تغییر فرهنگی و سلامت روانی در گرینلند: ارتباط بیماری های دوران کودکی، زبان و شهرنشینی با سلامت روانی و افکار خودکشی در میان مردمان اسکیموی گرینلند

In Greenland, the rapid sociocultural change of the last 50 years has been paralleled by an epidemiological transition characterized by a reduction in infectious diseases, an increase in cancer and cardiovascular diseases, and an increased prevalence of mental health problems. During 1993–94 and 1997–98, two health interview surveys were conducted among Inuit in Greenland and Inuit migrants in Denmark. The response rates were 71 and 55%. Information on mental health was obtained from 1388 and 1769 adults. As indicators of mental health, the prevalence of potential psychiatric cases according to the General Health Questionnaire (GHQ-12) and the prevalence of suicidal thoughts were studied in relation to childhood residence and father's occupation, current residence, and language. The statistical methods included logistic regression and graphical independence models. The results indicated a U-shaped association in Greenland of GHQ-cases with age and a high prevalence of suicidal thoughts among young people; a low prevalence of GHQ-cases among those who were bilingual or spoke only Danish; and a high prevalence of suicidal thoughts among migrants who grew up in Denmark and among residents of the capital of Greenland. In Greenland, women were more often GHQ-cases and had suicidal thoughts more often than men. The association between language and GHQ-cases is presumed to operate through socioeconomic factors. It is necessary to modify the common notion that rapid societal development is in itself a cause of poor mental health: as a result of successful integration into the modern Greenlandic society, some population groups have better mental health compared to other groups.

The contact of two or more cultures whether peaceful or hostile generally results in changes on both sides. During the 20th century, a large number of cultures have come in contact with the European–American, or Western, way of life and this contact has mostly resulted in profound changes in the culture and society. The changes have resulted in an epidemiological transition whose characteristics are observed in most affected countries. Among the Inuit, recent changes include a reduction in infectious diseases, an increase in chronic diseases such as cancer and cardiovascular diseases, and an increased prevalence of mental health problems (Bjerregaard & Young, 1998). In this article we present and discuss our empirical data on acculturation and mental health from two population surveys conducted among the Greenlandic Inuit. Rapid sociocultural change has been studied by a large number of researchers and has been variously described as acculturation, urbanization, migration, modernization, or westernization. Berry and Kim (1988) have proposed a model for acculturative stress that explains the relationship between cultural change and mental health. Berry (1990) and Berry (1994) has outlined a theory of acculturation and adaptation, and has discussed the specific situation of circumpolar peoples. According to Berry, acculturative stress gives rise to a number of health consequences such as lowered mental health status, homicide, suicide, substance abuse, and family violence, as well as changing patterns of physical health. Some physical health problems increase due to new sources of disease and to increased stress while other problems decrease due to improved health care, housing conditions and other factors. Berry defines four different modes of acculturation: integration, separation, assimilation, and marginalization, resulting from the perceived importance of maintaining one's own cultural identity and relationships with other groups. Moderators at different levels influence the degree of cultural stress experienced by individuals. It depends on the nature of the dominant society, for example whether its ideology puts emphasis on assimilation or on multiculturalism. Studies have shown that in pluralist societies, integration results in the least acculturative stress, but acculturative stress has been shown to exist both in multicultural and culturally homogenous societies (Sam & Berry, 1995). Denmark is a culturally homogenous country without a multicultural tradition. In Greenland, the official policy during the colonial period (until 1979) was consequently assimilationist, epitomized by the status of Greenland as a Danish county and the use of the terms “northern Danes” and “southern Danes” for Greenlanders and Danes, respectively, ignoring the cultural identity of the former. Since the introduction of home rule in 1979, the official policy has been integrationist, acknowledging the economic dominance of Denmark and the continued need for highly trained Danes in several areas of the new Greenlandic society. At the level of individuals, attitudes towards Berry's four modes of acculturation can vary, and whichever strategy an individual employs, demographic, social, and psychological characteristics of the individual are important determinants of acculturative stress. Helman (1985) and O’Neil (1986) working with an actor-centred model of participation in social change, points out the important fact that, in a changing society, different birth cohorts experience different worlds and must apply different coping strategies. For example, each cohort comes of age to find different economic possibilities available to them and different diseases prevailing in the community. Risk factors, for example those for youth suicides, are accordingly different and will change for successive cohorts of young people as they age and participate in the changing of their society. In the present study, culture change was estimated at the individual level by the types of community and family experienced during childhood by youth and by proficiency in Greenlandic and Danish languages. We are of course aware that culture and culture change cannot be isolated from educational and socioeconomic factors (Helman, 1990), but in a cross-sectional epidemiological study it would be very difficult to distinguish among these closely related factors and to identify their unique relevance. Greenland was colonized by Denmark/Norway in 1721, but the Inuit had had repeated contact with European whalers and explorers before that time. Over succeeding centuries, cultural exchange proceeded with the acquisition of European goods such as firearms, cloth, tobacco, and food, with the thorough Christianization of West Greenland by the mid-19th century and the introduction of literacy and paid work. New infectious diseases, like smallpox and probably tuberculosis, were also introduced with devastating results (Bjerregaard & Young, 1998). The shift from a traditional Inuit community to a modern society started in the beginning of the 20th century when fishing began to replace the hunting of marine mammals as the main livelihood. The shift was accompanied by a population movement from a large number of small villages to larger — although still small by any comparison — population centres, and by the gradual supplementation of the traditional subsistence by a cash economy. By the end of World War II, however, Greenland was still by and large an isolated and traditional society where most people lived in small villages and subsisted on small-scale hunting and fishing. The last 50 years of the 20th century have witnessed unprecedented changes in Greenland as it has become a modern society thoroughly integrated in the global economy and global politics. Fishing and jobs in the associated processing industry are the basis for an economy that operates largely at a fully modern level using ocean going fishing vessels in addition to smaller crafts and fishing from the ice. Subsistence hunting and fishing is still widespread but is increasingly becoming a leisure time activity. There are daily connections by air to Denmark and weekly to Canada, even small villages have telephone and internet cafés, and in the supermarkets of the towns fresh mangoes and pawpaws can be bought as well as a range of European meat, dairy, and vegetable products, and frozen Greenlandic fish and seal meat. Before 1950, 2% of the population was non-Inuit, almost exclusively Danes. In 1975 this had increased to 19% but has since then decreased to 12% as the result of a conscious process towards self-reliance (Bjerregaard & Young, 1998; Stenbaek, 1987). The population of Greenland was 23,500 in 1950 and had by 1998 increased to 56,000, of whom 49,000 were born in Greenland, an increasingly poor proxy measure for Inuit ethnicity (Statistics Greenland, 1998). Language is an important aspect of culture. In 1950, the language used in all areas of life by the Greenlanders was Greenlandic, an Inuit language that only differs in minor respects from the Inuktitut of the Canadian Inuit and the Inupiaq of the Alaska Eskimos. Today Greenlandic is still used as the everyday language of communication within the family, between friends, and at work but in the rapidly changing Greenlandic society Danish has gained a strong foothold as the language of administration, higher education, and technical matters. All children are taught Danish in school as their second language and the range of books and other printed matter is much wider in Danish. In Greenland, the rapid sociocultural change of the last 50 years has been paralleled by the development of mental health problems. At the population level information is available on the occurrence of two important aspects of mental health since 1950, namely alcohol consumption and suicide. Presently, alcohol abuse creates major health and social problems in all Inuit areas. In Greenland, alcohol consumption has increased dramatically. In 1950, the estimated average consumption among adults, expressed as litres of 100% alcohol, was 7 litres per year (Udvalget for samfundsforskning i Grønland, 1961); by 1987 this had increased to a maximum of 22 litres, but since then the consumption has decreased to 12–13 liters in 1993–98 (Statistics Greenland, 1999). Sniffing and the use of marijuana are widespread but there are no reliable statistics. Suicides were uncommon in the 1950s with an estimated rate of 4.6 per 100,000 person-years. During the following years, suicides increased dramatically and in 1990–94 the suicide rate was 107 per 100,000. It is predominantly young men who commit suicide but as many women as men attempt to commit suicide (Grove & Lynge, 1979). Several authors have tried to explain the “incomprehensible” adolescent suicides among Inuit and other Aboriginal peoples. In Greenland during the 1980s, the suicide rates differed greatly among municipalities, with the highest rates being recorded in the capital and in certain remote areas that were colonized late (around 100 years ago), while the geographic pattern for low rates was less clear (Lynge, 1985). On a countrywide scale, the suicide rate has stabilized in Greenland during the 1990s, and in the capital the rate is on the decrease. Geographical differences have largely disappeared within West Greenland but rates are 2–4 times higher in East Greenland than in West Greenland (Bjerregaard, 1998). Studies have shown that a common experience of those who commit or attempt suicide was a poor emotional atmosphere in the parental home, i.e. disharmony, quarrels, and alcohol abuse, while broken homes or cross-cultural exposure did not play a role (Grove & Lynge, 1979). Furthermore, the surplus of men in the Greenlandic community caused by the temporary immigration of single Danish professionals and skilled workers could very well increase the strain experienced by Greenlandic men (Lynge, 1994). One study on suicides among young Greenlanders concluded that the suicide rates were highest in the less developed towns; within towns it was highest among hunters, fishermen, and those unemployed or with unstable occupations. This was interpreted to mean that the social changes were not happening fast enough to meet the expectations of the young people (Lynge (1989), Lynge (1990) and Thorslund (1992)). This interpretation is not shared by other researchers (Lynge, 1994). The traditional Inuit upbringing that encourages independence, autonomy, supreme skill, and non-interference with other people's lives is believed to render young people very vulnerable to rejection (Gregersen, 1998). It has also been stated that the upbringing of a child as a “qujagisaq”, i.e. a pronounced favourite, will result in a person experiencing difficulties with handling competition on equal terms, conflicts, and rejections ( Lynge, 1994). Foulks (1980) suggested that, among the traditional Inuit, shamanistic practices provided culturally sanctioned forms of dissociation as a method of problem solving and escape from boredom and pain. He further argued that ritually prescribed dissociation fulfilled psychological and social functions that have since been taken over by alcohol and drugs, with an attendant increase in suicides ( Kirmayer, Hayton, & Malus, 1994). In a survey from Keewatin, North West Territories, Canada, 20% of adult Inuit answered “yes” to ever having planned or attempted to commit suicide with a considerably higher percentage of women among those below the age of 45 (O’Neil, Moffatt, Tate, & Young, 1994). In Nunavik, Québec, Canada, 12% of Inuit reported having had serious suicidal thoughts and 14% reported suicide attempts. Women reported suicidal thoughts more often than men did while there was no sex difference for attempts (Boyer, Dufour, Préville, & Bujold-Brown, 1994). In Keewatin the percentage of persons with suicidal behaviour ranged from 13 to 23% in individual communities but it was not possible to characterize the communities according to acculturation. Suicidal behaviour was significantly higher in persons living in private or government as opposed to public housing, and in those who did not speak Inuktitut. As private or government housing in Keewatin is usually inhabited by families, whose wage earners work in highly paid white collar jobs, this indicates that stress of culture change may be a predictor of suicidal behaviour. Suicidal behaviour was also high in persons living in households where the male household head was unemployed, indicating poverty as another independent risk factor. Further, individuals in both of these situations with a prior history of sexual abuse were at higher risk for suicide and in a multivariate analysis sexual abuse came out as the strongest predictive factor of suicidal behaviour (O’Neil et al., 1994). In Nunavik, young people with higher education more often reported suicidal behaviour. In one community in Nunavik, Kirmayer, Malus, and Boothroyd (1996) found that risk factors for suicide attempts included male gender, having a friend who had attempted or committed suicide, a history of being physically abused, a history of solvent abuse, and having a parent with an alcohol or drug problem. Protective factors included a family history of having received treatment for a psychiatric problem, more frequent church attendance, and a high level of academic achievement. Mental well being was studied in the 1993–94 Greenland Health Interview Survey: 19% of Inuit men and 34% of women reported having had mental symptoms during the last two weeks. Twenty three percent of the population (16% of men and 29% of women) had been gloomy, depressed, or unhappy, while 12% (8% of men and 15% of women) had been nervous, distressed, or anxious. Depression and anxiety were associated with several social variables in univariate analyses: not being in the labour force, experience of suicides among relatives or friends, sexual violence and other types of violence. Alcohol abuse was not related to either type of symptoms. In a multivariate analysis of Greenlanders aged 18–59, the only significant predictive factor for depressive symptoms was for men not being in the labour force and, for women, sexual abuse (Bjerregaard & Young, 1998). The same study also used Goldberg's General Health Questionnaire (Goldberg, 1972), and found that 35% of the population were potential psychiatric cases, with scores of 2 or higher. The purpose of the present study was to examine mental health problems and suicidal thoughts among Greenlanders in relation to childhood conditions (residence and father's occupation), current residence, and language capabilities.