Worker shortages

10 July 2007, Tuesday

Today is the second day for Salem nursing home. I got on a wrong train to Gentofte. When I realized I could still change the line, I quickly got off the train and changed the line. I am on time to meet Mrs. M, the director of Salem. In Denmark, people expect others to be punctual. Here, being punctual means being on time, neither early nor late. People apologize when they are early for an appointment. It is a country that lacks flexibility. Anyway, I was on time at 10 a.m. sharp. Mrs. M has designated a nurse for me this morning even if the nurse does not speak English well. The nurse Anni says she only started working at Salem two months ago and still learning things. She is one of three registered nurses in Salem. She says there are not enough educated nurses. The SHAs take over during the night, performing some of the nurses’ duty such as leading the four teams of SHHs, calling ambulances in case of emergencies, etc. But SHAs cannot pour pills to the medicine box. One of the main duties of nurses is to fill the two-week worth of small med box bins. The medicine box is similar to those in the U.S. with one box each for morning, day, evening, and night drug doses. Also nurses are responsible to schedule various shifts for SHAs and SHHs. It seems that nurses do more hands-off work and overall operation of the nursing home, while SHHs and SHAs mainly interact with residents.

Anni allows me to follow her on the morning medicine rounds. She tries hard speaking to me in English. Examples of medicine for one resident are Citalopram, Entreotabletter Pantoloc, Ibumetin, Kirexa, Marevan, Mirtazapin, Pamol, Simvastatin, Sumatriptan, and Viramune. Many residents have hypertension, high blood lipid disease, diabetes, and depression. Hjertemagnyl is an anti-coagulant that can cause internal bleeding. SHAs sometimes call doctors if they are suspicious of side effects of this medicine. Anni fills up total of 14 small boxes for next two weeks. Many different doctors prescribe all of these drugs. When one medicine runs out, nurse or SHA has to call each doctor for a refill. Sometimes after general physician refers a resident to a specialist, the dosage can change but the medicine chart does not get updated.

An SHA calls for Anni. Anni wraps up a resident’s prescription fill-up in hurry and goes to the staff office. For the next couple of hours, I have observed Anni’s frustration regarding an anti-dementia medicine Aricept. This is for one of three residents I have interacted with yesterday, Mrs. V. Her psychiatrist called in to check her current medicine and found out that Mrs.V has stopped taking Aricept. Nobody knows who stopped it. Anni and an SHA try to find the documentation in Mrs. V’s log. I sit and watch. Anni looks up on the computer records. Nothing. The SHA goes out and finds an SHH. The helper comes in to look at the log. Finally the helper finds a few lines of documentation about how Aricept was stopped. The log has a section that nursing home staff uses to document the nursing care. There is another section that doctors’ order is recorded. It turns out that Mrs. V’s daughter is a doctor and wanted her mother to stop taking Aricept. An assistant called Mrs. V’s general physician and got an approval to stop it. The assistant who handled it is on vacation now so nobody knows about it except the few lines of written documentation in the staff section of the log. There is no mention or record in the physician section of the log. Mrs. V’s psychiatrist did not know who stopped Aricept. The general physician apparently did not feel the need to contact the psychiatrist. Anni says doctors rarely visit nursing homes and ask nurses to take care of most of the health care. At this point, Anni looks confused and does not seem to be able to continue precepting me. That has been my brief interaction with nursing home nurse in Denmark. I am back at the garden where I was spending time yesterday.

Today is Mrs. V’s birthday and they made a birthday cake for her. Mrs. V’s family already took her to their house last weekend for celebration and today Mrs. V is alone in the nursing home with her friends. She probably does not know today is her birthday. I fed Mrs. M again today including ice cream and pear dissert. After the lunch, a helper and I transported Mrs. A to the weekly church service in the basement. About dozen residents came down for the traditional Lutheran service. Mrs. A says that usually a male minister comes to run the service but today his wife is running the service. She wears a neck collar that looks like the one a clown wears. She also wears a long black gown. I have sit in the whole service listening to a Danish sermon and many hymns. Out of five traditional hymns, I recognized the melody of one hymn. I tried to read the Danish lyrics.

In this first nursing home I have visited in Denmark, I am impressed with individualized care, innovation and idea of functionality in ergonomics, and standardization of health care policy. Individualized care goes all the way even to respect a resident’s wish to smoke. A helper has to move the resident to smoke outside every time he or she wants to. A group of residents help each other to form a smoke-break sometimes. But many times they forget to smoke from the result of dementia. At night, if residents do not want go to sleep and want to stay in the living room, they cannot be forced to go back to their rooms. Individual freedom is strictly respected exactly as they live in their homes. This IS their home. The helpers know each resident’s preference and character as time goes on. A couple of ladies always drink a glass of red wine together at lunchtime and they sit together for lunch. They look so cute.

The functionality of devices and furniture is improved but the difference is almost unrecognizable. A small wheel is attached to the front legs of normal dining room chairs and it helps move the chair close to the table with a resident on the chair. Without the wheels, it would scratch the floor and make squeaky noise but most of all it would be too heavy to move the chair. Nobody here uses the four-legged walker that is so popular in the U.S. Instead everybody uses the grocery cart type walker that has wheels. The walker has a small basket that they can carry their belongings. In the middle of the walker, there is a flat portion that they can sit on and rest. One of the residents goofed off by sitting a helper on her walker and pushed him to the living room for ‘her’ coffee break. I already mentioned the height-adjustable washbasin and dish sink in each resident’s room. Motorized lift device to move paralyzed resident to and from the bed is the most impressing machine. It would save helper’s back and at the same time be safer for residents too. There is no rotating motion to put the resident on the bed. This device will ease the hip pain many elderlies are suffering from. Bedside commodore also has wheels and a helper can move a resident from his/her bedside to the bathroom on the commodore. It would increase the mobility and safety. Wooden floor might improve resident safety and reduce the fall risk. Taking care of residents in 10 to 12 people in a group would be easier and cozier for residents and helpers as well. I asked the helper from Nigeria, Mr. Y, what level of facility class that Salem would belong to, high, middle, or low, among the Danish standards. He said Salem is an upscale high class nursing home but there are no big difference between all three levels of nursing homes. General nursing care and individualized attention are all the same in different class of nursing homes, he said. I imagine SHHs must work extra hard to fulfill the details of individualized care in Danish nursing homes.

height-adjustable washbasin in Salem resident's bathroom

I am back with the director to wrap up my two-day visit to Salem. It has been too short and I started to feel attached to residents and helpers. Especially Mrs. A has been really nice to me, asking for my marital status and my life in the U.S. Her sister and brother-in-law are visiting her this afternoon. She tells them I have come from the U.S. through Diakonissestiftelsen School of nursing. They praise the school and the foundation. Mrs. A keeps talking and I cannot leave. With the director in her office, I apologized her if I made Anni get confused. She said it was ok. She blamed doctors for not communicating with nursing home staff or other specialists in general. One of my questions about nurses was lack of clinical assessment by nursing staff. There are no regular vital sign checkups. Nurses almost never listen to heart and lung sounds. When I asked Anni, she said she was not taught how to do it. The director says that nurses should be aware of residents’ medical diagnoses and call doctors every morning to adjust any needed changes in the medication. Nurses discuss with residents’ family about the nursing home care. Nurses do staff scheduling every two months. Mental health care for the elderlies is one of the important aspects of nursing home care. She would like to introduce a therapy dog sometime and shows me an article about the effect of therapy pets on Alzheimer patients. Making the residents to feel good about themselves is the key through personalized care. She also emphasizes the policy implementation in nursing homes such as preventing bedsores by not allowing residents bed-ridden. Even if residents get seriously sick, they are moved about at least two hours a day and encouraged to stand up. When I mentioned Ms. E’s resignation, the director expressed the difficulty finding the new hire to fill up SHH positions. Probably SHH work is a bit harsh for Danes and foreign workers would have to fill up the positions. But it takes 7 years to get permanent visa and two years after that to obtain Danish citizenship. This number needs a confirmation but it sounds like the immigration rule in Denmark is strict. The director says there has been a heated construction boom recently and Denmark imported many foreign construction workers. There are 6,000 Indian doctors being imported to fill up the physician shortage. I asked if they would speak Danish and she said they would get by just speaking in English in the hospital. An Arab store manager in the poor section of Copenhagen near the Central train station tells me that Danish health system might be good but the medical and nursing education is behind and not producing enough well-educated doctors and nurses. Maybe that is why Danish health care is behind France or other Scandinavian countries, I thought.

Front-line Community Workers

What a week!
The last week has been an intense one with quite a ride,
literally with lots of bike rides. I am reflecting the
week and slowly writing my journals for the Community
course.

9 July 2007

Today I have met a 79-year young nice lady who speaks English very well. Her name is Mrs. A. She has had a stroke one and a half month ago and her left body has been paralyzed since then. When the Nursing Home director introduced her to me, she was exercising her wrists using a bike pedal machine. A middle-age physical therapist was helping a few other nursing home residents. The bike machines - those that users move pedals by arms not legs -- are placed on the corner of a square-shaped inner courtyard, with a glass ceiling all the way up to the second floor, surrounded by glass walls on all four sides. I can see what others are doing at the other side of the glass walls even people on the upstairs. The courtyard is filled with lovely plants, small tables and chairs. There are metal trellis, almost two-story tall, with climbing vines glittering with morning sunshine, which is rare one since it has been rainy and cloudy for the last couple of weeks. It is quiet and peaceful. It seems that the time has slowed down almost to stop, with the elderly residents enjoying their morning activities in a slow motion. This is a Nursing Home called Salem, meaning 'peace' in most Middle Eastern languages. It is a private nursing home in a municipality called Gentofte. The Deaconess Foundation administers and manages funding for Salem, together with Sister Sophie's nursing home in Frederiksberg. I am supposed to work with staff and residents in Salem for the next two days. I already like the atmosphere here very much.

The Deaconess Foundation (Diakonissestiftelsen in Danish) is 140-year old institution that has contributed in nursing education, medical care, and community health in Frederiksberg and beyond. The Danish Deaconess Foundation was established in 1863 on the initiative of Princess – and later Queen – Louise. The purpose was to provide Christian women with faith-based, compassionate nursing training. Deacons were later admitted. Today, the Deaconess Foundation provides care for children, the elderly, and the dying in particular, and offers community care services training. The nursing school I am privileged to be connected to for this summer belongs to the Deaconess Foundation. Gentofte is another municipality north of the Copenhagen city about 40 minutes on metro and S train. It is a charming and tranquil suburban town that is quite expensive to live even in Danish standard. Salem is an upscale private nursing home in Gentofte. It was built in 1963. Since the beginning, Salem has been built on the management and standard of the established Deaconess foundation. It was founded by a private donation from Johan V. Adolph who got the idea all the way into 1903, when he started a centre for convalescents on the place where Salem lies today. In 1963, it housed 44 residents.

There are still 45 elderly people living in Salem now. The building has been through an extensive renovation from 2003 to 2005 and the only unchanged structure might be the outside wall of the building. The inner structure contains four 'gardens' - 'Have' in Danish - that physically divide the nursing home residents. Their names are like Grete's garden, Mary's garden, etc. The four gardens are spread out in the two-story rectangular building with the inner courtyard at the center, with each garden holding 10 to 12 residents. Each garden has its own living room, kitchen, and dining room in the middle. The glass wall connects the kitchen and dining area to the inner courtyard from which the green plants and sunshine comfort the residents. The residents' rooms are located at the opposite sides of the central meeting place. About 10 times everyday the residents are transported from their rooms to dining room or living room, for meals, coffee or tea breaks, for watching movies, for song and dance, etc. The activity of moving the residents back and forth is intentional to help them wake up from their dementia, sleep, and boredom. There are three social and health care helpers ('social- og sundhedshjælper' in Danish, hereafter SHHs) assigned to each garden, performing daily routines of transporting residents, helping them wash themselves, taking care of their bathroom tasks, feeding them, and observing them for any changes in symptoms and behaviors. SHHs are the front-line caretakers for the community elderly care.

The three SHHs I met today have come from Thailand, Sri Lanka, and Nigeria. Another SHH, who came to help us from a neighboring garden, originally came from England. There are some older Danish SHHs in other gardens. The three SHHs helped me to get situated between residents on the lunch table. They have been very friendly, sincere, and honest to me. I have fed Mrs. M, an elderly female resident with Parkinson's disease. She could not move her body at all and only able to move her left arm to drink water in shaky motion. I am told she is able to speak English because she is half English and half Indian.

She has lived in India for quite some time. Her voice was harsh and sentence was short so I could barely understand what she was saying. She was also able to open her mouth just about half way and I had to chop up the food real small. She did not want any red meat so only chicken and fish were on her menu. Other residents’ meals were like that too. Each resident's food preference is strictly respected and there are even different choices of desserts for each resident. Diabetics get cakes with no sugar. SHHs work in three shifts, day (07:00 to 15:00), evening (15:00 to 23:00), and night (23:00 to 7:00), about eight hours each. I use the word 'about' since there seems to be flexibility in the time they can leave work. Most of the Salem residents have chronic diseases like Alzheimer's, Parkinson's, and paralysis after strokes. Also they are quite old, older than 80. I hear the oldest person is becoming 101 this year. A lady with big smile, who has worked as a nurse in the Frederiksberg hospital where I got my nurse uniform, is 94 years young. Another lady on her opposite side of the dining table is 96 and she still eats the whole meal by herself. Taking care of these ladies can be stressful sometimes, partly because of their physical and emotional dysfunction.

Two of the three SHHs commute from Sweden everyday because of the cheaper cost of living there. They say that the Danish nursing homes pay them more. But the guy from Nigeria, Mr. Y, expresses deep resentment about the Danish society. He is 26 and has a Sociology B.A. degree from a University in Norway. He came to Denmark with his family but he could not get a decent job using his major. Danish society demanded education from Danish educational institute. He blamed Danes not treating foreigners equally as themselves. He has been working SHH jobs in two nursing homes and was able to save some money though. He recently bought a car and apartment in Sweden. He says he does not have to pay much Danish tax if he only earns below the minimum taxable income per year, around 40,000 Kr. His girl friend drives his car because he does not have the driving license yet. He is going to take the license exam - driving test - tomorrow, which is his birthday. Later he would help me buy a used mobile phone in one of the poor neighborhoods in Copenhagen. Mr. Y and the SHH from England, Ms. E, had a discussion with me, after we transported all residents to their rooms for the afternoon nap. We had one hour before moving them back out for coffee and cakes. They explained the real working situation in Denmark. There is a serious worker shortage in Denmark. The turnover rates in the job like SHH are high. There was a strike and demonstration by SHHs a few days ago in Copenhagen asking for more workers. To be a worker like Mr. Y, one needs to pass Danish language exam and show fluency in communication in Danish. Many immigrants experience difficulties having command over the language, as well as being integrated into the society. Ms. E says another reason for nursing shortage is the low salary for nurses. The Danish government pays college students for their education and living. University students receive 6,000 Kr per month after tax and after tuition is paid. But the nurses’ salary compared to the minimum wage is quite low. The minimum wage is 98 Kr per hour, SHHs get 109 Kr./hr, and Social and Health care Assistants (SHAs) get about 118 Kr/hr. Nurses’ salary is not much higher than that right after their four-year education. A new nurse gets about 25,000 Kr/month and that is about 15,000 Kr/mo after 42-46% tax has been paid. SHAs need 18 months of training to assist nurses in nursing care. For Ms. E, even the SHH job at Salem is a bit stressful for her. Later in the afternoon before she gets off her shift, she tells me, waiting for the weekly staff meeting to be over, that she is going to announce her resignation to the nursing home director and move on to become a SHH for home health care. She can have more freedom and less stress and a bit more pay by doing the home health SHH. She says a guy from a home health agency called her this morning. She does not seem to be fond of the director or to be much concerned about the director’s own problem which she had discussed with me this morning. Ms. E does not think that the director is doing her job well.

I have been close to three residents today, Mrs. A, M, and V. Mrs. A’s room is very neat and clean. All rooms have wooden floor, height-adjustable wash sink and bed. Also motorized lift is installed from the ceiling to help transfer residents from wheel chair to their bed. I watched Mrs. A being ‘flown over’ to her bed by smooth operation by an SHH. She praises her SHH’s operation of the device. The SHH plays Mrs. A’s favorite CD softly. It is a jazz CD compiled by Mrs. A’s husband before he died of heart attack. Mrs. A showed me her husband’s pictures. Portraits of her two sons hang on the wall. She says she and her husband traveled all over the world including America. I can feel that she misses her husband so much.

Mrs. V’s room smells urine and I suspect she has some kind of bladder problem. She has serious Alzheimer’s disease to the level that when she stands up to go back to her room, she forgets what to do the next. The SHH has to keep remind her of her next move. Her emotionless face and lack of appetite worry me. But she thanks me when I move her to her bed. She does not need the motorized lift. Mrs. M had her cake in her room. I fed her a little while she was watching a TV cartoon.

The nursing home director Mrs. M has worked for the nursing home for a long time and about to retire in three years, according to Ms. E. Mrs. M gave me a brief introduction to Salem this morning. To be eligible to move to a nursing home like Salem, the community has to approve. Some residents do not have family to support them. All of the residents stay in nursing homes until they die. Each resident’s general physician and home health nurse play a big role in deciding if a person would need a nursing home care. Once that decision is made, the candidate is put on a 3-month waiting list to be placed in one of his or her three nursing home choices. Main principle is to place the elderly to a nursing home close to where they used to live. Applicants sign a contract about the financing of their nursing home care. Their pension fund is used up first. Also they pay certain amount by themselves. Then the rest of the cost is paid by the government though the municipal office. The fund is used to pay for the 55 employees’ salary, and the living and medical cost of residents. The cost of caring has increased recently and Salem spent 100,000 Kr more than the budget last month. Mrs. M is going to have staff meeting in the afternoon to discuss how to reduce the cost. Some of the residents went to a trip to Barcelona recently, Mrs. M said. I do not know if that is anything to do with the increased cost.

For me, I am a bit empty-handed because I have not been interacting with any nurse today. It is still not clear what nurses do in nursing homes. I asked Mrs. M to assign me a nurse tomorrow if it is possible. She says she would try.

Inner Courtyard of Salem Nursing Home, viewed from one of the 'garden'.

Functionality in Health Care

Too busy to write a long blog but here is a short one.

I had a 100% Danish speaking Lutheran worship service this
afternoon at the nursing home I have visited. Out of 5 hymns,
I recognized one song. The hymns were all written before 1870.
The nursing home was brand new and it was the most beautiful
and functional one I've ever seen. I am going to ride a bicycle
tomorrow to visit elderly people in their homes.

The schedules are tight but I will survive.

Danish health policy, uh quick one... they prohibit keeping
a person bed-ridden. Even turning nursing home patients
on their bed is not enough. Even if patients are sick, they are
supposed to get out of the bed minimum 2 hours a day.
So several times a day, they move about a lot. From their own
rooms to dining room, for a meal, coffee/tea and cake, to religious
service, to song and dance, etc. If the patient is really paralyzed,
then they use this wheel chair that falls backward to become
a reclining arm chair. Leg and body angles can be adjusted.
Innovations and functional improvement in ergonomics are used
to help individualize the policy according to a person's handicap
or need.

Very impressive.

Pictures of the chilliest summer

had some difficulties uploading pictures...
here are some.




The Queen protects the Nursing school.













The city hall

Street musicians
Sounded real good.














the little mermaid looks very unpretentious compared to those lovers...




a drunk on M1 line.
the brand of beer was not identified.

Design capital of the world

COPENHAGEN:

”Let’s create the perfect city. We’ll
start with a vast network of streets
lined with great stores and cafés.
Bicycle lanes will span the city,
encouraging a quiet, nonpolluting
means of transport, and we’ll
generously spread royal palaces and
rich museums about. Of course,
we’ll build our city along a pretty
yet functional harbor. And we’ll put
an amusement park right in the city
center, making carnival rides and
concerts accessible to all. Finally,
we’ll govern with a socially minded
philosophy that virtually eliminates
poverty, crime, and begging. This is
no fantasy – this is Copenhagen.
And without a doubt this very real
city’s richest gift is its quality of
life”.

Quote from Frommer’s 97, Frugal
Traveler’s Guides: “EUROPE from
$50 a day” by Nikolaus Lorey.

Copenhagen, being the Design capital of the world, is truly people’s city. Jette fixed her son’s mountain bike and it is mine to use for the next three weeks. The streets everywhere are divided into lanes for cars and bikes. The direction of the bike traffic on the bike lanes follows the car traffic. If you ride in the other direction, you risk yourself immediately being hit by other bikers. Even stopping in the bike lane, other than at the stop sign, causes other bikers’ harsh eyes or some Danish yelling sometimes. The width of bike lanes are right about the distance of two bikes passing together, so fast bikes can pass slower ones. Bikes stop at the pedestrian crossing when the cars stop. Bikers strictly keep traffic rules. There are amazing numbers of bicycles and bikers going all directions. People of all ages ride their bikes. Bicycling is a major way of transportation here.

I have not seen any fat people so far, except a Nursing faculty I was introduced to on the first day. People are very fit. Susan and I went to the Copenhagen downtown today.
There is a Jazz festival in the city for a week and many people were outside enjoying the music. Weather was not that good, cloudy and chilly, even with short pouring rain. People are wearing leather jackets. A major shopping corridor was filled with pedestrians. There were lots of street musicians, even a few clowns. Also there were plenty of Cafes and street food. We had to be happy with hotdogs but even hotdogs tasted better than those back home. My hotdog was 23 Krone, about $4.50. Typical restaurant food costs 200 Krone so I kept asking myself, “how people here can afford?” I had to have beer with my hotdog listening to Jazz under the rain. Tuborg is popular here, 50 Krone a glass.

Then we walked, walked, and walked all around the city to see the little mermaid, the new opera house, Queen’s residence, Royal castle, and Susan’s friends, the Royal palace guards. I did meet some of my friends, homeless people, drinking, eating, and sleeping on the street. I started a talk with a couple of them. (Actually I only saw four today on the street.) They were not even Danes. They were Swedes who ran away from the strict Swedish law. One guy said in Sweden, they couldn’t drink beer on the street or sleep on the street. The police would arrest them and put them in jail. So they moved here to have better life with more freedom. People would give them food and let them drink freely on the street in Denmark. In fact, I saw a few guys holding a bottle of beer, not wrapped in a brown bag, on the street as well as in the subway train. Maybe Denmark is going to have a new social problem? I don’t know.

More and more I feel that Danes know how to use the resources they have at hand and utilize it to its maximum with moderation, functionality, and simple beauty, without excess and waste. They respect individual’s freedom and choice even to give space to the homeless from neighboring countries. People are taxed from 40% to 70% of their income in sliding scale, so the rich pays more by tax rates. The rich still pays their own money to go to a private hospital. People are required to add 180% of tax for their imported cars like VW golf, ended up paying close to $70,000. But the quality of life in Copenhagen, not the quantity, seems to be good. I'll see some of that soon, I hope.

Promoting health gently

I am in the third floor of a building that houses the Nursing school and dormitory for its students. The building itself is a section of the huge complexes that are connected to each other. Other sections include a church, municipal health care center, etc. The whole structure was built 140 years ago. The health care center serves the municipality of Frederiksberg to promote healthy life and prevent diseases. It would correspond to our county Health Department but they truly reach out and influence people’s lives in ways we don’t do in the U.S. The center staff provided a two-hour presentation about their work in English, which was their first time ever.

Frederiksberg is only 3.4 sq mi wide but has 91,855 residents as of 2006. It is the smallest and most densely populated municipality. It belongs to Region Hovedstaden that contains 29 municipalities including the Copenhagen city. Frederiksberg is a short 5-minute away by subway from downtown Copenhagen. People here say it is a very good place to live and work. There are five Regions in Denmark and the five Regions contain total of 98 municipalities. Until last year, municipalities belonged to counties and counties belonged to Regions. The nationwide Municipal Reform on 1 January 2007 has merged small municipalities into bigger ones and eliminated the county structure. The State of Denmark funds municipalities directly even if municipalities belong to a Region. The Region does not control each municipality’s health care services. Each municipality has been reporting to the county but now reports to the State directly after the Reform. Through the new system the State expects better accountability from municipalities. Frederiksberg has not merged with other municipalities by the Reform because it was big enough and had a county privilege. The reform also gave the each municipality more freedom to create its own health care programs geared to its residents.

An example of such a unique health care program is Chlamydia prevention program in Frederiksberg Health Care Center. This kind of program does not exist in other municipalities and in fact other municipalities try to learn and mimic the health programs of Frederiksberg. Starting from 2001, the Center has sent a package of mail directly to men and women of the age between 18 and 22 in Frederiksberg. The annual mail includes the information about Chlamydia, how it is transmitted, and how it can be detected. Chlamydia detection is important because persons who contract the disease do not have any symptom. A self-test kit is also included in the package, along with the information that the test is painless. The Center receives the urine sample from young men and women and sends the result to the Center doctor. The doctor contacts each individual with the result. One of the goals of the program is to encourage the young residents in the municipality to have the ownership of their own health. The decision to send the urine sample back depends on each individual’s choice. A free test kit is also available in pharmacies. It is a soft nudging rather than forcing people into something to do. This particular method of direct mailing was preferred to public campaign because it was more effective and it only cost $10,000 per year. Throughout the 5-year program period, about 7% average positive Chlamydia result was gotten from all respondents.

Other programs in the Health Care Center include obesity and smoking cessation programs. Interestingly, boys have been gaining weight while girls have not. The government has ordered to remove all soda machines from schools recently. Coca-cola company will not be silent if that happens in the U.S. A home-visiting nutritionist program will be adopted soon to educate boy’s family to cook better meal and influence boy’s lifestyle. The reason for the boys’ weight gain is that they would go out with friends more and eat junk foods. Peer pressure for boys may be higher in this country than that of girls. It will be interesting to find it out.

The Health Care Center offers smoking cessation classes regularly. Private companies offer the class for their employee at workplaces. The program is effective. But so far, I have seen many smokers in restaurants and public places. In 1970, 47% of women and 68% of men smoked. In 2006, 23% of women and 26% of men smoked. The death rate from diseases caused by cigarette smoking is seven times higher than other causes like alcohol, obesity, drug abuse, or traffic accidents. The government will prohibit smoking in public places, bars and restaurants, starting from 1 August 2007. Exception will be one-person office. If you smoke and have your own office, you can still smoke in your office even though all the smoke goes out to the hallway. Individual freedom and choice is respected and honored here. Small detail seems to be well taken care of in Denmark.

The First Day

Susan and I are here in Copenhagen. We finally met Jette, the mystery woman, who will be our preceptor during the Community Health clinical rotation in the town of Fredericksburg. The flight to Amsterdam was crowded with many people but fast after watching two in-flight movies, Philadelphia and Pan's Labyrinth. Both made me tearful and emotional. The first impression at the Amsterdam international airport was generosity. First, there were smokers everywhere. They have smoker's section in the middle of airport lounge and they are allowed to smoke in any restaurants that sells alcohol or in casino. The smoke smell was quite disturbing but people seemed to tolerate it well. Another side of the generosity was facilities to give comfort to travelers. There were many relaxation reclining chairs on which people can sleep between flights. One big space was equipped with a large screen display of movie called Holland Horizon to provide visual illusion of spaciousness. Meditation chamber for quiet time and Yoga. Restroom next to this chamber had a sink for Muslims to wash their feet before their ritual. Museum that had an exhibition of Dutch Realism. First Aid service desk. Chair Massage area. And most of all, the security personnel were kind and more personal and less authoritative compared to the States. Thoughtfulness to detail was impressive. Efforts to service people were apparent.

Not so generous thing was the food price. Average mundane lunch was about 15 Euros, which is $20. A small bottle of water was 2.50 Euro ($3.40) while a can of Heineken was 2.60 Euro. We wandered around a long time to find a noodle restaurant. A simple Asian noodle was 14 to 18 Euros and it was not even that inviting. We ended up buying cheese, cracker, smoked salmon, apple, and beer at a store for about 7 Euros per each person. It was good.

After a short flight to Copenhagen, I found one of my luggage was missing. Giving up on the bag, we got out of the baggage claim area to meet Jette. She probably waited for us for quite a while and after a brief moment of excitement of our meeting, she helped me go back to the service desk to submit a lost baggage search request. Again, the people at the desk were quite laid-back and even soothing. Dealing with the frustrating circumstance like lost bags, the staff were kind and sincere. The lady searched for my bag on the computer and confirmed that the bag was still in Amsterdam. She noticed the forwarding address was a Nursing school and asked me about my trip. I asked her if she liked Danish Health Care. Quite surprisingly, she said she might like German system better. The reason being doctors don't pay enough attention to patients. These doctors are primary care doctors or general practice physicians. She said that it takes a great effort to get a referral ( I had to explain the word) to specialty doctors. But I told her that the U.S. government doesn't take care of its citizens as well as Danish one does. She said she heard in the States a million people were 'hungry', eating in a soup kitchen, etc. Well, not THAT many, I hope not, I talked to myself. She gave me an apology gift that had a shirt, socks, and personal hygiene stuff. It seemed like a routine gesture but it made me feel better. I have not seen such a 'gift' after losing a bag in any of U.S. airports. Another attention to detail.

And Jette took us to her car and drove us around the city a bit. The air was so fresh and cool. So many people were on bikes. Most cars, quite a few Japanese cars but no Hyundais, were compact or sub-compact cars. The old buildings looked they were taken care of well. The nursing school Jette teaches at is the smallest nursing school in the city, she said. There are about 25 students for each year. The school is ‘protected’ by the Queen. The nursing school building used to house catholic nuns and it is about 150 years old. But it has been renovated to meet today’s standard, including security doors and classrooms. The classroom area used to be a small hospital before. Everything is so neat and well kept. Then, Jette took us to a typical Danish restaurant. The price of a veal steak was about 170 Danish Krone, equivalent to $30. The meal was so good and the service was excellent. Jette said the Dean of the school provided the meal. It was around 10 p.m. when we left there and it was still bright outside. We are supposed to meet the school faculties and staff tomorrow. Including tomorrow’s orientation, my clinical rotations will be spread out over 9 days.

One more interesting thing I found: the toilet papers are narrower here. At the Amsterdam airport and in Copenhagen, the papers are about 30% narrower than the American ones. It would perhaps save a lot of trees, I thought.