Week 74: Goodbye Mr Sjöberg. And shame on you, Mr Høie and Mr Tveit

Written by Lars Haakon Soraas
22
Jan

We have had a good week, but not all families are as lucky. First our update:

  • Dyanne has been in good shape all week.
  • We have been to the mountains and chilled out with my parents. The air is not the best in Oslo these days, and it was good to hang out with the mountains and snow a few days. We should note that we appreciate the efforts that the city council of Oslo are putting in to try to reduce the air pollution. However, it should also be noted that despite their efforts, the pollution forecast for Oslo has still been “high” five out of 21 days so far this month. Wouldn’t it be good if the air in Oslo was safe to breath every day and not only 70% of the days in January?

We learned with sadness this week that Mr Bengt Sjöberg passed away (article in Swedish). Mr Sjöberg was a Swedish businessman who made a fortune in Asia in the past few decades. When he was diagnosed with stage IV cancer around a year ago, he quickly decided to donate 2 billion Swedish kroner (210 M€) to a foundation that he set up. The purpose of the foundation is to fund cancer research. We met Bengt and his wife last summer and had a lovely lunch near their summer home in Lysekil, Sweden. I also met Mr Sjöberg on a couple of other occasions. He always came across as a humble, intelligent and realistic man with a real wish that his fortune would benefit future generations of cancer patients. It is sad that he will not be around to lead the work with his foundation. Bengt leaves behind a wife and two grown children.

While visionaries like Mr Sjöberg strive to drive the world forward, there are plenty of people who are trying to put the brakes on. Like Norway’s lackluster minister of health, Mr Bent Høie. As mentioned in last week’s post, he recently congratulated himself on keeping the corridors of Norway’s hospitals quite empty of patients. To make sure the corridors are empty also in 2017, he has repeated his goal of “empty corridors” in the document describing the targets for Norway’s hospitals. If you don’t believe it, you can read it for yourself on the bottom of page 5 here (in Norwegian). And, to be clear: there are no targets to improve outcomes for cancer patients in Mr Høie’s list of targets for 2017. His main goal is to keep the corridors empty. Whether cancer patients live or die, does not seem to concern him a bit.

Some may think that targets such as “empty corridors” are innocent. They may be ill-conceived, but not terribly harmful, you may think. But is this really the case? Is this just an innocent target set by minister who wants to do good, but lacks the intellect or courage to have any real impact? I beg to differ. In my view there is nothing innocent with these kinds of targets. They do great harm and cut short the lives of thousands, if not tens of thousands, of patients. The reason is that if you ask bureaucrats and hospital bosses to keep the corridors emtpy, and don’t give them any targets to improve outcomes for cancer patients, they will make real life and death decisions with these targets in mind. And, remember, hospitals, like pretty much everybody else, also have limited budgets.

To see that these targets are not just stupid and innocent, and actually do great and real harm, consider the following. Norway’s hospitals are, like pretty much every hospital in the developed world, phasing in the use of an immunotherapy medicine called pembrolizumab in the treatment of lung cancer patients. If your target is to improve outcomes for patients, you would pretty much want to give this medicine to as many patients as possible. If your target is to keep corridors empty, you would want to limit the use of this medicine. One of the effects of this medicine is that it keeps lung cancer patients alive for longer. Not a good things if you want empty hospital corridors. Needless to say, this medicine is also expensive. So if you give it to many patients, not only do you risk filling up corridors with patients, but you also risk breaking the budget.

In such circumstances, cynical bureaucrats and hospital bosses will do their best to limit the use of this medicine. Their choice is between the following:

  1. You can limit the use of the medicine and quietly let the patients die. You hope that the patients and their caregivers don’t protest too much.
  2. You can use the medicine widely and improve the survival of lung cancer patients. But then you risk missing the “empty corridors” target AND you also have to find other places where you can cut costs (remember the budget constraint). And as most of your costs are personell expenses, cutting costs means cutting people. This means that you do not only risk making the minister of health angry (by missing the “empty corridors” target), you will also make the unions very angry.

As lung cancer patients are poor lobbyists, and most of them have their plates full fighting for their lives, it is a pretty safe bet they won’t protest too much. The other alternative, which includes cutting costs, must be a nightmare for hospital bosses. Remember the fight the doctor’s union put up when hospital bosses tried to make some small changes in the working schedules for doctors last fall? Well, imagine the hell that will break loose if you try to fire any of these people… So the choice is easy: do you pick a fight with nearly dead lung cancer patients, or do you pick a fight with the unions and your own minister? Any seasoned hospital boss will know what decision to make. Especially when our dear minister has made it so clear that he does not care five cents about how many lung cancer patients live and how many die.

If you want proof that this kind of dynamic is actually happening, here is a document that should convince you:

https://nyemetoder.no/Documents/Innspillsskjema%20fra%20leverand%C3%B8r/16-41204-1%20161215%20Innspillskjema_pembrolizumab%20NSCLC%2016575597_1_1.pdf

As it is in Norwegian, here is a very brief summary: it is basically the head lung oncologist in Norway (Odd Terje Brustugun) protesting that some unnamed bureaucrat has limited the use of pembrolizumab for lung cancer patients by adjusting the text in the national “how to treat lung cancer patients” guidelines. Over the next years, these seemingly tiny text changes will limit by the thousands the number of lung cancer patients who will be offered pembrolizumab.

I don’t think it is good governance that people who make such kind of life and death decisions affecting thousands of patients should be anonymous and unaccountable. Hence, as I have been been informed of who has made this decision, I choose to mention his name here in this post. His name is Mr Kjell Magne Tveit and he is the head of cancer strategy at Norway’s Directorate of Health (Helsedirektoratet). He is, apparently, also the head of the cancer clinic at Oslo University Hospital. What great love Mr Tveit shows for lung cancer patients.

Kjell Magne Tveit, head of cancer strategy at Helsedirektoratet, trying to limit lung cancer patients’ access to life saving immunotherapy treatments

So, there is nothing innocent with the targets that Mr Høie has set for our hospitals. These targets steer the priorities and decisions of top bureaucrats like Mr Kjell Magne Tveit. And with poor targets, poor decisions will be made. And the poor decision of Mr Tveit is now set to cut short the lives of thousands of lung cancer patients in Norway.

Shame on you, Mr Tveit, and shame on you, Mr Høie.

PS: I will ask Mr Tveit and Mr Høie if they would like to comment on this. If they do, I will post their comments here.

 

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