Foreign exchange: Comparing health policy in Scotland and Norway
Apr 25, 2011 No Comments
Correspondence between Phil Hanlon, professor of public health at the University of Glasgow and his Nordic counterpart, Freja Ulvestad Karki reveals a common purpose
The idea of a dialogue between Scotland and our Nordic neighbours is interesting because there is no doubt that in Scotland there is a strong belief that we can learn from places like Sweden, Norway and Finland. From our perspective, Norway and Sweden have enviable health outcomes and our perception is that this is through creating two of the most open and equal societies in the world.
I think the main reason is that health is perhaps the area of policy in which Scotland performs least well. If the United Kingdom countries were regarded as separate entities, then life expectancy in Scotland would, for women, be the lowest in the European Union, and for men, the second lowest after Portugal. Yet, Scotland has not always performed so poorly. In the first half of the 20th century, life expectancy in Scotland was actually higher for both men and women than in other Western European countries such as France, Spain and Italy. In the mid-20th century, however, while other countries, many of which had once lagged behind Scotland, improved, Scotland began to slip down the table of European life expectancy.
To understand this, it is necessary to look at differences in deaths at different ages, among men and women, and from different causes. This shows that Scotland’s position is not exceptional in infancy and childhood mortality. At older ages, while worse than the European average, it is not the worst; although while improvements among elderly men parallel the European average, among elderly females, Scots are slipping further behind. Instead, Scotland’s overall poor position is driven, to a considerable extent, by the very high mortality of working-age adults, where both men and women lag well behind European counterparts. The main causes are the chronic diseases of mid life (heart disease, cancer and respiratory disease) and increasingly, deaths from alcohol, drugs, suicide and violence (particularly among younger men).
So, I begin this dialogue with a conundrum. Scotland is a wealthy Western European country that seems to be performing less well than it should in heath outcomes. We blame deprivation and post-industrial decline but these factors, while important, do not seem to be the complete answer.
With all best wishes,
Firstly, thank you very much for starting this dialogue! It as a very useful way of exchanging and developing ideas about historic and current states of health and wealth in our respective societies, that share many cultural and historical features yet differ in a number of aspects. Introducing myself will help explain my perspectives. Born in Finland, I moved to Sweden in the 1980s and then emigrated to Norway – considering myself a kind of ‘atmosphere refugee’ – as I held strong views and observations about Swedish society in transition that were not necessarily positive.
I find your observation about our society being perceived as fair and equal, mutually supportive and a model to the rest of the world very interesting and to explore it we need some history. As you know, there was a major change in wealth in Norway thanks to the discovery of seemingly unlimited natural resources, oil, in the 1960s. This, to a large extent, changed the world’s (stereotypical) perception of Norway, and had a substantial impact on Norwegian self-perception. The balance between the Nordic countries then changed. Norway, from being a kind of adjunct to Sweden, substantially improved its status which translated into a large number of Swedes moving to Norway to work in trades unpopular amongst Norwegians.
Finland, for its part, from the Norwegian perspective, is seen as successful in educational terms with good pupil outcomes, which Norway cannot match. In our schools, children and youngsters perform relatively poorly by international comparison, and the long-standing explanation has been that our school system fosters social competence not academic performance. The Finnish school system is traditionally more focused on discipline and performance. The latter evokes pressure, and issues about performance, that can translate into anxieties and later mental health problems – perhaps unsurprisingly, Finland tops the suicide statistics among the Nordic countries.
To turn to the Norwegian self-perception, the stereotypical image of a Norwegian used to be an outdoor, mountains type, living the simple life. This would be a good thing for public health if still true, as much work is being done by Norwegian health authorities to combat sedentary life styles. Having a humanistic/humanitarian approach to one’s life and neighbours is also important in Norway, linked to a very high awareness of human rights including reducing social inequalities, welcoming refugees and so on. It is important to add gender equality, as the Norwegians have achieved a very good level of equality between the sexes. Of course, in wages and public representation we have some way to go but relatively, and comparatively, Norwegians are performing nicely. Individuality, demonstrated historically through the number of Norwegian Antarctic adventurers as in choosing a strategic political position outside the European Union, is also a praised characteristic.
It is also important to recognise widespread notions in Norway about balancing ideals of modesty with wealth, which can be seen as guilt about being privileged and also links to ideas of wanting forgiveness.
During the last decade or so, there has been an explosion of people applying for compensation for a ’lost childhood’, sometimes because the care system intervened in a negative way, but mostly for not intervening. The current trend is dichotomous, as while the scientific paradigm supports an evidence base, society itself increasingly trusts the subjective experiences and disclosures of its citizens.
One area where this notion can also be observed is the number of people on disability pension: Norway is the only country in the world where the level of public health has no correlation to the number of people receiving disability pensions! Of course the welfare structure influences this to a large extent, as does the status and role of general practice.
So to summarise, the Norwegians perceive themselves as a model for others whilst reminding themselves of the need to be humble. And welfare institutions have increasingly become receptacles for contemporary hopes and disappointments – a position not very different from that of the God of our ancestors.
Thank you for your thoughtful and interesting comments. I was struck that you considered yourself a kind of ‘atmosphere refugee’ and would like to hear more about the ‘atmosphere’ in Sweden and the detrimental transition that you perceive in that society. To explore further, I will draw on the work of Richard Eckersley (2004), an Australian writer, who observes that there are a series of ‘isms’ that afflict many modern societies. They are certainly evident in Scotland. These are: economism – the tendency to view events through the prism of economics, skewing society and politics away from other goals and towards growth; consumerism – the belief that fulfilment and happiness comes through the acquisition and ownership of material goods; individualism – the idea that the individual, individual rights and fulfilment are the most central dimension of life and scientism – the belief that the kind of science that helps explain the physical world is the only legitimate approach – and applicable to all spheres. This has led to another characteristic of modern culture – technocracy¬ – in which specialists have high status and make the rules.
The consequences of these influences and ‘isms’ are evident in our society. Arguably, the most widespread set of dysfunctional activities are “space-filling” activities. A large number of people experience contemporary life as insecure, uncertain, difficult and risky with no deeper meaning, and understandably, try to suppress these unpleasant feelings in a variety of ways. They overeat, overshop, overindulge, overwatch television, engage in much activity (being busy is a virtue in modern culture) or use sex or drugs (legal and illegal). These behaviours often lead to obesity, addiction, mental health problems, alcohol-related damage and sexually-transmitted diseases, the very health problems prominent in Scotland today.
The oil wealth of Norway will have solved many problems but what you say about the relationship that Norwegians have with ‘their welfare institutions’, which you say have increasingly become a receiver of high hopes and deep disappointments, is interesting. Wealth on its own does not seem to satisfy. The ‘ism’ of modern societies can undermine a deeper sense of purpose and meaning in life. You seemed to be hinting that in Norway these tensions are also being experienced by ordinary people. It is certainly true of Scotland.
With all best wishes,
Thank you for your most interesting and thought-provoking reflections! I forgot to mention previously that I also briefly lived in Denmark while working for the WHO, an experience also giving some insight into Danish society. The circumstances for my emigration from Sweden indeed coincided with some of the emerging features in the atmosphere mentioned in the list of –isms. In my subjective opinion, Sweden was corresponding to various idealised national characteristics – an old and free civilisation, still reflecting the cultural glow of ancient heroism, invincible in wars long ago (true, to some extent), yet demonstrating a current deep devotion to political neutrality and a social democratic value system.
Furthermore, Swedish society was able to afford freedom of speech and thought for its citizens. To reflect upon how it was possible to create a burgeoning welfare system, and openness and hospitality, in a country with originally scarce resources on the outskirts of Europe, some historical interpretations should be made. During World War Two, Sweden received a number of ‘war children’ from Finland, and continued to welcome foreigners from different countries through labour immigration but also through refugee reception. As early as the 18th century, a flow of Finns were welcomed to inhabit and cultivate under-populated areas in the Swedish forests. (Finland, then, was part of the same kingdom, though considered a cultural and historic backyard.)
A cornerstone in Swedish self-understanding is ‘The People’s home’ (folkehemmet). The construction itself was a political and societal reform intended to ensure every member of Swedish society equal rights and welfare in the framework of solidarity but without giving up the capitalistic economy. Adherence to this idea was demonstrated when the social democrats finally lost to the right wing in the 1970s and the latter ruled the country implementing the former’s politics! However, changes came, and the originally Swedish homogenous society went through a transition in the 1970s to 1980s, and these social democratic ideas, implemented on a large scale since the 1930s, were tested. They no longer had the same legitimacy, and commitment to shared values and collective responsibilities were gradually pulverised. The Swedes would probably say even today that the ‘good old principles’ still reign, and the economy indeed still works in line with them – but the glue in the system no longer exists to the same extent.
One hypothesis could be that the population no longer has access to the same historic value system due to integration challenges, and where Sweden (even if it, in the 19th and 20th centuries, also had a cosmopolitical orientation) increasingly found its new ideals from European contexts on the cost of nation-specific political ideas and its own identity. Urbanisation proceeded and the countryside was more or less emptied (in Norway this development has been deliberately restricted through governmental subsidies to the least densely populated areas), leaving behind a sense of continuity embedded in the earlier self-understanding.
That was when I moved to Norway. In Norway too, the –isms are emerging gradually, and the general discourse has for a number of years been individual rights over the collective sphere, however, the latter is defined. The classless society has been realised to a greater extent than in Sweden where the upper classes never lost their privileges in the same way as in Norway. Instead, a new upper class – through inherited or self-made wealth – has been growing, but the nouveau riche are strangely not considered a threat to equality.
Another big question was, at least before the financial crisis, whether Norway should join the EU. Some voices supported membership, arguing for more influence internationally, others because of a solidarity principle. The majority has all the time been against. The contemporary economic situation, though, has contributed to silence these discussions.
But to return to your question about the –isms and whether they are experienced by people on a large scale, indeed they are, and one of the consequences is the growth of small groups that could be characterised as aspects of the new age-movement, as spirituality is sought through alternative medicine, healers and spiritualist teaching. But Norway was again recently selected as the number one country in terms of good living conditions. At the same time, alcohol consumption increases and free time is so packed with activities that reflections about the meaning of time itself leave us stressed and frustrated.
Paradoxically, while being ‘connected’ to whoever, whenever, we gradually lose connection to ourselves. The ideal of being a global individual suppresses the fact that the only way of living one’s life is to live it locally. This is the contemporary trend, supposedly shared with both Scotland and other western societies.
I was fascinated by your most recent letter and am learning that the countries in which you have lived have profoundly changed. I would like to explore the problem that our countries seem to have with alcohol (and in Scotland also with illegal drugs). Scotland is sixth in the world rankings for illicit drug use – only Afghanistan, Iran, Mauritius, Costa Rica and Russia have worse problems! This is new. As recently as the 1970s, official reviews concluded that we had no major drugs problem. The situation with alcohol is similar. The rise in deaths from alcohol took off during the early 1990s, since when male death rates from alcohol have quadrupled and female rates more than doubled.
Throughout history, addictions are less problematic when societies are more stable and cohesive. Modern free-market societies like the UK create wealth but also subject people to irresistible pressures towards individualism and competition, tearing them from the social and spiritual ties that normally constitute human life. People adapt to their dislocation by finding the best substitute for a sustaining social and spiritual life that they can, and addiction can serve this function all to well. Currently, drugs and alcohol are being confronted by linked policy initiatives – prevention, harm reduction, treatment and law enforcement. Each component has value but despite all these efforts, the problem is growing.
Many in Scotland see Norway and Sweden as having resisted some of the worst manifestations of modernity. They argue that if we were more like you (less inequality, more support for children, greater community solidarity, more meaningful work) there would be less addiction in Scotland. Most recently, this has led our government to try (without success) to raise the price of alcohol. My feeling is that price is important but we need a change throughout Scottish society and not just among those who are struggling with ‘overwhelming involvement’.
There is a yearning for change. Yet, there is also denial over the scale and severity of the problems we face. We look to the Nordic countries for inspiration but from what you say and from what I have read elsewhere, you also have a problem with alcohol – and you have very expensive alcohol. I would be really interested to hear more about your understanding of why this problem has developed and what you think might be done about it?
Thank you very much for your letter! It is interesting how attitudes towards alcohol and drug use and abuse change in different time periods. In Finland, Sweden and Norway, there is (or was until the EU regulations somewhat altered the praxis for Finland and Sweden) a state monopoly for trading alcohol. There is also a history of several decades of combating negative consequences of alcohol abuse, but with modest outcomes. Strategies and plans have been developed to control the problem but rail against seemingly insurmountable industrial unwillingness, and deep rooted beliefs in individual free choice and determination. Drug abuse is a growing concern too, and a few years ago there was a heated discussion among Norwegian politicians about whether regular heroin users should be granted their daily dose financed by the state. The topic among other things was which measures to use to guarantee a ’worthy life’” for all the citizens in the Norwegian society.
The change in drinking habits in the Nordic countries has mostly been towards urban wine drinking adopted from the more southern latitudes in combination with traditional binge drinking, especially during weekends. Finns would be (as they have been all the time) the leading nation here but the others also qualify. The wealthy drink more expensive and more sophisticated choices – the less wealthy stick to their ancestors’ choices and patterns. One special issue are districts near national borders with access to inexpensive alcohol – Denmark (Germany), Norway (Sweden) and Finland (Estonia). European approaches to alcohol taxation don’t consider public health priorities as much as trade and economic aspects!
During the last decade, the consumption of alcohol has increased most in Finland, Iceland and Norway and decreased or remained the same in Denmark and Sweden. Finland tops the list of alcohol-related deaths, liver dysfunctions and intoxications, and arguably the Finnish melancholic mind-set, social patterns and family structures, combined with influence from Russian drinking traditions, greatly affect the attitudes and practices of its population.
So in terms of societal changes reflected in increased use and abuse, increasingly, we perceive the abdication of the middle generation, the one which the younger ones previously turned to for supervision and advice. In our society the three generations conduct very separate lives in their respective cultures, and the exchange between them can often be characterised as alienated rather than fruitful. The ideals and idols for each are to be found outside the traditional value systems. TV, of course, has had an enormous impact on our relationship to alcohol since the 1960s, and liberal American habits have been adopted accordingly.
At the same time, the combination of more leisure time, beliefs in freedom of choice for all and disappearing parenting skills have resulted in an unhappy situation where the cornerstone in reframing the life of the next generation is replaced by an army of so-called experts giving advice about things that previously were a part of normal life experiences.
But speaking about the specific Norwegian situation (because I think that even if high levels of alcohol consumption are the same across Nordic countries, the mechanisms behind might be at least slightly different), the special conditions in Norway reinforce a strong belief that everybody can become whatever she or he chooses and that life choices are virtually unlimited. Everybody should take higher education (high school at the very minimum), and everybody is entitled to a good life with handsome rewards, quite independently of their efforts or abilities. Practically, this means that initial differences should be compensated for (by society) or denied. I think that the trend has been a kind of state of denial now moving rapidly towards compensation.
School drop-out is a problem, and Norway has many people on disability pension as mentioned before, and only 0.5 per cent of those return to work. But the employment climate in our country is no worse than others and we embrace work migrants from other countries. However, Norwegians increasingly see themselves as fragile creatures and implant this attitude in our children – and this is one of my main points. We don’t, from the start, think that pain or sickness should be a part of life. We give a great amount of painkillers to children and youngsters. Alcohol can be used for the same purpose, it can compensate for discomforts minor or major, and is also part of the urban, cosmopolitan life that we want to embrace. Elderly people in care homes too are given tranquillisers to make them more easy to manage for the busy and stressed staff.
But to return to reflections about the causes – I think that primarily, imaginary choices and frustrated hopes make us vulnerable, rather than the burdens of our postmodern lives. It goes without saying that this is not to deny vulnerable groups in need of special attention, I’m just speaking about the majority. Addiction is a rising concern, whether the internet, food, alcohol or shopping. We are allergic to feeling bored, and need to be compensated with new stimuli that is ready-made and entertaining. Alcohol is expensive in Norway but everybody can afford it. Decadence originally reserved for the selected few is now within everyone’s reach!
Promotion and prevention is the key from very early on. Champions should be used to give children healthy ideals, and parents should be reconnected to their parental ability. Parents and schools should collaborate to a much greater extent to the benefit of children, and we should all learn to postpone gratification to give the growing generation a good example.
But if we ourselves are unwilling to speak and think making these suggestions is a morality issue. Culture is gradually changed through introducing a set of attractive values that compete with the ruling negative ones. For example, refusing alcohol in company should boost identity rather than foster shame. At the end of the day, adults must lead the way.
With best wishes, Freja
This is my final communication in what has been a fascinating dialogue. I have learned that Scotland is not really so different from Norway and Sweden. We face similar challenges and seem to be employing very comparable approaches when it comes to devising solutions. Norway and Sweden have a great deal to teach us in Scotland as I think some of your social and economic policies have softened some of the harsher impacts of the competitive market economy. We can learn from these specific examples but, more importantly, all the countries that face these problems can learn from each other.
I identified strongly with your use of the term ‘three generations’ to better understand what is occurring in our societies. As a member of the middle generation, my observations of the generation above and below confirm much of what you said in your last letter. The older generation were born into the great depression and the Second World War where personal resources were often scarce and they had to learn resilience when young. It was a harsher world in which family and community solidarity were strong but it was also intolerant of outsiders and minorities, and women often suffered from discrimination. So, we must not fall into the trap of imagining that things were better in the past.
So, where does this take us? My own thinking is that we are entering what might best be called a ‘change of age’. That is, we are already in a process of change as revolutionary as the transition from agriculture to industry: from the pre-modern to the modern world. This is the ‘modern world’ of which we have been speaking in this dialogue and it is clear to me that the similarities between our countries come from this common experience of modernity.
The ability of modern people to understand, predict and control the natural world has brought many undoubted benefits, such as health and material prosperity. However, evidence is also steadily accumulating that the methods and mindset which were successful in the early period of modernity are now subject to diminishing returns and adverse effects. One manifestation of this is the rise of new forms of ‘dis-ease’ (rather than disease): obesity, alcohol related harm, loss of wellbeing, rising rates of depression. For these challenges the tools of modernity have proven largely unsuccessful.
This prompts me to suggest that a new approach is needed. As yet, however, there is little evidence that many people are responding to modernity by embracing a new mindset. You called at the end of your last letter for adults to lead change. By this I assumed you meant the middle generation I refer to above. I agree that this would be wonderful if it happened but instead we seem to observe denial, resistance or – at best – passive adaptation. Whilst we might be able to ignore or deny the effects of these dis-eases, there are still other threats that we cannot ignore, because of their massive potential effects on our lives. Climate change, peak oil and resource depletion (amongst other problems) provide convincing evidence that there are limits to conventional ideals of economic growth. If we are to avoid a total collapse in our civilisation (I think some collapse is inevitable and some dimensions may even be desirable), profound change will be needed.
None of us can predict in any detail what will happen next but radical change is surely coming. And if change is inevitable, then we urgently need to identify opportunities as well as threats: we need to find the ‘upside of down’. Although daunting, I honestly believe that the fundamental nature of the emerging ‘change of age’ is hopeful. The reasons for hope include the obvious resilience of all human beings and our ability to reach out to each other. Thank you for being so willing to share your insights.
With all best wishes,
It has been a great pleasure to correspond with you around some of the most burning societal topics of our time! I very much liked the hopefulness at the end of your final letter even if the challenges are massive.
Indeed, there are many signs of awakening, not least in the youngest generation, even if hope must be nurtured continuously. And indeed, Scottish experiences are, to a large extent, shared by our Nordic countries. The days of escapism are definitely over, and realities have to be faced. Your description of the middle generation’s dilemma was very pertinent, and it is easy to recognise the features you are mirroring.
The things were not, as you mention, better in the old days, but the choices seemed more clear-cut and controversies more explicit where they emerged. This goes also for generational controversies. A friend once asked, looking at youngsters enjoying themselves – ‘What do they have that we don’t ?’ and I answered, ‘The knowledge about how it is to be part of the next generation’.
There are two mythological creatures in Norwegian folklore – Peer Gynt (Ibsen) and Askeladden (a popular adventure). The first one is manically convinced about his invincibility, and ends by recognising the existential emptiness in all his opportunistic fortune seeking. The second one is creatively using everything he finds for practical purposes, independent of other people’s opinion – and eventually wins the princess and half of the kingdom. I think that we must make our way from the false premise of Peer Gynt to the practical wisdom of the fairy tale. We also have to find the holistic approach to change of age even if we are being bombarded by both quality time and junk food and by easily adapted face-value solutions to serious problems.
All the best,
Taken from Gerry Hassan and Rosie Ilett (eds.), ‘Radical Scotland: Arguments for Self-Determination’, just published by Luath Press £12.99.