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Concern about the state of Finnish healthcare

Leena Itkonen


Professor Sirpa Asko-Seljavaara, Head of the Department of Plastic Surgery, Helsinki University Hospital (Töölö Hospital), was granted the Pohjola and Suomi Award of the Finnish Medical Foundation. Asko-Seljavaara specialises in burn and breast cancer surgery. She has been Head of the Department of Plastic Surgery since 1990 and, since 1994, she has also been Professor of Plastic Surgery at the University of Helsinki.

The award brought Professor Sirpa Asko- Seljavaara a great deal of publicity, which she has used to open a debate on the state of public healthcare in Finland. Furthermore, she created a huge stir, and made headlines, with her statements about silicone breast implants. Asko-Seljavaara is a leading expert on post-cancer breast reconstruction therapy. She has performed several hundred reconstruction surgeries using the TRAM (transverse rectus abdominus myocutaneous) method. Surgery queues are long.

"In Finland, some 3,400 women contract breast cancer annually. In 40 per cent of the cases, the breast has to be removed, which means that some 1,500 women lose their breast every year. About half of these women are under 65 years of age, and the younger women, in particular, want a breast replacement. Most women experience problems with their body image after mastectomy." In TRAM surgery, a piece of abdominal wall skin with the underlying fat is cut out, approximately half a kilo or more. The flap is then cut to size and shape and sutured into place. The blood vessels within the flap are united micro-surgically in the armpit. "The TRAM method is well-suited to Finnish women. We have more fat, unlike Swedes, for example, who often fail to have enough tissue for the operation. Finns are fatter. Women also enjoy the added benefit of the flatter abdomen that results from this operation. If a woman is very thin, she needs an implant. Finnish women, however, usually do not prefer silicone, since it can harden the breast."

Burn therapy as teamwork

Asko-Seljavaara is particularly famous in Finland for her work in the development of burn surgery. Approximately one hundred severe burn cases occur in Finland every year. Asko-Seljavaara works in one of the two Finnish units specialising in burns. Operations are lengthy and demanding, and post-operative therapy is difficult. For the patient, a burn means pain, scars, a series of treatments and rehabilitation. Asko-Seljavaara's Burn Team includes a plastic surgeon, an anaesthesiologist, nurses, therapists, a psychiatrist and a pastor. Such a versatile team is used to provide the patients as holistic a treatment as possible: “Since the therapy has been concentrated here, it is our duty to see that everything is fine. Burn victims readjust themselves to society surprisingly well, even though they are often quite scarred. They just have to accept the fact that they look awful. Social relations help them to accept their changed looks. And we will also be here later to help old patients with their relationship problems.”

Asko-Seljavaara considers it a good idea that the severe cases are concentrated in the Töölö Hospital. Even the most severe burns used to be treated in various hospitals. However, she criticises the fact that the hospital itself has not responded to the concentration: "We have not received more resources or space, on the contrary, our resources have been cut. The machinery is so slow that no results seem to be achieved. Resources are not given and planning is ineffective in our society. The number of the aged population increases and diseases change. Yet the resources are still allocated to where they used to be needed. Planning crawls ten years behind reality."

The attraction of the private sector

At the award ceremony, Asko-Seljavaara gave a talk on the topic "The Faceless Girl". She talked about an 18-year-old girl who lost her eyes, ears and mouth in a fire started in a traffic accident. One of the main points in her talk was the fact that the public sector must be able to treat cases like this: "Accidents can occur to anyone. Public healthcare has to be supported so that these cases can be taken care of. We cannot take them to the private sector. They don't have the same knowledge, resources and teams as we do. Who would pay for all that," Asko-Seljavaara asks.

Professor Asko-Seljavaara has continued the debate on the state of public healthcare after the ceremony. "In Finland a total of 6.7 per cent of the GNP is used in healthcare, which, compared to other OECD countries, is very little. What kind of public healthcare do we want? I fear that the private sector will select the cream of the crop and we'll be left with winos, the mentally ill, the rabble and those who have fallen seriously ill. This is the last moment to act," Asko-Seljavaara says demanding solidarity.

Asko-Seljavaara is afraid that as the situation gets tighter, more and more doctors will leave for the private sector. "Public healthcare still is of a high quality, but if resources and staff are decreased further, nobody can stay. We are cheap labour in the public sector. It is out of vocation that most of us are here. Even the university hospitals don't employ enough plastic surgeons to treat breast cancer patients, so surgeons end up in the private sector enlarging healthy breasts. You get more money for less effort there," Asko-Selja-vaara says.

As one solution, she proposes the creation of a more encouraging pay policy: "Skilful and hard-working doctors would be paid more. The compensation would be based on the work done, not academic degrees," Asko-Seljavaara says. She takes micro-surgery as an example, which is only mastered by a few doctors in Finland. Such special skills should be rewarded.

The stir over silicones

Asko-Seljavaara created a huge stir when she commented on the silicone breasts of the popular former Miss Finland Lola Odusoga. In an interview Asko-Seljavaara had told about a study conducted in the USA that said that women who had silicone implants were usually less educated than others. The headline quoted her somewhat harsher: "Women with silicones are dumb". Today Asko-Seljavaara laughs at the whole stir. "But I kind of meant it. It is dumb. It cannot be healthy."

She thinks that the stir was created by the fact that someone had the nerve to say out loud that the whole situation is twisted. "It isn't normal to put 200-gram lumps inside a perfectly healthy person. Why do we have this insane fashion? Nobody asks whether it's rational. If there's no disease, there's no reason to perform such an operation," she says.

Asko-Seljavaara also calls for doctors' responsibility and ethics. "In this profession, you should maintain good morals and ethics so that people are not lured. A doctor has to say that foreign objects inside the human body aren't always good for you. Quack medicine is gaining ground all the time. Men have breast muscles of silicone since they are too lazy to go to the gym to get real ones. Implants are used to enhance the buttocks and calves. It's just insane," the professor says.

Patients' unrealistic expectations should also be discussed. Aesthetic surgery is not necessarily the way towards a better self-esteem. Marketing has also increased. "Marketing may give you the idea that an operation is necessary for every woman. But an aesthetic operation is, on no account, an every girl's operation," Asko-Seljavaara says.

Plastic surgery a popular field

Asko-Seljavaara does not denounce aesthetic surgery as such. She completely approves of correcting problems created by ageing and liposuction used for the right purpose. Facelifts are often done on patients with facial paresis and post-operative liposuctions when fat has settled abnormally. Many plastic surgeons work both in the private sector's aesthetic surgery and the public sector's reconstructive surgery. Asko-Seljavaara thinks it is good: "It is great that people with good education and morals perform aesthetic surgery."

As a specialisation field, plastic surgery is quite popular among students. According to Asko-Seljavaara, the main reason for this is the fact that the field is very interesting. "Plastic surgery is about teamwork. It is done together with professionals from various other fields. That's why it's so fascinating. Though some people must also be thinking about the money."

The award, and the debate that has followed it, has helped the public realise that plastic surgery is much more than just wrinkles and silicone. Asko-Seljavaara finds it very positive. It is similarly positive that we finally have a public debate on the state of hospitals and public healthcare. But now Asko-Seljavaara has to rush back to her work. She is yet again faced with a round-the-clock day at the hospital.