represented 11% of studies. Two clinical trials were identified [11,12]. Basic research studies represented a diminutive fraction. See Figure 3 for distribution of study designs.

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Figure 1.

Selection of publications on health in Greenland, 2001–2020.

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Figure 2.

Annual number of publications on health research in Greenland, 2001–2020.

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Figure 3.

Distribution of study designs of 640 publications on health research in Greenland, 2001–2020.

Characteristics of researchers

Corresponding authors represented 148 different institutions. The three most productive institutions were the Universities of Southern Denmark, Copenhagen, and Aarhus. Combined, corresponding authors from these institutions contributed with 33% of all publications. In accordance, most country affiliations for corresponding authors were Danish with 63% of publications, followed by Greenlandic with 15% and Canadian with 6% (Figure 4). All inhabited continents except for South America were represented in author affiliations.

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Figure 4.

Country of origin of corresponding authors of 640 publications on health research in Greenland, 2001–2020.

A total of 1485 unique authors contributed to the publications over the period. Across the 640 publications there were 3536 author appearances yielding an average of 5.5 authors per publication and 43 (7%) single authored publications. A small number of researchers conducted a large part of the publications with Dr P. Bjerregaard being the most productive author with 119 authorships, corresponding to 19% of the publications during the period. Moreover, the medical doctors M. E. Jørgensen, A. Koch, H. S. Pedersen, M. L. Pedersen and G. Mulvad each contributed to more than 7% of the 640 publications.

Discussion

In this study, we characterized the landscape of health research in Greenland from 2001 to 2020. To our knowledge, this is the first overview of its kind. We found an average of 32 annually published articles, an average annual increase in publications of 2.9% per year. The global annual health research output is challenging to quantify, yet bibliometrics estimate that within the biomedical field around one million articles are added to the PubMed database each year across all scientific areas, with an estimated annual growth rate of 8–9% [14]. Rough estimates of the abovementioned figures reveal a noteworthy difference with an annual publication rate of 13 health research articles per 100,000 world citizens as compared with 57 health research articles per 100,000 Greenlanders. This difference emphasizes the unique research opportunities within the Greenlandic population, characterized by distinctive genetics, extreme living conditions and a swift transition from traditional Inuit lifestyles to a more Westernized way of life [2]. The annual growth rate was nonetheless lower than the global growth rate. Second, we investigated the production before and after the implementation of GCHR in 2008, with 26.5 articles per year before compared with 35.7 after. This suggests an effect on publication, although 2019–2020 showed a decrease in publication (Figure 2).

A strong collaboration between the health-care sector in Greenland and Denmark exists and this is reflected in our overview. The three most productive institutions were Danish universities, which collectively contributed with 33% of all publications. This confirms the strong health care and health research relationship between Greenland and Denmark. Unsurprisingly, the remaining significant contributors to Greenlandic health research were countries geographically situated around Greenland.

Most of the Greenlandic health research in the period can be categorized as primary, with an epidemiologic study design as the most prominent and a scarcity of basic research. Although we did not compare with other countries, neither finding is surprising, considering the size of the Greenlandic population and hence scarce laboratory facilities. Thus, epidemiological studies are by far more feasible to carry out in Greenland.

Research within infectious diseases and environmental medicine were the most common areas during the 20 years. Generally, health research areas in Greenland appear to be of considerably disproportionate sizes, with some fields having been studied sparsely. This is not surprising for a variety of reasons. The burden of infectious diseases is high in Arctic populations although incidence and mortality from infectious diseases reduced substantially in the 20th century. For environmental medicine, the particular environmental dietary exposures in the Arctic region, for example, high concentrations of persistent organic pollutants and heavy metals in sea mammals, have caught substantial scientific attention as to possible health effects of exposures that are prominent in the Arctic [15].

While incidence and mortality rates from infectious diseases have decreased since the 1950s, incidence and mortality rates from chronic diseases and cancer have increased in the same time period [16–18]. A shift in lifestyle with an increase in risk factors for chronic diseases including an increase in obesity, sedimentary work, aging of the population, decreasing physical activity and a high number of smokers are believed to be explanatory factors [19–22]. This trend is not unique for Greenland, but is seen worldwide [23]. Today, cardiovascular disease is a major public health issue in Arctic indigenous populations with, for example, a higher incidence of cerebrovascular diseases among Inuit than among other Western populations [19]. In the future, we expect an increasing number of Greenlanders to be affected by chronic diseases, and as this may be prioritized by funders and researchers, we also expect an increase in studies on non-communicable diseases in Greenland [18]. Recently, the Novo Nordisk Foundation granted 382 million Danish Kroner in the period 2020 to 2030 for the establishment of a Steno Diabetes Centre Greenland with the focus of improving care, prevention and research in chronic diseases in Greenland [24]. However, the relative weight of the different research areas also reflects the interests of the individual researchers and research centres. With a small population and few researchers, the number of publications within the different research areas may not necessarily reflect the burden of disease in Greenland. As an example, seven medical specialties that are relevant in the daily clinical work in Greenland (dermatology, nephrology, urology, allergy, traumatology, orthopaedics and rheumatology) accounted for a total of only 2.7% of publications in the period (Supplemental Figure 1).

During the past 20 years, we found that public non-Greenlandic funding (62%) was the most common type of funding and Denmark the largest source of contribution. The number of fundings from public Greenlandic funders was considerably less at 38%. A study by Madsen and Aagaard [25] found that in Denmark funding from private foundations represented 20% of all public research activities, which is considerably less compared with the 43% from private non-profit funders in Greenland. We did not determine whether changes in funding sources had occurred over the 20-year study period, so alterations in the funding environment could have happened over the period [26]. Overall, health research in Greenland proved to receive the majority of funding from Denmark with substantial contribution from private funders.

Corresponding with the Greenlandic population size of 56,421 inhabitants, the actual number of health researchers is limited [27]. We were not able to estimate the number of Greenlandic health researchers due to several factors. First, a definition of a Greenlandic health researcher is challenging. Few physicians in Greenland have full- or part-time research positions. Still, full-time and substitute physicians prove to hold authorships. Second, we found that 148 institutions (corresponding author affiliations) have engaged in Greenlandic health research, thus, complicating the quantification of Greenlandic health researchers. Nonetheless, a small number of researchers conducted a large share of the research, with the most productive researcher having authorship of around 19% of all publications during the 20-year period. This is substantial, although expected due to the population size, but consequently research environments and expertise are at risk of diminishing. In 1989, the Ilisimatusarfik was established. Together with the Steno Diabetes Centre Greenland this institution may be a main actor in Greenlandic health research conducted in Greenland for years to come.

Strengths of the present study are the long time-period, the absence of language restrictions and that two authors independently reviewed and extracted data from publications. Furthermore, we utilized The Lens, which is a comprehensive open-source database which relies on data from Microsoft Academic, ORCID and PubMed, among others [7]. There are also some limitations to this study. First, impact of health research is traditionally expressed in quantitative methods such as citation counts, but many factors influence citation rates. Solely relying on citations may be an inadequate tool for assessing impact, although no single system for complete impact measurement exists. Factors that may influence citation rates include a potential favour of older articles, biases due to self-citation and variations due to the size of the given research areas [28,29]. Second, classification of health research by type and area can be challenging, as individual studies may touch upon several types and areas. Third, analysis of affiliations of authors was not complete as we restricted affiliations to the primary affiliation of the first author. Last, funding information was not available for a larger share of studies and the monetary size of the funds was not available.

In conclusion, for the past 20 years, health research in Greenland has been primarily centred around epidemiologic research, with infectious diseases and environmental medicine being the most common research areas and with an overweight of Danish author representation. Corresponding to the Greenlandic population size, few researchers conducted a large proportion of the average annual 32 health research publications with an average growth rate of 2.9%. Some medical fields are modestly represented in the publications, suggesting that future research in these fields is warranted. Our findings suggest that more research is conducted on Greenlanders than on the average world inhabitant.

Supplemental Material