Health in Norway

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Health in Norway, with its early history of poverty and infectious diseases along with famines and epidemics, was for most of the population not good at least into the 1800s. The country eventually changed from a peasant society to an industrial one and established a public health system in 1860.

History

In the early 1800s Norway faced major challenges. The differences between rich and poor were large, living conditions poor and infant mortality high. Economic conditions in the country improved, but still some social groups lived under constrained conditions. The nutritional status was poor as well as hygiene and living conditions. The conditions and class differences were worse in the cities than in the countryside.[1]

Immunization against smallpox was introduced in the first decade of the 19th century. In 1855, Gaustad Hospital opened as the first mental asylum in the country and was the start of an expansion in treating people with such disorders.[1] After 1900 living standards and health conditions improved and the nutritional status improved as poverty decreased. Improvement in public health occurred during development in several areas such as social and living conditions, changes in disease and medical outbreaks, establishment of the health care system and emphasis on public health matters. Vaccination and increased treatment opportunities with antibiotics resulted in great improvements. Average income increased as did improvements in hygiene. Nutrition became better and more effective also improving general health.

In the 1900s the situation improved in Norway and, as a result of decreased poverty, nutritional status improved. Within 100 years Norway became a wealthy nation. Even though Norway experienced a setback during World War II, the country achieved steady development. Improved hygiene led to fewer infectious diseases and scientific discoveries lead to breakthroughs in many fields including health.[1]

However, an economic downturn in the 1920s exacerbated the nutritional situation within the country. Nutrition therefore became an important part of social policies.[2] In periods there were high rates of unemployment, and poverty affected women and children most. Children often had to walk long distances to get work as shepherds during the summer in order to help their families with income. In mining towns as Røros, children also had to work in the mines.[1] Living conditions improved during the 1900s. From being a poor country, Norway developed within 100 years to become a wealthy nation. Even though the country experienced a set back under the Second World War, the country achieved steady development. From 1975 Norway was self-sufficient in petroleum products and oil became an important part of the Norwegian economy. Improved hygiene led to fewer infectious diseases and scientific discoveries lead to breakthroughs in many fields including health.[1]

After 1945, smoking became a relevant factor. While infectious diseases decreased, chronic diseases as cardiovascular disease was blooming.[1] From 2000, life expectancy was still on the increase. There are, however, still social differences when it comes to health. While globalization increases the demand for infectious control and knowledge, the Norwegian population demands more from the government in regards to health and treatment.[1]

Infant mortality

Early on, there were no statistics kept for the whole country on infant mortality, but in Asker and Bærum in 1809 infant mortality was 40 percent for all live births.[3] In 1900, infant mortality was higher in Norway than in any other European country. Development of the welfare state has contributed to a great decrease in infant mortality rates. This can be attributed to better nutrition and living conditions, better education and economy, better treatment possibilities and preventive health care (especially immunization).[1] The infant mortality rate increased again between the 1970 and 1980 due to sudden infant death syndrome (SIDS). SIDS was unknown from earlier, but the increase was dramatic. The trend was reversed when Norwegian parents were encouraged to lay their children on their backs and not their stomachs when sleeping.[1]

Population

At the beginning of the 19th century the total population was just under 1 million, however it doubled within the next hundred years even though many decided to emigrate. Industrialization resulted in many people emigrating from the countryside to the major cities for work.[1] At the beginning of the 1900s the population was 2,2 million and increased to about 4,5 million through the 1900s. 15 percent of the country’s population lived in Oslo and Akershus. The proportion of people associated with agriculture, forestry and fishing declined while the percentage affiliated with industries increased.[1]

Communicable diseases

The Norwegian government recognized that the population needed to improve its health if the country was to become a nation with strong economic development.[4]

  • Cholera and typhoid fever were common communicable diseases in the 1800s. Norway experienced several epidemics; cholera was the worst. The last epidemic outbreaks were around the 1840s. Even though these were not as severe as the Black Death in the 1300s, mortality rates were high.[1]
  • Sexually transmitted diseases also caused widespread problems. These were, however, not defined and divided into gonorrhea and syphilis until later on[when?].[1]
  • Smallpox was the most serious disease in the years around 1800; legislation for vaccination against smallpox was introduced in 1810. At first, the law was not strictly enforced but when people were commanded to show their vaccination cards at confirmations and weddings, there was an increase in the vaccinating of children and Norway finally gained some control over this disease.[1]
  • Leprosy, also known as Hansen's disease, ravaged the west coast of Norway. Patients were isolated in leprosy hospitals with room for up to 1000 patients. Gerhard Armauer Hansen (1841-1912), working in Bergen, discovered the leprosy bacillus. He revealed the association between hospitalization for infected patients and a decrease in the number of new cases.[5][6]
  • Tuberculosis caused many deaths in the late 1800s while leprosy rates declined. Mortality of tuberculosis was high around 1900, but decreased steadily for the next fifty years. The greatest decrease in tuberculosis happened before vaccinations and medical treatments were available; the decrease was caused by improved living conditions, nutrition, and hygiene.[1]
  • The Spanish flu of 1918 affected the country. This influenza pandemic took many lives, especially those of young people who lacked immunity to the new flu virus.[1]
  • Diphtheria, a common childhood disease, raged during the early years of World War II, but with new vaccines available, the country experienced an immediate positive response.[1]
  • Polio had its last major outbreak in 1951 when 2100 cases were registered.[7] In 1956 immunization of polio started.[1]

Discovery of microbes

In the late 1800s microbes were discovered and prevention of diseases were now possible. Until now, spreading of infections had only been debated. With new discoveries within the field and greater understanding on how bacteria and viruses transfer and spread among humans it was possible to make significant changes in treatment and care of patients. One example was to isolate people with leprosy and tuberculosis in order to stop spreading.[8]

Antibiotics

In the 1900s many vaccines were developed and the first antibiotic, penicillin, came about in the 1940s. These introductions were very powerful tools in preventing and treatment of childhood diseases.[1]

Vaccines

More vaccines became available and the child-vaccination-program was growing rapidly. Almost all feared childhood diseases were going extinct. Vaccines against measles (rubella) were introduced to the childhood immunization program in 1978. Rubella is dangerous to the fetus if the mother is affected during pregnancy. Today, all children are offered free vaccines and the offer is voluntary. The coverage for most vaccines is high.[1]

HIV/AIDS

In the early 1980s AIDS came as an unknown disease. Norway was early in preventing it in high-risk groups, through information campaigns. The HIV virus was later discovered and HIV tests became available from 1985.[1]

Cardiovascular diseases

Incidences of tuberculosis became fewer and an increase in cases and mortality of chronic diseases appeared, especially cardiovascular disease. Tobacco is one of the most important causes of cardiovascular and cancer diseases. During World War 2, the tobacco use in Norway was limited because of strict rationing. After the war, sale of tobacco bloomed and so did the implications from consuming it.[1] In the late 1900s, chronic diseases are dominating and because of increased life expectancy, people live longer with these chronic diseases. Around millennium new treatment and prevention for cardiovascular diseases ensured a decrease in mortality, however, these diseases are still one of the greatest public challenges in the country.[1] The incidence of coronary heart disease in Norway reduced significantly between 1995 and 2010 about 66% of the reduction due to changes in modifiable risk factors like activity levels, blood pressure, and cholesterol. Mortality reduced from 137 per 100,000 Person-years to 65.[9]

Lifestyle diseases

Lifestyle diseases are a new concept from the second half of the 1900s. Tobacco use and increases in cholesterol levels show a strong correlation to higher risk of cardiovascular disease.[1]

Mental health

Mental health services are part of the Norwegian special health care services. In some cases this includes involuntary mental health treatment.[10] The four regional health service institutions, owned by the state, receive fixed economic support from the state budget. They are responsible for special health services including mental health care in hospitals, institutions, district mental health centers, child and adolescent mental health services and nursing homes.[11]

In addition to providing treatment, the mental health care services provide research, education for health personnel, and follow-up of patients and their relatives.[11]

There are different sectors within the mental health services. District mental health centers are responsible for general mental health service. They have outpatient facilities, inpatient facilities and emergency teams. Patients can be referred to the district mental health center by a general practitioner for diagnosing, treatment or admission.[12]

There are specialized centers, ideally at central hospitals, for children and adolescents, the elderly, and severe cases such as drug addiction, personality disorders, obsessive compulsive disorders etc.[12] Normally people who are discharged from treatment at central hospitals are referred to the district mental health centers for follow-up and treatment. Treatment can consist of psychotherapy with or without medications. Physical treatments, such as electroconvulsive therapy, are used for specific disorders. Treatment usually starts at the hospital, with the aim of continuing treatment at home or at the district mental health center.[12]

Children and adolescents

Child and adolescent mental health outpatient facilities offer mental health care for children and adolescents between 0–17 years of age. Central child and adolescent mental health service is aimed at challenges which cannot be handled in the regional state facilities, such as the general practitioner, school nurse, school, outreach services for youth and child services. The child and adolescent mental health services work closely with psychologists, child psychiatrists, family therapists, neurologists, social workers etc. Their aim is to diagnose and treat psychiatric disorders, behavioral disorders and learning disorders in close collaboration with care givers.[13] For patients below the age of 16, parents must consent to admission.[13][14]

Involuntary care

Involuntary mental health care in Norway is divided into inpatient and outpatient facilities and observation.[14] In involuntary inpatient facilities patients can be held against their will, and can be picked up by the police if needed.[14] In involuntary outpatient services the patient lives at home or is voluntarily in an institution, but regularly has to report to the district mental health center. These patients cannot be held against their will, but can be picked up by the police in the case of missed appointments.[14] For involuntary observation in hospital a person can be held for up to ten days, or in some cases for twenty days, in order for the hospital to decide whether the criteria for involuntary mental health care are met.[14] The control committee has as their main task to ensure that every patient’s rights are secured and protected in a meeting with involuntary care.[15]

Financing

Mental health services are financed through needs-based basic funding to the regional health services, outpatient clinic refunding, deductibles and ear-marked grants from the state budget. Rates for outpatient work are partly based on hours worked and partly based on procedures; there are rates for diagnosing, treatment and follow-up per telephone or in collaborative meetings. In addition patients pay a deductible for outpatient consultations.[11]

Burden of disease

A survey done in 2011 showed that 10.2% of the population of Norway reported to have experienced symptoms of anxiety and depression within the last two weeks.[16] The life time prevalence of severe depression is estimated to be 15.6%. Treatment and social services for the mentally ill cost society about 70 million Norwegian kroner (more than 10 million US dollars) yearly.[17]

Today’s health status

Norway has a birth register, death register, cancer register, and population register, which enables to authorities to have an overview of the health situation in Norway. The total population in Norway as of 2012, was 4,994,000. The life expectancy at birth was 80 years for males and 84 years for females. The under five mortality per 1000 live births in 2012 were three cases. The probability of dying between 15 and 60 years for males is 73 and 44 for females per 1000 in population. The total expenditure on health per capita (international dollars) was 5,970. Total expenditure on health as percentage of GDP was 9%. Gross national income per capita (PPP international dollars) is 66,960.[18] Total fertility rate per women in 2012 was 1,9, the regional average was 1,7 and global average was 2,5. Prevalence of tuberculosis was 10 per 100 000 in population and the regional average was 56 while global average was 169.[19] In Norway today, there are 5371 HIV positive people 3618 men and 1753 women. In 2008 the incidence of HIV positive people had a peak and the highest incidence of HIV positive. Since that, there have been a decrease in new cases.[20] Norway was awarded first place according to the UNs Human Development Index (HDI) for 2013.[21]

Norway was awarded first place according to the UN's Human Development Index (HDI) for 2013.[22]

Statistics for Norway:[23]

Total population (2012) 4,994,000
Gross national income per capita (PPP international $, 2012) 66,960
Life expectancy at birth m/f (years, 2012) 80/84
Probability of dying before the age of five (per 1 000 live births, 2012) 3
Probability of dying between 15 and 60 years m/f (per 1 000 population, 2012) 73/44
Total expenditure on health per capita (Intl $, 2012) 5,970
Total expenditure on health as % of GDP (2012) 9.0

The total fertility rate per woman in 2012 was 1.9, the regional average was 1.7 and the global average was 2.5. The prevalence of tuberculosis was 10 per 100 000 in the population and the regional average was 56 while the global average was 169.[24] Tuberculosis incidence in Norway has increased from about 200 cases in 1997 to 400 cases in 2013.[25] Vaccination against tuberculosis, BCG, was part of the National vaccination program but has not been included since the school year 2008/2009. In Norway today, there are 5371 HIV positive people: 3618 men and 1753 women. In 2008 the incidence of HIV positive people peaked. Since then, there has been a decrease in new cases.[26]

New challenges

A wealthy economy makes it possible to buy tobacco, fast food, sweet drinks, and sweets that few people had access to or could afford until after 1950. These days many people have desk jobs, cars, and less demanding housework. In large, physical activity is decreasing, electronics, computers, social media, and the internet demands more of daily life. Drugs have also become more available in society. ‘New living conditions’ such as these give rise to new challenges for public health.[1] Only 30 percent of adults in Norway are fulfilling the advice to stay physical active for 150 minutes per week.[27] In Norway today, municipalities have a higher health responsibility then earlier. Preventing diseases from birth should be prioritized in public health.

Non-communicable diseases

Diseases in the 21st century that are dominating in Norway are cardiovascular diseases, cancer, COPD, and diabetes. Technological progress and development within medical treatment have since the 1970s had huge impact on survival of diseases and especially cardiovascular diseases.[1] Elders suffer from disabilities and chronic diseases such as cancer, dementia, and pain disorders. Elderly often have multiple diseases simultaneously, which together affect functional capacity, quality of life, and mental health.[1]

Social differences in health

The living standard of the Norwegian population has increased, though there are still differences between educational groups. Those with higher education and economy have generally the best health status. New legislations on public health (Folkehelseloven) came into play in 2012 and the purpose of this act is to contribute to a society that promotes public health and evens out social inequalities in health.[1]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 Lua error in package.lua at line 80: module 'strict' not found.
  2. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  3. ↑ Fure E. Spedbarnsdødeligheten i Asker og Bærum på 1700- og 1800 tallet. Tidsskr Nor Lægeforen 2005; 125: 3468-71.
  4. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  5. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  6. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  7. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  8. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  9. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  10. ↑ Psykisk helsevern[better source needed]
  11. ↑ 11.0 11.1 11.2 Lua error in package.lua at line 80: module 'strict' not found.
  12. ↑ 12.0 12.1 12.2 Distriktspsykiatrisk senter[better source needed]
  13. ↑ 13.0 13.1 Barne- og ungdomspsykiatri[better source needed]
  14. ↑ 14.0 14.1 14.2 14.3 14.4 Lua error in package.lua at line 80: module 'strict' not found.
  15. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  16. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  17. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  18. ↑ http://www.who.int/countries/nor/en/
  19. ↑ http://www.who.int/gho/countries/nor.pdf?ua=1
  20. ↑ http://www.fhi.no/dokumenter/48c40c10e0.pdf
  21. ↑ UNITED NATIONS. Human Development Report 2013. United Nations Development Programme (UNDP). ISBN 978-92-1-126340-4.
  22. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  23. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  24. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  25. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  26. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  27. ↑ http://www.fhi.no/eway/default.aspx?pid=239&trg=Content_7242&Main_6157=7239:0:25,8904&MainContent_7239=7242:0:25,8907&Content_7242=7244:110551::0:7243:3:::0:0
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