What does emergency medicine have to do with good health?*

*If you have gone to the Rick Bukata school of medicine you would automatically conclude the answer is no based purely on the title, but maybe there’s room for debate

I’m returning to Australia from a holiday in Scandinavia and Germany. As my return flight loomed closer, insecurities were growing about my abilities as an emergency physician. Had I spent the previous six months living up to the standards of clinical credibility that I hold myself to? Had I tried to foster a culture of kindness and caring towards my colleagues whilst trying to nudge for small improvements (usually less radiation, more ultrasound and history+exam)?  

When travelling, I love the privileges afforded by walking almost everywhere. There is usually a beer:exercise mismatch which needs managing, and lots of thinking to be done about life. When thinking gets tiresome whilst walking, podcasts offer an alternative form of simulation.  In the depths of my introspection tonight whilst walking home from a museum, my self-admonishment was interrupted and dissipated by an ABC Radio National Big Ideas podcast on refugees – specifically on the systematic and codified methods of physical and psychological abuse of fellow human beings meted out by my own national government, who are nominally the democratic instrument of the Australian population.  Having spent most of my day at the Deutsches Technikmuseum Berlin and seen railway wagons which transported Jewish people to their deaths, perhaps I was already primed to react strongly against state-enacted human rights abuses. Feeling somewhat impotent to meaningfully deal with this issue, I started to reflect on the social determinants of health (since the refugees on Manus Island are completely screwed in this respect). What does it means to have “good” health?  Can emergency medicine influence this in anyway?  My holiday experiences suggested some answers.

I spent seven days in Norway and did not see anyone who was obese.  This is in contradistinction to the town I live in, where some days it seems like I do not see a single person who is non-obese.  I spent five days in Sweden and I did not see anyone who was drunk and disorderly or drug affected.  To contextualise – I specifically went to Sweden to attend several electronic music concerts which went on well into the early hours – I think I had a fair crack at trying to find drug or alcohol related problems.  On the whole, the people in Scandinavia seemed to be far more healthy. Why could this be so? I’ve tried to identify some possible determinants of the perceived differences

Attitude towards the environment
In Norway, I observed a pervasive respect for natural beauty, and a desire to preserve, improve, and be a part of the physical environment.  Perhaps it’s related to colonial heritage, but when the scrubby forest surrounding my town was first surveyed, settlers concluded that the trees were not good for anything except for chopping down to make handles for stock-whips – hence The Whipstick.  54% of Swedish energy is renewable. The current Prime Minister of Australia jokes that coal won’t hurt anyone. Could Australian poverty in environmental values translate into poverty of health? 


The physical environment itself
There is no denying that the Lofoten Islands are stunningly beautiful, as is the Swedish archipelago. It could be argued that the natural beauty draws people out of their homes, thereby keeping them more fit and active. Beautiful it might be, but if you do want to go outside in winter you have to contend with temperatures of -10.C or less, with wind chill factors more again.  It clearly didn’t stop the numerous nanas I saw from getting out and about on their 3-runner push sleds which appeared to be the equivalent of our 4-wheel frames.  With the snow and ice, “#NOF central?” as one of my colleagues suggested. I don’t think so. The older adults I saw looked pretty darn robust.  I couldn’t find any nursing homes either. A different attitude to supporting elderly people as well perhaps? Thinking about the Australian relationship with nature, for many I suspect “The Great Outdoors” is a TV show.


Treatment of marginalised people
For a small town in the arctic circle, I was astounded to find a host of resettled refugees in Svolvaer. Taking a straw poll from various locals, they all spoke warmly about the refugees who had come to their town, and acknowledged with compassion that when other people are suffering, you have a morale duty to try to help them.  How reasonable! In Australia, meanwhile, there are concerns that marginalised people will take our jobs, erode white Christian values, or terrorise us.


Poster of a healthy nation?

boat people

Short memory?


The Norwegian perspective

Attitude towards alcohol
In Sweden, outside of bars/clubs/restaurants, the only place you can buy alcohol is the state-owned monopoly of stores: Systembolaget. The trading hours are restricted compared to Australia, but if you plann your alcohol purchases in advance it’s easy. Interestingly, the cost of alcohol in Sweden seemed notably less than in Australia. The drinking culture seemed to be sensible. This had not always been the case – as readers of Per Anders Fogelström’s “City of my dreams” could well attest to, so somewhere along the line alcohol use in Sweden alcohol attitudes changed for the better.


No need for refrigeration in winter

Relationship with animals
In Scandinavia it is very natural for dogs to go everywhere – trains, buses, bottle shops. The dogs seemed happy, as did the owners. I’m sure that this happiness translates into health. If 25 million people can do it in the northern hemisphere, why do 25 million people in the southern hemisphere have conniptions at the mere thought of a dog riding a VLine service?


Social connectedness and harmony
The places I’ve recently visited seemed disinterested in identity politics. A person is a person is a person, and that is good enough.  Gender neutral toilets everywhere in Sweden were just one example of the population getting on with focusing on togetherness rather than divisiveness.  


Relationship with work
In Norway people are heavily taxed if they work too much (financial disincentive for not looking after yourself?).  In Australia, despite hollow gestures from employers and regulators, people in health care are routinely punished by being worked got the point of severe health problems. This is tacitly culturally accepted by the powerful as being “what you have to do”.


The response so far…

Sense of humour
The Scandinavians didn’t seem to mind taking the piss. Seriously, when your national language is Swedish, why not give your train an English name to stick it to the poms? (The poms couldn’t bare the thought of not being taken seriously and despite popular vote chose not to go with Boaty McBoatface; I fear the colonial apple doesn’t rot far from the tree).   I feel that being too serious is bad for your health – look at the NHS.


Express Stockholm to Gothenburg

Screen Shot 2019-02-06 at 11.39.08 pm

What happened to the ministry of silly walks?

Can do attitude
In 2016 the Norwegian airforce used a fast jet to deliver an ECMO circuit to Bødo (a remote but incredibly beautiful town, I can recommend) for a time-critical emergency.  Meanwhile if you have a STEMI complicated by cardiogenic shock on a weekend in Bendigo, the cardiologist can be at your bedside but the Cath lab won’t open because “it can’t”.


Putting it all together, people in Scandinavia are almost certainly not more healthy than Australians because they have better access to statins, ECMO circuits, or a tax on sugar (they don’t, as the number of cinnamon buns I have consumed attests to). I wonder if it’s because they have better relationships with their fellow citizens, their neighbours, their planet, and their own individual inner moods and emotions on their journey in life to obtain meaning and happiness.

So can emergency medicine help influence good health? Sometimes it really feels like it is pushing shit up hill. But I guess it depends. The fabulous work done by people such as Diana Egerton-Warburton have clearly had a profound positive impact on health at a population level.

At present, I disappointingly don’t think I’ve got the staying power to take the path Diana has. To start with, I might aim to nudge good health into my immediate surroundings by trying to set an example of the Scandinavian values I’m so admiring of. Maybe in another 10 years I’ll be frustrated and take the public health route, but then again emergency medicine is just so much fun…

One thought on “What does emergency medicine have to do with good health?*

  1. Lots I agree with here Tom- Scandinavia is a beautiful place.

    But I wanted to highlight a few things: while most of Norway’s electricity is produced by hydro, Norway is one of the world’s largest exporters of oil (1,647,975 barrels of oil a day in 2016 and natural gas is even more impressive: 123,200 million cubic meters in 2016). Health and wealth are strongly associated and a significant proportion of Norway’s wealth can be attributed to this. So while attitudes to the environment and respect for natural beauty may explain some of the population’s good health, so do the attitudes towards gas and oil exports.

    I don’t know what defines a sensible drinking culture but Sweden suffer’s a significant health burden from alcohol as well. Alcohol consumption pattern for Sweden and Australia:

    It is pretty cool that the air force delivered an ECMO circuit to Bødo. Though a comparison of Norway and Australia’s delivery of health services to remote areas probably should have a little more to do with the fact that Norway’s geographical area is 20 times smaller, Norway’s population density is 5 times higher, per capita Norwegians are richer, than a can do attitude.

    Connectedness to the planet and inner emotions aside, there are probably more tangible reasons for differences in health e.g. higher income inequality and lower income per capita. Furthermore, Australia’s low population density and large geographic area makes it difficult for the population to utilise public transport or to cycle. Countries with high rates of walking and cycling (many European countries) have less obesity + diabetes than those that are highly car dependent (us). Also, the evidence for a tax on sugar sweetened beverages is growing and I feel it needs whole hearted support from the medical profession https://apps.who.int/iris/handle/10665/260253

    Anyway, Norway is an absolutely beautiful place and we certainly can learn a lot from them. One thing they have completely wrong however: they don’t have emergency physicians! https://www.laakariliitto.fi/site/assets/files/1268/physicians_in_the_nordic_countries_2016.pdf But they may be following our model and changing that soon.

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