Saturday, July 4, 2009

My Purple Door

Three of my four grandparents emigrated to the USA from Sweden, and one of the highlights of my adult life has been reconnecting with cousins in the small village where my father's people have lived for hundreds of years. Sweden is a rural country of 9 million people, with a population size that mirrors my home state of Georgia and a land mass similar to California's.

Sweden's bucolic beauty shares elements of the pacific Northwest, coastal New England, and Alaska. Most remarkable, at least to my American eye, is how Sweden's infrastructure complements its natural beauty. No suburban sprawl, no ribbons of strip malls connecting one group of Walmart shoppers to the next, few fast food outlets beckoning always-hungry, rarely-satiated citizens.

Homes in the country, like the one here that belonged to my great, great grandparents, are usually painted wood. They showcase traditional designs and palates, contributing to a landscape that is even more beautiful than the sum of its parts. (If you get a chance to bet on the color of a house in rural Sweden, choose barn red; light gold; or wedgewood blue. You're going to win.)

One night, while drinking with my cousins, it occurred to me to ask about the social customs and constraints that produced such a holistic landscape. "Stefan," I asked, "What if a Swede wanted to paint his house purple? Could he do that?" My cousin paused to be certain he understood the question, explained a little about local zoning, then said, "But a Swede would never want to paint his house purple."

This led to the telling of a story about the desirability, from the Swedish point of view, of being an average citizen, "a middle Svenson," as my cousin explained it. In Sweden, people are discouraged from living or behaving in ways that substantively distinguish them from their peers. This doesn't mean that individuals aren't creative or expressive. It simply means that one's efforts should reflect established norms, building upon principles, traditions, and aesthetics that have withstood the test of time. A person who painted his house purple would invite unwelcome attention, irrespective of how lovely the shade. So would a person who parked a broken washing machine on his porch.

My cousin's insight helped me understand why the Swedish countryside looks the way it does. The explanation helped me understand a little more about rural Georgia, too.

Culture impacts more than paint colors and where old appliances are laid to rest. Take health outcomes for Georgia and Sweden, two locales that share both population size and challenges that come with providing care in rural settings:
  • In Sweden, deaths of infants in the first month of life--a statistic that's considered a reliable marker of overall population health--number 2.1 per 1,000 live births.
  • In pockets of Georgia, where the least healthy and poorest citizens are clustered, the neonatal death rate is 17 per 1,000.
  • Some of Georgia's citizens do much better, with neonatal mortality rates in the weathiest suburbs at 4.2 per 1,000.

These comparative health outcome data are especially important for Americans, who, like me, can access highest end healthcare and often believe they have something to lose when the subject of healthcare reform is broached. Sweden's best--a best that represents outcomes for all citizens, not just the healthiest and weathiest--is far better than what the most privileged Georgian can expect.

The take-away? No matter how well you think a market-driven healthcare economy works, it's important to remember that you can't buy what doesn't exist.

My husband, an ex-pat Canadian and naturalized American citizen, worries less than I do about identifying an appropriate healthcare model for Americans to emulate. Americans, he says, are not like anyone else, even though we are, in point of fact, a little bit of everyone else. My husband believes that a uniquely American solution, one that accepts our good intentions, bad behaviors, unparalleled diversity, and independent ways will emerge. I hope he's right.

From the looks of our front door, I kind of need him to be.


Reality Rounds said...

Neonatal deaths are not so much indicative of population health, but of societal health. It is not just about access to health care, but also about access to clean water, good nutrition, clean air, and too much access to drugs and alcohol. Sweden (which is a great country, visited there in 2002) is a homogeneous society compared to the US or Georgia for that matter. The number one reason for neonatal deaths (deaths before the 28th day of life) are due to prematurity. Sweden has infrastructure in place which limits prematurity such as: limits on fertility treatments, higher gestational ages for appropriate resuscitation, low rates of obesity, drug use and smoking, less air pollution etc. I also hope your husband is right the the most diverse country on earth can find a solution to the health care mess we are in.

Barbara Olson, MS, RN, FISMP said...

Yeah, me too. I've been trying to bring more "appreciative inquiry" ("glass 1/2 full") to my writing. Most days I think it's highly probable that we're going to continue paying way too much for not-great-outcomes. Thanks for rounding out the discussion about the variables that inform neonatal mortality rates!


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