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WONCA RURAL INFORMATION TECHNOLOGY EXCHANGE (W.R.I.T.E.)

RURAL MEDICINE ON TOP OF THE WORLD
REPORT OF VISIT TO ICELAND, NOVEMBER 1998
PROFESSOR ROGER STRASSER

Iceland

Iceland is a nation of 270,000 people located in the North Atlantic Ocean just south of the arctic circle on an island of 103,106 sq kms. There is a well developed health system supported by a medical school and tertiary teaching hospital in the capital city of Reykjavik (pop 100,000). Specialists dominate the health system with only 20% of doctors being general practitioners. There was a government move in 1996 to require that patients only saw specialists on referral from GPs. This was vehemently opposed by the Icelandic Medical Association and ultimately not implemented. The antipathy between GPs and specialists continues to this day. Despite this, the government has continued to support the establishment of Community Health Centres first in rural areas and more recently in and around Reykjavik.

There are obvious differences between Australia and Iceland, yet I found that there are also some remarkable similarities. Like Australia, Iceland has 70% of its population concentrated in urban areas on the coast (in and around Reykjavik in the south west) with the remaining 30% of the population distributed in the rural areas. Currently 25% of the places for rural doctors are vacant and a recent survey suggests that none of the current students and new graduates are interested in rural practice as a career. Currently undergraduates and new graduates experience only two weeks of general practice in their six year course and may have no opportunity to experience rural medicine since the mandatory rotation in the intern year was removed four years ago. In addition, the new Director General of Health designate (an Infectious Diseases specialist) has indicated his support for closing small rural hospitals and replacing them with helicopter flying squads. In short, Iceland has a crisis in rural medicine.

Visit to Northern Iceland

I was invited to Iceland primarily to speak on "Rural Medicine around the World" at the 20th Anniversary Conference of the Icelandic College of General Practitioners. A very full program of visits and presentations was organised for me beginning with three days in Northern Iceland. Husavik is a town of 2,500 people serving a total district of 4,200. I was very impressed with the health service arrangements in this town consisting of a hospital/nursing home (25 acute beds, 25 nursing home beds) co-located with a Community Health Centre together with a 50 bed hostel and associated elderly citizens village. The team of six doctors together with nursing and allied health staff provide a very comprehensive service to their community.

Kopasker is a small village (200 people) in a very sparsely populated area 100 kms north-east of Husavik. On my visit to Kopasker I met with the local doctor whose responsibility covers two other villages and a total population of 1,500 currently with the assistance of one other doctor. I was impressed that the facilities of this clinic and services provided were very similar to a comparable remote community in Australia.

Akureyri is the regional centre of Northern Iceland 90 kms south-west of Husavik. The town itself has a population of 17,000 and a 185 bed hospital, FSA, (the Central Hospital for Northern Iceland). The specialist staffing and service profile of this hospital is similar to Latrobe Regional Hospital. In Akureyri I also visited the Community Health Centre which is staffed by nine general practitioners together with nurses, a midwife, allied health practitioners and visiting specialists. In general I was impressed by the similarities between the Northern Iceland region and Gippsland the potential for establishing a rural education and training program based on Akureyri similar to that in Gippsland.

Talks and Presentations

In Husavik I talked informally over dinner with the doctors and administrators of the Husavik hospital and community health centre. On the next evening, I gave a presentation on Rural Based Education and Training for Rural Practice to the local Medical Association in Akureyri. This talk was attended by 25 doctors including GPs who had travelled in from outlying areas as well as GPs and specialists in Akureyri. Following the talk there was lively discussion regarding the integrated approach to education and training for rural practice adopted in Australia and the world rural health movement led by the WONCA Working Party on Rural Practice.

In Reykjavik I was invited to address the Icelandic Association of Community Health Centres and spoke about Development and Delivery of Health Services in Rural Areas. In addition to describing the integrated system of education and training for rural practice in Australia I presented the view that rural health service development and delivery should be specific to the rural context. This presentation generated considerable discussion as did a similar talk given to staff of the Ministry of Health including the current Director General of Health in Iceland. Media coverage of my presentations included the local newspaper in Akureyri, the National Daily newspaper and the national television news.

On the Friday lunchtime, I was the guest speaker at the weekly clinical meeting in Landspitalinn (the national hospital). On this occasion I presented by views on the Role of the Teaching Hospital and Medical School in Rural Health. This talk generated many questions. My final presentation was a Keynote Address to the 20th Anniversary Conference of the Icelandic College of General Practitioners. I spoke on "Rural Medicine around the World" again describing the comprehensive approach to rural medicine education and training in Australia as well as developments around the world including the World Rural Health Conferences and the WONCA Policies on Training for Rural Practice and Rural Telehealth. Discussion after this talk centred not only training and support for rural medicine, but also the importance of substantial teaching in and about general practice in the undergraduate curriculum.

Icelandic Society of Rural Medicine

The Society of Rural Medicine in Iceland was formed only one month prior to my visit. On the morning before I left Iceland, I met with the Executive Committee of the new Society. We discussed many of the issues and challenges facing rural practitioners in Iceland and I shared experiences from Australia and other parts of the world. I provided the new Society with a collection of reports and other documents from the Centre for Rural Health, the Australian Government and WONCA and so provided for the beginning of the Society's library. I encouraged the Icelandic Society to make contact with other rural doctor organisations around the world including EURIPA (the European Rural and Isolated Practitioners Association) and WORD (the World Organisation of Rural Doctors). I also encouraged the Society to send representatives to the Third World Conference on Rural Health to be held in Kuching, Sarawak, 1-4 July 1999. From these discussions, there is considerable potential for liaison between the Monash University Centre for Rural Health and the Icelandic Society of Rural Medicine both in the provision of support and assistance in developing rural practice education and training in Iceland and also in undertaking joint research activities.

Conclusion

Despite the many obvious differences between Iceland and Australia, there are remarkable similarities between the two countries on the issues and concerns regarding rural medicine. My hosts were very interested to learn of the initiatives undertaken in Australia in rural health particularly the integrated approach to education and training for rural practice epitomised by activities of the Centre for Rural Health. There is real potential for assisting Iceland in establishing family medicine and rural medicine education and training, and for collaboration in relevant rural research.

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