The Current State of Affairs

Iceland's much-vaunted universal health care system is completely nationalized; 85.2% of the system is paid for by taxes, and access is equal for everyone. The administrative cost is minimal, and the coverage of services has been broad. Before cardiac surgery was established in Iceland in 1986, the rate of coronary artery bypass operations for Icelanders was among the highest in Europe, even though these operations had to be performed in other countries. We could, of course, argue about the appropriateness of such a high rate, but the point is that the cost and trouble of sending patients abroad apparently did not lead to withholding of treatment. To me, that is reassuring.

Today, these operations are done in Iceland. Seventy-five operations were performed per 100 000 inhabitants in 1995 (our total population is only about 270 000), with mortality rates of 0.5% for first operations and 1% overall. Complication rates were low, apart from an infection rate of 5.5% [1]. The health care system also provides for all types of organ transplantation, including heart and lung, but these procedures are still done abroad. The survival rate for patients with cancer ranks in the upper half of the Nordic countries [2], and the Nordic countries as a group have the highest survival rates in Europe [3].

Iceland's health care system is similar in structure to that of the other Nordic countries, and recently it has also been more successful in some areas. The system is unique because the small population makes it necessary for almost all physicians to go abroad for further training. Those who do bring back cutting-edge knowledge from and contacts in the United States, the other Nordic countries, the United Kingdom, and the rest of Europe. In my view, Iceland has mixed much of what is best about the Nordic social and welfare structures with the most advanced international medicine. In this respect, our small size and our isolation have been advantages.

Inevitably, the cost of health care has increased in Iceland. Between 1970 and 1990, costs doubled but since then have leveled off. The cost of health care, including nursing home care, was 4.03% of the gross national product in 1970 and 8.1% in 1994. (In 1994, the United States spent 14.3% of its gross national product on health care.) Our story is a familiar one. The total national budget has been in the red for many years. Because health care consumes about 25% of that budget, health care spending has been reined in. As a consequence, we have gone quickly from vigorous growth to painful re-engineering. Hospitals have merged in Reykjavik, and improved transportation and telemedicine have led to a questioning of the role of small hospitals in remote areas. Length of hospital stay is much shorter everywhere, and ambulatory care has become more frequent. These two trends have increased the pressure on health care professionals.

We now have two "high-tech" hospitals in Reykjavik and a smaller one in Akureyri. Whether there should be one or two hospitals in Reykjavik is a subject of intense debate. Some believe that having one hospital will lead to lower costs, more specialization (as technology advances), and a stronger medical school. Those who argue against having one hospital think it will be too big. They point out that people already agree to have only one specialized unit in the city in many fields (cardiac surgery and neurosurgery are examples) and cooperation in others, that patients and staff would have no choice if there were only one hospital, and that such a "monopoly" would increase the risk for stagnation. Is competition needed in medicine to maintain the highest standard, or will it prevent us from attaining that standard? What is the value of choice for patients and for staff? Is Iceland too small to have a choice? Or should we have such choice because we are so isolated?

The Historical Context

A struggle for independence first brought the Vikings to Iceland in the ninth century. According to a written document by Ari Thorgilsson (1068-1148), seven tenths of the original population came from Norway and the rest were mostly of Celtic origin. During the first half century of migration, about 800 settlers came, each with an average "family" of 25 people. Nature's gifts supported a good life for the next 300 years, and by the year 1200 the population is estimated to have been 78 000, close to the maximum that the farmland could sustain [4].

The language, old Norwegian, has developed into modern-day Icelandic. Now that the spelling has been brought up to date, schoolchildren can read the Icelandic sagas in their original language. Some of the classics are The Poetic Edda [5], Njal's Saga [6], and Egil's Saga [7]. Interpretation of the sagas has recently taken a medical turn: Some suggest that the main character in Egil's Saga may have been afflicted with Paget disease [8]. Egil was born in the early 10th century and lived to the age of 80, an astounding accomplishment for the time. He was a powerful man but is portrayed as ugly, irritable, and brooding. In old age, Egil became deaf, often lost his balance, went blind, suffered from chronically cold feet, endured headaches, and probably experienced bouts of depression [9].

Life in Iceland between 1300 and 1900 must have been extraordinarily hard. Many of the novels of Halldor Laxness (1902-1998), who won the Nobel prize for literature in 1955, are rooted in this old and underdeveloped peasant society. (Many of his works have been translated into English, including The Atomic Station [10], Under the Glacier [11], and Independent People [12].) Iceland's extreme isolation was disturbed by visits of seafarers, often at a high cost. Bubonic plague, imported from the British Isles, killed one third of the population at the beginning of the 15th century and another third toward the end of that century. Smallpox raged 21 times between 1240 and 1839, killing between 2% and 4% of the population in each epidemic (except between 1707 and 1709, when one in four of the 50 000 inhabitants died). During the 17th and 18th centuries, malnutrition reached major proportions. Scurvy was rampant, and dysentery killed many, mostly children and the elderly. The population hovered around 50 000 during these centuries but eventually crept back up, reaching 78 000 in 1901, the same size it had been 700 years earlier. Then, between 1870 and 1901, more than 12 000 Icelanders emigrated to Canada and the United States in the hope of finding a better life.

Iceland has developed rapidly since 1944, when the nation became independent of Denmark. From the shadows of the dark ages, a nation has emerged that is now approaching 270 000 strong-big for us, but about the size of many smaller U.S. cities. Because of these accidents of history, Iceland's population is relatively homogeneous biologically; perhaps some natural selection has favored survival. A population such as this provides new scientific opportunities. A company in the field of genetics, de-CODE, is taking advantage of the "founder effect"; it is looking at the genetic makeup of persons who have various common diseases and comparing them with those who do not have the disorders. The company is also examining the genetics of familial tremor and multiple sclerosis, to mention two examples [13]. A recent contract for U.S. $200 million over 5 years will enable the company to explore the genetics of more complex afflictions, from asthma and diabetes to schizophrenia and Alzheimer disease.

About 11% of Iceland's population is already older than 65 years of age. In 1992, life expectancy at birth was 76.9 years for men and 80.8 years for women. The infant mortality rate in 1993 was 0.48 (as a percentage of live births), which compares favorably with the lowest rates in the world (0.44 in Finland and Sweden); the rate in the United States in that year was 0.85. Being small and isolated has until recently meant that we have not had to worry about drugs and violence, but that is unfortunately changing as transportation improves and we become less isolated physically. Illegal drugs seem to flood into the country. Murders have been few, perhaps because handguns have not been allowed, but violence seems to be on the rise. In most families, both parents work outside the home for long hours, so we need day care and nursing homes to take care of people at the opposite ends of life. Some children are home alone for half of the day during the school year, but that is now changing as "whole-day school" is being developed.

Back to the Future

Iceland, like most other western nations, will eventually need to decide how much it is willing to spend on health care. In 1995, a national committee was formed to lay the ground rules for prioritization in medicine. Our small, homogeneous community helps us reach consensus. In its report, the committee was not willing to go the route of Oregon by ranking treatments but made recommendations more in line with recent Swedish and Dutch national health policy documents that emphasize ethical principles (human dignity, autonomy, justice, and solidarity) and cost-effectiveness [14-16]. This will probably lead to standardized waiting lists that are based on objective criteria for diagnostic workups and operations and a maximum waiting period of 3 to 6 months for elective operations. Physicians will also push for the practice of evidence-based medicine, and an effort will be made to optimize the flow of patients through the system. Technology assessment and evaluation of drugs will be emphasized, not only to exclude what is of little use but to allow quick and flexible adaptation to new technologies and therapies that produce true benefits.

Medical Education

Our formal medical tradition is short. The first Surgeon General took office in 1760. He educated only 11 physicians, but the University of Iceland School of Medicine is now a 6-year medical school from which 30 to 36 students graduate each year. About 200 students compete annually for entrance after a 4-month introductory course in medicine. The population is too small and interrelated to allow interviews or any other flexible way of choosing students for medical studies, so acceptance is largely determined by the entrance examination (rather like the system for selecting students for many U.S. law schools). Most students who are accepted enter only after having made two or three attempts at the examination, spending much valuable time doing so.

Because my daughter just finished her medical training, I have had the chance to reobserve the medical school. The school is limited in resources and has had the same basic structure for decades. Its curriculum is based on the fact that 50 to 60 years ago, physicians usually went straight into practice after 1 year of rotating internship and had to be able to deal with the whole of medicine as it was then. Students went, and still go, through many separate clinical courses with examinations in each subject, such as radiology and anesthesiology. One year is devoted to psychiatry, neurology, pediatrics, and obstetrics and gynecology, and almost 1.5 years are spent on internal medicine and surgery. The major change for the better over the past 20 years is the introduction of elective time in the fourth year, during which medical students spend 3 months doing research of their choice. Under faculty supervision, students plan a project, carry it out, present it, and write it up. Some have been published, and many students have followed up on their acquired interests by obtaining bachelor of science or master of science degrees.

We have long accepted the reality that a nation this small cannot provide full and adequate postgraduate training for physicians, although we now offer good internship and first-year residency experience. It has been of enormous benefit to us, therefore, that most Icelandic physicians have sought postgraduate training abroad. My own residency training was at the New Britain General Hospital in Connecticut, which has an excellent general internal medicine program. This training pathway became a tradition, and we estimate that by 1990 some 10% of all internists practicing in Iceland had trained at this one hospital. For social support, it helped that from about 1970 on, many Icelandic families were in the central Connecticut area, because in addition to internal medicine, the University of Connecticut also accepted many Icelandic residents in pediatrics. After training in Connecticut, physicians have entered a variety of subspecialty fellowship programs all over the United States. Subsequently, similar "Reykjavik West" settlements have developed at the University of Wisconsin in Madison and at the University of Iowa. Fewer opportunities for Icelandic medical graduates to train in the United States would have a considerable effect on the way Icelandic medicine is practiced in the future. The Icelandic government may have to contribute hard currency to postgraduate training abroad to preserve the international aspect of medicine in Iceland.

Medical Manpower

Most Icelandic physicians have returned home after their training "off island." Because we are no longer isolated and the disposable income of Icelandic physicians is low, however, we now face the challenge of competing for medical manpower on the international market. Three years ago, an Icelandic physician's average annual pretax income was around U.S. $60 000. All groups of physicians have been unhappy. The hospital-based physicians have negotiated new contracts, but as of this writing, the practicing physicians have not. It may make physicians in the United States feel better to know that our income tax is 40% to 45% and that we have a value-added tax of 24% on all goods. It is also true, on the other hand, that the tax system has limited out-of-pocket costs for health care and education; thus, on a lifetime basis, it is still feasible for physicians to return and practice in Iceland. But rapidly increasing marginal taxation over the past 5 years now threatens that equation. These new economic realities have already discouraged some physicians from returning. An equal threat to the health and welfare of the Icelandic nation in the long term may be the potential loss of those who receive PhD training abroad; these professionals may only earn the equivalent of U.S. $30 000 per year in Iceland. In this regard, we are watching with considerable interest the establishment and growth of deCODE.

Heated discussions have recently erupted within the medical community about the need for gate-keeping. Physicians have been polarized, with 190 family practitioners at one extreme and most of the 400 specialists at the other. The conflict is limited to Reykjavik because only a few specialists practice elsewhere and health care outside Reykjavik is predominantly delivered by family practitioners working in community health care centers. The system of community health care centers in Reykjavik is less well developed, and in Reykjavik these centers are subject to competition from all types of specialists, including internists and pediatricians with subspecialty training who practice in their own offices. Most of these internists and pediatricians have been trained in general internal medicine or in pediatrics, and most practice primary care to some extent. Family practitioners consider this arrangement inappropriate. They maintain that the most cost-effective strategy would be for all primary care contact to be with family practitioners, whom they feel could deal with 90% of all the medical problems that are presented to them. In their view, specialists should see patients only by referral and should work solely within their specialties. Specialists, in contrast, want patients to have a choice, particularly because, in their view, it has not been shown that specialty care on a private basis is any more expensive than community center-based family practices that are run by the Ministry of Health. Specialists also point out that a small and relatively isolated society such as Iceland needs to have access to all types of subspecialists. It is probably also true that many specialist physicians would not have a full-time job if they were limited to patients in their own specialties.

Are we making the best possible use of all of our available medical manpower? Do we have a health care system that functions in practice but does not fit a theory? Is it healthy to have a certain degree of chaos in the system? Or are our struggles just another unique feature of our small size and isolation? These are some of the questions that we grapple with. The only thing that is clear is that, in the end, family practitioners and specialists will have to resolve their differences, both with respect to the care of individual patients and the function of the health system as a whole.

The Geriatrics Perspective

Because 11% of the population is already older than 65 years of age and the number of those older than 85 years of age is growing steadily, geriatric care is becoming the key to Icelandic medical care. Health care professionals would like assessment to become the key to care of the elderly. The process of agreeing on standards and guidelines for geriatric care has been facilitated by our homogeneity and small size. Geriatric assessment units have been established at the three main hospitals, and they in turn are connected with subacute geriatric care. In 1991, a national nursing home preadmission assessment (NHPA) system was put in place. Its content was standardized and included evaluation of social, physical, and mental health, along with activities of daily living [17]. Before a patient can be placed in a nursing home, all diagnostic, rehabilitative, and social support efforts in the community must be exhausted. One important unresolved issue in this plan, however, is that nursing homes can admit any patient who has undergone a valid nursing home preadmission assessment. Because nursing homes prefer to admit those living at home, disabled hospital patients have difficulty finding nursing home placements and continue to occupy hospital beds.

For assessment of the elderly once they are in the nursing home setting, the Resident Assessment Instrument has been adopted from the United States [18]. It helps physicians assess the quality of care delivered and provides a good understanding of resource utilization. A similar assessment tool for home care is under development by the InterRAI group [19]. The use of standardized, international assessment instruments in Iceland paves the way for some interesting cross-national comparisons [20].

Conclusions

During dark winter days, we will always find something interesting to argue about in the local newspapers. One year, we argued about whether dogs should be allowed in Reykjavik; another year, it was our problems with gatekeeping in health care. Currently, it is the question of one hospital or two in Reykjavik. Coming home to Iceland clearly has its ups and downs; these have, in fact, been "interesting times" for Icelandic medicine. But despite the warning of the old Chinese curse, it has been important to me to be an Icelandic physician at this point in our history and to take part in our local struggles. When all is said and done, I suppose I am like the salmon that still swim in the river that runs through Reykjavik, seeking out their place of origin: For better or worse, Iceland is home. My country is no longer as much a world unto itself as it was 20 or 30 years ago, and coming home has not meant cutting myself off from the rest of the world. For physicians in Iceland these days, it is not only possible to be part of the international medical community, it is an inescapable necessity.