Health post: Let’s get into it

In my last health post, I described the CTMH Fellowship program, which follows a problem- and need-based approach to developing medical technology solutions. Though the idea for the fellowship was conceived by Stanford University in the U.S., the focus on finding a real need ahead of developing a solution seems well-aligned with the Swedish tradition of human-centered design (ergonomics). Sjoerd and I discussed what factors influence the success of a medical device based on what he’s learned from the CTMH fellowship program, the Stanford program, and eHealth companies in general.

These are factors that are important to consider when designing a medical device anywhere. However, we also talked about what specifically makes Sweden so “healthy” – that is, what cultural and political factors affect its healthcare system and eHealth innovation. I’ve talked about this with many other Swedes, including doctors and researchers; for example, I first visited Karolinska Institute to meet with Gösta, a professor of medical engineering there. He’s the one who first suggested that I contact Sjoerd at CTMH, and I’ll include some of his thoughts in this post.

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The closest train station to Karolinska Institute is Flemingsberg. As you exit the train station, you’re greeted with this sign. “Flemingsberg: From Brains to Business.”

One of my favorite questions to ask is, “What is the main reason that Sweden has such a high health standard?” Sjoerd’s answer was that the public system provides access for all. I would say about three-quarters of the Swedes I’ve interviewed share this sentiment that the free (or nearly free) healthcare is #1 reason why Sweden is one of the healthiest countries in the world. Sjoerd showed me a slide with the actual numbers, which I’m not sure I’ve ever shared in detail:

  • Healthcare and dental care are separate.
  • Each visit to a doctor costs 150kr, about $18. The maximum you would pay in doctor visits per year is 1,100kr, about $150. After that the government pays for everything.
  • Dental care is entirely free until the age of 20. After that, each dentist visit costs 150kr for a total of 1,100kr per year.

So even if you go to the doctor and the dentist many times, you won’t pay more than $300 in medical fees in one year (unless you seek special, non-mainstream treatment).

Nationwide access to public health is a political (or perhaps economic) factor contributing to the country’s high health standard. Another political factor is the country’s functioning infrastructure, which allows it to support and maintain hospitals and new technologies. Also, the government makes a concerted effort to invest in medical technology. The Stockholm city government established the SLL Innovation Fund two years ago to help medical device companies address the needs of the country’s growing and aging population (http://sllinnovation.se/). While this is a good step, Gösta said that the money in the fund is “not enough” yet.

Moving on from government, Sjoerd and Gösta also identified some of the cultural and historical factors that relate to Sweden’s health and medical technology. First, history. Sweden was not a part of World War II and thus came out of the war completely unharmed, leading to a period of thriving industry in the 1950s and 60s. I was happy that Gösta, along with a couple other Swedes I’ve met in the past week, mentioned history as a reason that Sweden is so healthy and technologically advanced. I hadn’t been thinking about Sweden’s recent history, at least not in relation to my project. I had been thinking of medical technology as a here-and-now thing, a view supported by my meetings with young start-up companies. Also, despite Sweden’s small size, it has produced many inventors over time. People always point to Ericsson, Spotify, and Tetra Pak as classic examples of Swedish invention; furthermore, the first implantable pacemaker was invented in Sweden, at Karolinska Institute. This strong engineering background and history of innovation (especially considering the importance of the Nobel Prize to Sweden, as I mentioned yesterday) might be why so many Swedish innovators are inspired today.

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The student library at Karolinska Institute.

Next, culture. In Sweden, there is a prevailing attitude of trust in the government. Gösta, Sjoerd, and many other Swedes have expressed this. I’ve also noticed it myself, not just in healthcare but in taxation, transportation, childcare, education, and more. There is a trust that the government does good, plus the corollary that government workers want to do good. Swedish people often seem passive and obedient due to this trust, accepting what the government offers since they know, truly, that their government has their best interests at heart. I’m not sure how this relates to attitudes towards medical tech, though, except to say that attitudes might be filtered by the government’s opinion. If the government recommends some medical device, the public will be inclined to use it.

However, it’s not as though people are wary of tech that doesn’t get government recognition; rather, I have heard from many that there is an openness to new technology in Sweden. This is a cultural trend that is important for creating an environment in which medical devices are successful and adopted. In fact, Sjoerd described the Swedish as “early adopters,” often the first to try out a new device or system. Gösta put it more broadly, saying that the acceptance of technology is due to Swedish people being tolerant and flexible overall. Today, I spoke with a Swedish Swarthmore alumna, who said that not only is it the norm for people of all ages to pick up new tech, but it’s considered strange for elderly people not to text or have smartphones or want to learn new technologies (for example).

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Inside Karolinska’s new main building.

Early adoption has its pros and cons, however. It leads to instances of “legacy tech” or “legacy software,” meaning that older or original versions of a technology are used even if newer versions have become available (https://www.techopedia.com/definition/635/legacy-system). For example, Sjoerd told me about EHR systems in Sweden. As I’ve mentioned earlier, EHR systems allow hospitals to keep electronic records of all their patients. In each of the 21 counties of Sweden, the county government is responsible for managing the hospitals in that county and deciding what software they use (http://salusdigital.net/ehr-records-sweden-future-brings/). Back in the 1980s, these counties started adopting EHR systems one by one. Now, the 21 counties have different EHR systems, some far older than others (the so-called legacy tech). Unfortunately, it isn’t so easy to upgrade legacy technology, as I alluded to in my last health post; for a hospital to change EHR platforms, for example, they would have to hire a large engineering team, successfully transfer massive amounts of sensitive information, get the government’s support, and find a time that works for the hospital. This isn’t a problem in countries that are “late adopters,” who adopt technologies after they’ve been available for quite some time. Then these countries can pick one up-to-date system to deploy nationwide.

There is a second problem with being an early adopter: what if you adopt something really bad? What if you sign onto a technology too early, before it has been tested? It’s finally time to tell you about Paolo Macchiarini. Originally from Italy, Macchiarini is a throat surgeon who just lost his job as professor of regenerative medicine at Karolinska Institute here in Stockholm. He rose to fame for his trachea transplants, replacing patients’ tracheas with synthetic tracheas built from their own stem cells – a completely new and innovative approach. However, the idea was too bold; six of Macchiarini’s eight transplant patients are now dead, and he has been charged with research fraud,scientific misconduct, and even falsifying credentials on his résumé. Karolinska Institute seems to be thoroughly embarrassed to have hired him, and they fired him as soon as the scandal came to light. Sjoerd mentioned Macchiarini – though I’ve heard of him many times now – to illustrate that “bending the rules usually goes well…until it doesn’t.” Macchiarini is an example of the Swedish drive to try new things can come at the expense of trying them too quickly, overlooking various rules and regulations.

One of my first project posts for Sweden was entitled “Barriers to Business.” It was about how the strict medical regulations in Sweden can make it difficult for new medtech companies to succeed and can even kill innovation. The Macchiarini story – which I’ve now heard many times – put that in perspective. Yes, it is very difficult to break into the health technology market. While this was initially presented to me as a disadvantage of the system, I have since heard from many Swedes that it is an advantage. Sjoerd said that the system might need to make it more difficult, in fact, if such a change would have prevented the Macchiarini disaster.

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