The story of the “Norway Solution” to hospital infections reminded me of a letter that I received in the fall, written by Svein U. Toverud, a Norwegian who lived in the U.S. from 1969 to 2003. While he was in the U.S. Toverud taught medical and dental students pharmacology at the University of North Carolina, Chapel Hill, and received medical care there. When he returned to Norway in 2003, he had an opportunity to reflect on the difference between health care in Norway and in the U.S.

I have been meaning to publish this letter for the last two months, but the battle over health care reform intervened. So many lies, so much misinformation. Blogger could barely keep up.

At the moment, I am just a bit weary of Washington’s war on health care reform. (Yes, I mean “on”). So many seem bent on “winning” what they perceive as best for themselves or the small group they represent. Narrow self-interest carries the day.

To be sure, a core of courageous legislators fought hard for the public good, and they won on some important points. Insurers will no longer be able to shun the sick. Most low-income and lower-middle income families should be able to afford care. But, by and large, this fight has not been about patients or medicine. It has been about money and politics as liberals and conservatives battle to see who will hold power in Washington over the next three years. The differences run deep, and are not limited to the Capitol. The electorate is more polarized than at any time since the 1960s. 

This can be seen as progress. For years, it was difficult to distinguish liberals (a.k.a. the “New Democrats”) from conservatives (a.k.a. Republicans), and the idea of “values” rarely entered into the discussion. But today the argument has come down to bedrock values: conservatives emphasize the rights of the individual, and, in particular, the rights of wealthy individuals to conserve and preserve their wealth and power. Progressives would like a more egalitarian society, and they are trying to learn how to think collectively—though, in that regard, they still have quite a ways to go.

I think that Washington may have taken reform as far as it can for the time being. I suspect that we now need a reform movement outside of  D.C. I’ve been reading Marshall Ganz, and thinking about what a movement would really mean. It would be something quite different from the political coalitions that were formed to support change in Washington. It would be more like the civil rights movement: it would be designed to educate. It would not rely on Focus Groups to find out what people want to hear. It would tell them the truth. It would need passionate leaders who are ready to act and begin to reform the system from within, without waiting for legislation. Doctors, nurses, public health experts and other health care professionals know, better than anyone, just how and where our system is broken. It they would put self-interest aside, they could lead.

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But today, I decided to take a break from the war at home and contemplate health care in Norway—a country where medicine is patient-centered. There, health care is not a commodity that you “market” to “customers.”  It’s a service, delivered with an eye to husbanding resources while providing safe, high quality care to “patients.” 

What stands out in Svein’s letter is how egalitarian the system in Norway is. All citizens and residents are insured. Health care is financed through tax revenues, and taxes in Norway equal 45 percent of  GDP. (In the U.S. total taxes collected by state, local and federal government  add up to about 33% of GDP).

In return, Norwegians receive generous benefits and are free to choose their own doctor.

Norway’s very practical and rational system makes better use of medical professionals: midwives deliver most babies. Nurses make home visits to the elderly and the chronically ill, saving the cost of nursing homes. Surprisingly, even doctors make home visits—in the middle of the night, if necessary. The system is designed with the patient in mind, but experts make the final medical decisions based on medical evidence. Patients must get a referral from a primary care physician before seeing a specialist. A board of experts decides which drugs are available at no charge. And, as noted in Part 1, some antibiotics are not registered in Norway. Public health trumps Pharma sales.

While at UNC Chapel Hill, Svein was seriously ill and received some of the best health care available in the U.S.  Returning home, he reflects on health care in Norway, where everyone has access to very good care.

Norwegian Health Care

by Svein Toverud

My wife, an American, and I, a Norwegian, lived as a couple in Norway from 1956 to 1969 and again from 2003 until the present time. In the intervening years we lived in Chapel Hill, NC, so we are familiar with the present health care in the US. Personal medical challenges have caused us to be intimately familiar with both health care systems. In the US we were advantaged by comprehensive health insurance provided by my employer. We have been afforded exemplary care in both systems. In this brief essay I offer a description of our experience in Norway with the intent of providing some balance to the health care debate. 

Every Norwegian citizen or legal resident is entitled to receive services from the National Health Service supported by the national government and funded by taxes. Our first encounter with the NHS was the free prenatal care offered by a Health Care Center for Mothers and Children, staffed by a gynecologist, pediatrician, nurses and a dentist prior to the birth of our first child, and then our next three children. These centers are present in most communities in the country. Prenatal care can today also be obtained by gynecologists/obstetricians in private practice who receive full reimbursement from NHS while the patient pays only a nominal fee.

Babies are born in public hospitals, delivered by well trained midwives free of charge.  Experienced obstetricians are always available at no additional cost in case of complications. All health care for children until age 13 is free.  After that age there is a small fee for each service.  Children receive free dental care until age 18.  Orthodontic care is partially covered, and the extent of coverage depends on the severity of the malocclusion.  Dental care for adults is not covered by NHS and is provided for the most part by dentists in private practice. 

Regular health care (office visits) for the adult population is provided primarily by private practicing physicians who have contracted with the NHS to provide care for a given number of patients in their local community. At the beginning of each year the physicians charge a small fee for each service until the patient has met a deductable of $300 after which subsequent services are free. These physicians (“contract physicians”), many of whom have a specialty in family medicine, are also committed to participating in a system to provide emergency home visits at night.  My own experience with this part of the service illustrates its efficiency and benefits.  While suffering from a cold I suddenly developed labored breathing one night, called the medical emergency number and talked with a nurse who said she would send an ambulance right away.  The emergency medical technicians arrived within 30 minutes, did their examination and made the presumptive diagnosis of pneumonia, and contacted the physician on call that night.  He arrived within the hour, confirmed the diagnosis of pneumonia and started me on penicillin which he had with him.  I was saved a trip in the ambulance, exposure to other patients in the emergency roo
m at the local hospital, as well as hours of anxiety.  My “contract” physician took over the care the next day.

There is free choice of  “contract” physicians and people can change  physicians if they choose. Specialists are usually contacted after the “contract” physician has written a referral , and again patients  can choose their own specialist.  After the initial referral patients can continue seeing the specialist without involving the “contract” physician.  The specialists are also reimbursed by the NHS.

When hospitalization is required for further examination or a surgical procedure, patients have free choice of hospitals anywhere in the country. 

Waiting lists for certain hospital procedures do exist but have been reduced over the last several years.  Access to hip replacement is the most difficult and the waiting period varies now from 18 weeks at the most experienced hospital in Oslo to 3 weeks at a smaller hospital 80 miles north of Oslo. The PHS usually does not pay for elective surgical procedures outside the country. I did receive emergency arthroscopic surgery on a knee while working as a visiting scientist at the Karolinska Hospital in Stockholm,  Sweden after paying only a nominal fee. The health Services in Sweden and Denmark are very similar to that of Norway.

Physical therapy and occupational therapy, when recommended by the “contract” physician or a specialist, is provided free or after payment of a small fee. While recovering from a knee fracture suffered in a car accident I was even entitled to free physical therapy in my home.

Norway has made extensive use of visiting nurses (RN and LPN) in the home for chronically ill people or the elderly at no cost, and has consequently kept many people from having to be admitted to nursing homes, thus saving health care costs.  Many communities allow a temporary stay (up to 3 weeks several times a year at no cost) in a nursing home of a person who requires daily care but is still being cared for by a spouse in the home.  This respite care allows the caretaker spouse to travel or simply be free of the daily chores for a few days.

Drugs prescribed as essential treatment of chronic illnesses are provided free at any pharmacy.  As long as new drugs have been approved by a national board of experts as essential treatment they can be provided free even when the drug is expensive. I was diagnosed with the wet type of macular degeneration in one eye two years ago and have been given 16 treatments with the recently developed drug Lucentis which costs the hospital over $300 per treatment. So far the treatment has been effective.

As a double amputee in a wheelchair I have received a number of free benefits including a light-weight wheelchair that can be taken in and out of the trunk of our car, an electric wheelchair that allows me to travel outdoors even on snowy and icy roads in the winter, access to transport in my wheelchair in a van to physicians or hospitals for a small fee until I have met my annual deductible after which the transport is free. This service is available to any person unable to use public transportation. In addition every year I receive 80 trips in a wheelchair van for leisure purposes, such as attending cinemas, theaters, restaurants, anywhere in the city of Oslo with my wife or other attendant for a small fee, approximately 10% of a taxi fare.

Svein U. Toverud, DMD, PhD, Professor emeritus, Department of Pharmacology, School of Medicine, University of North Carolina at Chapel Hill.

Last week, I received a very sad e-mail from UNC’s Dr. Nortin Hadler, who had introduced me to Svein Toverud via e-mail. On Christmas Day, Toverud suffered a massive stroke and died on December 28.  (A CT scan confirmed the extent of the damage.) Hadler described Svein as a wise and gentle man. I wish I had had an opportunity to meet him.