Thursday, October 11, 2007
Struck by Stroke, but not Stricken
BY JOSEPHINE JOHNSTON

This July 3, at around 9:30 in the evening, my father stepped outside to look at the moon. He didn’t stay out long; it was a cloudy night and the moon was hidden. When he returned to the living room, he was stumbling, one of his shoes had come off, and his mouth was hanging open, drooling.

“What’s wrong with you?” my mother exclaimed. “Nothing’s wrong with me,” he slurred. She jumped up. “Something’s wrong with you,” she yelled. “Stop yelling at me,” he yelled back.

My mother hurried my father into the car, pausing only to pull on her boots and to think: “Not now. This cannot be happening now.” My father is 59 years old, slim, and fitter than almost anyone I know. He does not have high cholesterol, he does not have high blood pressure, he does not smoke. Both his parents are alive and in their eighties. But my mother recognized his stroke right away. She drove ten minutes to their local hospital and ran with my father, still wearing only one shoe, into the emergency room.

My father had not one, but four strokes that night out on his porch. He spent the next two weeks in hospital. An ultrasound revealed that a section of the carotid artery in his neck was 86% blocked. Bits of plaque had broken off and traveled to the right side of his brain, leaving his speech slurry, his swallowing reflex impaired, and his left hand almost useless. His blocked artery was, in the words of one doctor, “a ticking time bomb,” and the chief of surgery operated the next day to clear it out. My father kept saying, tears in his eyes, how good it was to be alive, and my mother, my sister, and I were buzzing with elation, thinking over and over how much worse it could have been.

He spent the next four weeks in residential rehabilitation, where a team set to work. A physiotherapist put him through daily exercises to get his hand functioning again, applying small electric shocks to remind his fingers how to spread right out instead of hanging in a soft claw. Occupational therapists tested his cognition in ways so subtle that I wondered whether I would have appeared a stroke victim myself. He met with a dietician and he worked out every day in a gym in the basement. By the time he was discharged, his speech was almost perfect and his swallowing was back under control. On beginning rehab his left hand’s grip had measured four on the “grip meter,” in contrast to 16 for the right. On discharge his left hand was up to 14.

Although he was officially a patient for another six weeks, my father spent the remaining time at home on paid sick leave, finishing his recuperation and perfecting his grip. During this whole ordeal, he filled in only three forms (one for admission to the hospital, one for admission to rehab, and a consent for the operation) and he did not spend one dollar of his own money.

My father lives in New Zealand, which provides all its citizens with health care. Many times over the past weeks I have wondered what his experience might have been like if he had lived in the United States, where I live and work, and he has asked me the same thing. “It would depend,” I say, “on whether or not you were one of the 47 million Americans without insurance.” Anyone who walks into an emergency room is treated, I tell him, but only those with health insurance have the cost of that treatment, and everything that follows, defrayed across a risk pool. It’s not just that the uninsured are at increased risk of stroke.¹ Studies show that in the year following a stroke, they are three times more likely than people with private insurance or Medicare not to have visited a physician and over five times more likely to be unable to afford their medications.² And even for people with insurance, policies can vary from person to person, employer to employer. Some things might not be covered. There will often be a significant copayment. There will always be copious paperwork.

New Zealand’s health care system is not perfect. Quality and efficiency are hot issues in every national election. Candidates argue over whether limits should be placed on the treatment provided to citizens and how to reduce waiting lists for nonemergency surgery. Even my father, who has no complaints about the quality of his care, noted that emergency room staff were stretched thin and that the ward nurses were overworked.

But it is a system that served my dad beautifully, and it would have done the same for him had he been a freelance writer, an investment banker, prime minister – or unemployed. He got the care he needed and he got it quickly. He was not put on a waiting list for the carotid endarterectomy he needed to remove his risk for another stroke. They did not hurry him out of the hospital to free up his bed. They did not hurry him out of rehab – in fact, the team worked harder than we expected and they returned his mental and physical function to close to 100%. He will now be taking three drugs for the rest of his life – aspirin, a statin, and an ACE-inhibitor. His co-pay for these medicines? Five U.S. dollars a week.

Moreover, my father had this experience in a system built on limited resources. New Zealand is not an especially rich country. In 2006, the World Bank put its Gross National Income per capita at just 59% of the GNI of the United States. And it spends a smaller percentage of its income on health care than the United States. According to a recent Commonwealth Fund publication, health care expenditures in New Zealand were $2,083 per person in 2004, compared to $6,102 in the United States.

What happened to my father is just one story, but I offer it to counterbalance the tales of waiting lists in Canada and denials of care in Britain. Having grown up with “socialized medicine,” I am confused by the negative images of life with universal health care. And I am struck by the contradiction between the American love of choice and the reality of piecing together health care under complex insurance plans – between the American love of freedom and the fear many here have of leaving or losing jobs on which their health insurance depends.

A few weeks ago, my father returned to full-time work.  To look at him, no one would know that this July he had four strokes under a cloudy night sky. As you contemplate the future of your health care system, think about his story. No universal coverage system is perfect – they all struggle with the ballooning cost of medical care, just as America does. But they do not suffer from the problem of exclusion: they offer the same life-saving and life-preserving care to all.

 

1. A. Fowler-Brown et al., “Risk of Cardiovascular Events and Death: Does Insurance Matter?” Journal of General Internal Medicine 22 (2007): 502-507.

2. D.A. Levine et al., “Younger Stroke Survivors Have Reduced Access to Physician Care and Medications: National Health Interview Survey From Years 1998 to 2002,” Archives of Neurology 64, no. 1 (2007): 15-16.

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