WHEN surgeon Liam Kirwan decided to write a book about his experience of the relationship between medicine and politics, he quickly realised that such a study would have to include the historical role of religion on Ireland’s healthcare system.
Kirwan, who worked for 35 years as a consultant/professor at Cork University Hospital (CUH) and is currently professor of surgery at Penang Medical College in Malaysia, has vast experience of medicine.
He has also worked in the US and in the UK’s National Health Service (NHS).
“I wanted to study aspects of how we got to where we are today with what people call our two-tier system,” he says.
“One of my main criticisms of our health service is that it is inequitable. Throughout the book, I acknowledge that all countries have financial difficulties in providing funding for modern healthcare which is very consumptive of resources. But we have additional organisational anomalies which, to a degree, impact on the efficiency of the system.”
Ireland has inherited different types of hospitals — voluntary, statutory, private.
“Some of our private hospitals are doing good work. But it’s dubious as to whether some would stand up to scrutiny, especially the ones set up in the past few decades.”
The voluntary hospitals “are essentially religious-run. Examples would be the Mater in Dublin, St Vincent’s Hospital in Dublin, and the Mercy Hospital in Cork.
"The Mater would be the flagship one, well resourced and traditionally run by the nuns. While I may be critical of certain aspects of the religious input to hospitals, I’m not critical of the nuns.”
Noted for their high standards of hygiene and organisational skills, the nuns’ service is “hankered after now with a kind of naive sentimentality. You’re never again going to get a cohort of great women taking vows of poverty and working 24 hours a day.
"But the nuns did pass on a good ethic to generations of nurses. The nuns are almost gone out of the hospitals now and the training of nurses has become more scientific and more secular.”
Kirwan says it’s necessary to go back to the events of the 1950s “to appreciate how our inefficient and inequitable health system has developed”.
He says the seeds of this dysfunction were sown in 1951 when health minister Noel Browne, attempted to introduce a free Mother and Child Scheme.
“It was a perfectly sensible concept that was much needed. But it was obstructed by an alliance of the Church and medicine.
"The Church (headed up by the deeply conservative Archbishop John Charles McQuaid) essentially wanted a small State and a big Church, with the Church participating in a lot of the health service.”
Kirwan says “it is no secret that doctors at the time were afraid that private medicine would disappear. I make the point in the book that private medicine will never disappear and is essentially a good thing in proportion.
"But in the UK, doctors had resisted, tooth and claw, the introduction of the NHS. The Irish medical establishment had been watching this and said they were not going to have such a service here.
“They recruited His Lordship of Dublin as their ace in the pack. They didn’t like the State intruding into any matters. It was a case of essentially wanting to pursue a policy of laissez-faire where everybody should look after themselves rather than having a paternalistic set-up where the State would provide a lot of services. So there was an ideological clash.”
The prevailing international political climate didn’t help.
“World War II had just finished and the Cold War between east and west was ramping up. There was terrible tension and paranoia about communism.
"Socialised medicine, which we now have to a degree, was described by the Irish Medical Association as a cancer. That’s a really shocking adjective for the Hippocratic profession to apply to what was a much needed proposed service, the Mother and Child Scheme.”
The defeat of Browne “saw the victory of an unelected sectional interest with the bishops retaining control of most important hospitals which they delegated to compliant senior doctors.
"The elites, Church and medical, effectively ensured that patients should be triaged according to their means rather than their pathology — a hybrid and unequal arrangement.”
As well as being critical of the Church (although Kirwan is a practising Catholic) and the self-serving medics keen to uphold the status quo, he also criticises Irish journalists’ coverage of health matters.
“I’ve always had a realistic appraisal of the resources that could be provided to the public service. But journalism has no sympathy towards the idea that there is a finite amount of money with which you must do your best. Irish journalism is very naive in this respect.
"The journalists want huge amounts of money lavished on the cystic fibrosis people (with the very expensive Orkambi drug). I understand the reason for it but it would unfortunately deprive other patients.”
Kirwan says that journalists approach such issues “on an emotional basis. In the UK, there’s the National Institute for Clinical Excellence which adjudicates on these matters dispassionately and without emotion. We don’t do that. We politicise everything. It is actually a philosophical problem.”
Kirwan is critical of what he perceives as journalism’s failure to “cover the social changes that have taken place in this country such as the breakdown of the extended family. The loyalties of children towards their parents and all of those virtues which we formerly had — and which I still see in Asia — have disappeared.”
He says that “journalism always blames the HSE or whatever but it never blames society”.
With our growing elderly population, “we should try to keep elderly people away from medical institutions as much as possible. We should try to set up some kind of assisted housing scheme which would support them more cheaply in the community.
"And the elderly would be much happier. Some, as they become very debilitated, will require full-time institutional care which is very expensive.”
Kirwan says that Alzheimer’s and dementia “used always be called the ‘second childhood’. Some old people behave like children. Medicine has been perhaps too successful in prolonging life.
"The diminishing use of tobacco has been, for pension funds, an actuarial nightmare. People aren’t dying. They were killing themselves before (by smoking.)
"When ministers for health were deriving revenue from tobacco consumption, at the same time, they were succeeding in getting the old people to disappear through smoking-related diseases. There has been a big demographic change.”
In Malaysia, people are far more empathetic towards the elderly.
“Families are always around the bed, looking after the elderly patient, getting them out of bed, washing them, stuff that we expect to be done by nurses here. And fair enough. But there is much more concern that I see in Malaysia.
“Educated sons and daughters who’ve gone abroad come back when their mother gets sick. They try and get a career locally. It’s much more humane, what we like to call Christian.
"In Western Europe, we like to think we have a monopoly on all these wisdoms. When I see the rest of the world, I feel that we don’t have that. All countries and religions have their own wisdom.”