Tag: nursing home deaths in Ireland

  • A Contract of Indefinite Duration

    The voice on the other end of the line was shaky and uncertain. ‘Are you alone?’ he asked. My wife had come upstairs with the phone just as I was getting out of the shower, ‘It’s your father,’ she said, eyebrows to the ceiling.

    My father and I have a good relationship now, a better one than when I was a teenager at least. My mind began to race as I sat on the edge of the bed, evaporating in my bathrobe, the bedroom door closed behind her with a polite click of the latch. ‘Yes I’m on my own Dad, is everything alright?’ I was half expecting a diagnosis of some kind: prostate, the big C, or something worse?

    ‘I couldn’t sleep last night son,’ his voice became a little more relaxed once privacy was assured. ‘I was up pacing the floor after watching that RTE documentary about abuse in the schools.’ As a rule, I don’t watch RTE – haven’t done so since the Covid years – so I wasn’t sure what he was talking about. Child abuse has been grist to the media-mill since Angela’s Ashes. Indeed, I suspect people are becoming comfortably numb to the perennial revelations. Perhaps he was having a delayed reaction to the trauma of it all?

    ‘They mentioned Rosmini and the Carmelites,’ he continued,  ‘Jaysus it’s terrible son, terrible!’ he repeated, his voice wringing as though he was going to start crying. The penny finally dropped, and I realised where he was headed. ‘You and your brother went to those schools; Me and your mother sent yous there,’ he added soberly. ‘I couldn’t live with myself if I thought anything happened to either of yis. So I wanted to ask you,’ he spoke slowly, struggling to find words. I sighed, somewhat relieved there was no bad news or terminal diagnosis in the offing. Quietly smiling to myself, I tried to think of a clever answer that might reassure him.

    My Dad is a good man, he likes old things and the occasional pint. He worked hard all his life; a bus man, a taxi driver, a father to nine children. He doesn’t need to be unnecessarily upset in his twilight years. Had I been abused as a child I probably wouldn’t have told him. I suspect a lot of victims tell no one, and instead try to keep the hurt buried in a dark place, away from the growth inducing sunlight. I wondered how he was going to phrase the impending question?

    ‘Did you em, did you have any bother with that sort of thing when you were at boarding school?’ he spluttered, his tone rhetorical as though he expected me to answer in the affirmative. Perhaps he suspected that some of the harmless mischief I had been up to as a boy might have been some kind of ‘a cry for help’? I got into a lot of trouble at the Carmelite Boarding School in Moate. Mostly escaping into the town in the late evenings, to buy chips, drink cider, or try to meet up with my girlfriend Maggie. I restrained a chuckle, ‘what do you mean Dad?’ I pressed him. He sighed deeply, probably assuming I was being stupid and hadn’t got to the gist of the matter.

    ‘Ah for God’s sake son, I mean did any of them ever?’ His words crackled dryly, and then he blurted it out: ‘Did any of them ever interfere with you?’ The distasteful question hung in the air like a strand of hair pulled slowly out of a sandwich. There it is, I thought, that strange word: ‘interfere’, inextricably bound to the adolescence of Irish males for generations. Joyce’s A Portrait literally climaxes on the notion.

    In 1980s Ireland, most  boys were sinners, entirely guilty of ‘interfering’ with themselves. The risk of being interfered with by a person of authority, that particular ‘sin’ wasn’t on the horizon. Indeed, given the scale of abuse in Ireland unearthed in recent years, some people might wonder if child abuse was ever considered a ‘sin’ at all?

    The RTE programme that had upset my father did not arise out of any investigative journalism on the part of our national broadcaster; rather it was on foot of a ‘scoping inquiry’ that was initiated by the government in 2023, in response to a previous run of ‘new revelations’. This inquiry findings were published in September and contain 2295 allegations of sexual abuse across 300 schools between 1960-1990. In a somewhat nauseating twist, 590 of the allegations were recorded in 17 schools for children with disabilities and these allegations relate to 190 alleged abusers. Of the 884 alleged abusers across 42 religious orders, half are now believed to be deceased.

    To describe the report as grim reading would be an understatement. The Carmelites ran my boarding school in Moate, but I knew nothing about the Inquiry until my father’s phone call. Given the difficulties experienced by the few victims who come forward in these types of inquiries, I imagine the number of allegations (shocking as they are) are but the tip of the iceberg. Interestingly, a recent BBC news report on the Inquiry findings was quick to touch on the sacrilegious question of social complicity:

    Survivors also had a “strong belief that what was happening was so pervasive that it could not possibly have gone unnoticed by other staff, and the members and leadership of the religious orders”. People who had been abused told the report authors that: “the power of the Catholic Church permeated their lives in every way” and they believed there was no-one they could tell, including their parents.

    In Ireland since the early 1990s, religious abuse scandals have become a regular staple on the news. The official response follows the same prescription: establish an expensive tribunal headed up by a retired Judge; dispense a vulgar sort of financial compensation to the victims; and hopefully that’s the end of the matter, at least until the next batch of revelations. It’s an entirely post-colonial response, closely imitating the manner in which his lordship might on occasion have compensated a peasant farmer for the rape of his daughter.

    In reality, there is little if any appetite for understanding the conditions that made systemic child abuse possible. One might reasonably argue that there is little appetite to change a culture of abuse that dates back several hundred years. In Ireland, institutions get away with abuse. In a way, it is almost expected of them. The abuse (or at least the acceptance of it) is in our very nature; with time, all that appears to change is the form that the abuse takes.

    Consider that most elderly people have a medical cabinet overflowing with prescribed medications. More often than not this is an abuse of the elderly perpetrated by the medical establishment in Ireland. The technical term for the abuse is: ‘polypharmacy’. Despite this being common knowledge, is not yet a ‘scandal’ because of the blind faith that is afforded to the medical establishment in Ireland. Polypharmacy in the elderly will only become a ‘scandal,’ if and when it becomes safe and permissible to criticise the medical profession. This will only happen if and when society comes to realise that it is not in need of much of the medicine it is all-too-frequently prescribed.

    To honestly ameliorate child abuse (or any kind of abuse), one must come to understand and accept the conditions that made it possible, or even inevitable. In my opinion to accomplish this, RTE would first have to be dismantled, and the looking glass would have to be repaired. News must not be subject to the censorship of the market. Unpleasant truths are unpopular truths. They just don’t sell. RTE (like all advertisement dependent media) are compelled to tell us what we want to hear, not what we might need to hear. Scandals must therefore wait until they become marketable before they can actually become scandals.

    The gullible nature of Irish society; our collective willingness to elevate sacred institutions and afford them the blind faith they demand needs to be explored. As a consequence of this blind faith, the only institution capable of exposing abuse whilst the abuse is unfolding; is the abusing institution itself. Neither paedophile nor neonaticide scandals caused the collapse of the Catholic Church in Ireland. Those scandals were common knowledge, they were well known and delicately concealed within the vernacular of the day. They only became scandals because (in the 1980s) the Church had already begun to collapse in the face of increasing capitalism. RTE became free to flog a dying horse; a space in the consumer market had been opened for criticism of the once infallible Church. Those stories could be sold once they had inadvertently received the sanction of the market.

    The market and the multinational are the ultimate arbiters of ‘news’ and how it is to be portrayed in the media. For example, look at the invasion of a highly organised and sophisticated Israeli army into a Third World shantytown, deprived of an infrastructure or organised defence forces; this obscenity is invariably referred to as Israel’s ‘war’ against Hamas. Similarly, the low-wage crisis in Ireland and abroad that permits the rich to get richer, is almost invariably referred to as the: ‘cost of living crisis.’ Media sells ‘news’ to the market and sells advertising pages to the corporations. These two institutions are the moderators of language and subsequently of thought itself.

    Israeli military during ground operations in the Gaza Strip on 31 October

    The Contract

    I suspect my own parents’ along with other generations of parents since Irish independence were locked into a kind of unspoken contract with the Church. One wherein they sublimated the signs and symptoms of systemic child abuse in return for a sense of belonging, and a right to participate in our newly won independence. Having been deprived of that for several centuries perhaps the price was considered to be minimal. Children were not as valued then as they are, at least ostensibly, today.

    By the 1980s in Ireland, Church and state were practically indistinguishable. Being on the outside can (in many ways) be equated to life in a tent on the Grand Canal as an ‘unwanted immigrant sponger.’ Back then, Catholic identity was a fundamental prerequisite for belonging; for education, social mobility; for salvation and all the trimmings. Perhaps it is only now since we have become less dependent upon the Church that we can read the terms upon which the bargain was concluded. Those sick and vile terms make it difficult to determine whether or not the new landlords are any less unsavoury than the one who had been so recently deposed.

    I often wonder who the whistleblowers were over the decades of systemic child abuse in Ireland? I’m sure there were many of them. How were they treated by the authorities? How many were shunned by RTE, and sanctimoniously smeared in the broadsheets like the ‘right-wing loonies’ and ‘anti-vaxxers’ of today?

    Did a significant number of people know what was happening to children, and simply turn a blind eye? What kind of human beings are they? Who were the doctors and officials who visited the laundries or the mother and baby homes, and saw what was happening with their own eyes? Who treated the women and delivered the 796 babies that were dumped into a cesspit in Tuam over a period of thirty-six years? These types of crimes are not perpetrated by a particular priest, a nun, an order, or even a Church. They require a formal bureaucracy and a veritable army of participants. They are crimes that are not perpetrated on society, but rather by society itself.

    I cannot help but wonder if the same silent contract exists today between the mainstream media and our ostensibly more liberal and progressive society? As long as they avoid fixing the cracks in the looking glass, we remain unreservedly committed to buying whatever it’s selling, whether news, vaccines or Renault cars. In a broader sense that same contract defines the type of news we receive, and the type of Ireland we quietly choose to live in.

    ‘Dad!’ I replied to my father in that firm but ineffectual tone that I sometimes effect to inform my kids that I’m being serious. ‘As I’m sure you remember, I was kicked out of boarding school and labelled a ‘bousy’ and a ‘gurrier,’ I said.

    These terms are not in common parlance today, but they are descriptive nouns that were often applied at parent teacher meetings in the seventies and eighties. They are terms that my parents are quite familiar with.

    ‘I imagine,’ I continued, ‘that being a gurrier or a troublemaker offered some protection from the perverts. It was probably the meek and vulnerable kids who were preyed upon. The ones who did well, and did what they were told.’ He digested this for a moment as I’d hoped he would. ‘There might be something in that son, but it wasn’t always the case, the bousies wouldn’t have been believed if they told anyone,’ he said. It then occurred to me that back then whilst my father sent us up to mass on Sundays he rarely attended himself. ‘You were always getting in trouble with your cheek and your big mouth,’ he continued, ‘maybe in a way it kept you safe,’ he sounded somewhat relieved by my reassurance.

    I have never told my Dad, but when I was at boarding school in Moate in the eighties, there was a particular priest or ‘brother’ who acted as a kind of bursar. He would issue small loans to the tune of five pounds (a princely sum in those days), but there was a catch. One had to sit on his knee and have him slip his hand under your shirt and rub your back for five long minutes, before you got the loan. As the end of the month approached, myself and my smoking companions were often reduced to some tobacco dust in the arse of an Old Holborn pouch: lots were drawn and straws were pulled. As far as I can remember I only had to endure one back rub, hardly grounds for complaint when I consider the horrors that so many others have endured.

    As kids, my siblings and I were sent to mass, but I think it was more to keep the neighbours happy and let my parents have some peace on Sunday mornings. It was a half hour walk from our house, through the valley of squinting windows, to the church in Lusk village where I grew up.

    Recently I asked my Dad if there was much known about paedophilia in the Church when he was a boy? He said: ‘there was plenty known about it!’ That he and his pals knew of the priests to be ‘avoided like the plague’. He went as far as to tell me what one Father used to do in the dark of the confessional box whilst questioning boys about their wet dreams and sexual fantasies.

    I write these words not out of a desire to kick at the old bones of Irish Catholicism. Surprisingly perhaps, I feel a kind of sadness at the departure of the Church from Irish society. Just because the Church/State experiment has failed (again), it doesn’t mean that it was entirely devoid of good ideas. For a short time, there were parallels that might be drawn between Plato’s Republic and Catholic Ireland; a society run by saintly philosopher kings disinterested in power, sex and money.

    Perhaps a separate Church and state, antagonistic and fearful of each other might be the next variant of that age-old experiment? It is not unreasonable to argue that without some spiritual compass, a society like ours – one that does not even teach philosophy in its schools – is more vulnerable and prone to the extremes of advanced capitalism that are ravaging the Earth and perhaps also, the soul of humanity as well.

    I recall being fined for attending Mass in Cavan during the Lockdowns. A defiant priest in Mullahoran continued to say mass and refused to lock the doors of his Church. He was repeatedly fined and vilified in the broadsheets. He persisted defiantly for a time even refusing to pay the fines, (as I initially refused to pay mine); but in the end they broke him, (and me), and many others. That courageous priest reminded me of the ones who said mass in the hedges and the ditches at the time of the Penal Laws. What was it the then Taoiseach said about heroes, during one of his televised fear mongering addresses? ‘Not all of them wear capes!’

    Christian philosophy is of course as distinct from priestly messengers, as good health is distinct from doctors. Personally, I enjoy attending mass nowadays; the ceremony, the costumes, the acoustics, the aromas, frankincense and two thousand years of flatulent history. In Joyce’s Ulysses Leopold Bloom expressed a similar kind of reverence for the iconography and the theatre as he sat in a vacant pew in St. Andrew’s Church on Westland Row:

    Letters on his back: I. N. R. I?
    No! I. H. S.
    Molly told me one time I asked her.
    I have sinned: or no:
    I have suffered, it is.
    And the other one?
    Iron nails ran in.

    Ulysses: 5.372-4

    I try to go on those Sundays when I’m not working in the out of hours. Mass is much safer now, it’s like flying with an airline that has just endured a terrible crash, in fact it’s even nicer without the bustle and the crowds. Should they return, I will have to travel to the Buddhist temple at Jampa Ling on the border between Leitrim and Cavan; a calm serene setting for healing and meditation. Naturally there’s a different ethos there; vegetarianism, karma, reincarnation and a different type of magic. For me, however, the basic principles are practically the same. If Christ had been a bit fatter and less confrontational, he could just as easily have been the Buddha.

    On the Sunday following the documentary that had so rattled my father, the parish priest at the little Church in Annagassan (where I live now), almost cried as he spoke about the ‘new’ revelations. To the small gathering of mostly elderly stalwarts, the anguish and hurt in his voice was palpable as he apologised on behalf of the Church. As one of our living literary legends: John Boyne reminds us in his History of Loneliness: the good priest (and nun) have also become a certain kind of victim; one who’s vocational isolation is compounded and who’s suffering is invariably overlooked.

    During the Covid years, at the height of the engineered panic, when my colleagues were being bribed to embrace bizarre draconian policies and an experimental vaccine, several doctors were forced to resign from our posts or be fired. My faith in the medical establishment and much of the enjoyment I once took from my role as a GP, evaporated at that time. Presently I work as a locum, confining myself to immediate medical problems and short-term fixes. Unlike most of my colleagues, I’m no longer contractually engaged by the State to keep people ill. To keep them ‘chronically managed’, maintained, and terminally dependent upon an expensive cocktail of iatrogenic pharmaceuticals.

    Saint Bernadette of Lourdes.

    Christian Heroics

    Last week the ‘relics’ of Saint Bernadette of Lourdes went on display at St Patrick’s in Dundalk. (I can hear the yawns). The impressive Gothic cathedral contains some of the most beautiful mosaic walls in Ireland, and is hardly in need of saintly bones to big it up. Nonetheless, a crowd of several thousand showed up to view the macabre display of desiccated body parts. Had those bones arrived from Lourdes in the eighties, they would have made national headlines. There might have been a day off work for everyone, and an entirely different type of Taoiseach would have been compelled to be represented; to lick ice-creams and hug someone’s grandmother.

    In the late eighties and at the turn of the century many things in Ireland were changing; travel, entertainment, contraception, a shift from varied forms of self-sufficiency to consumption as a national pastime. It was an era of televised heroics; the A-Team, Star Trek, The Dukes of Hazzard, the Incredible Hulk, and a hundred more heroes. As we became wealthier and more overtly American, the old Catholic virtues associated with restraint and frugality were being shed in favour of a new skin. Shopping malls and concert venues were usurping the cathedral in size and scale, and became the new loci for pyrotechnics and Sunday worship.

    The present day is very different from how I imagined it would be when I was a teenager. Back then my friends and I had a saying that helped us explain the uncertainties of life: ‘the plan that you don’t plan is the one that always works out!’ Few in the Catholic hierarchy could have foreseen the changes, even fewer could have imagined they would culminate in the collapse of the Church itself.

    In his Pulitzer prize-winning book: The Denial of Death, Ernest Becker proposes that one of the main drivers behind human behaviour is our desire to go beyond the painful reality of our mortality. We accomplish this by seeking to do something ‘heroic’ with our lives. By becoming heroes; hero Dads, hero Mums, hero criminals, hero Journalists, empire builders etc., we can (in some small measure) cheat death and be present in the world or in people’s minds, after we are gone. The problem with the Church (Becker argues) is that it no longer affords an opportunity for the heroic. It had failed to compete with Magnum PI or Charlie’s Angels.

    The great perplexity of our time, the churning of our age is that the youth have sensed – for better or worse – a great social historical truth: that just as there are useless self-sacrifices in unjust wars, so too is there an ignoble heroics of whole societies: it can be the viciously destructive heroics of Hitler’s Germany, or the plain debasing and silly heroics of the acquisition and display of consumer goods, the piling up of money and privileges that now characterises whole ways of life, capitalist and Soviet. And the crisis of society is the crisis of organised religion too: religion is no longer valid as a hero system, and so the youth scorn it.
    (From The Denial of Death by Ernest Becker: Souvenir Press, 1973 p.197)

    Notwithstanding Father P. J. Hughes in Cavan, today’s Catholic ‘heroes’ are invariably presented in the antithetical form of; fundamentalists holding vigils outside abortion clinics, homophobic protestors, or teachers who embrace prison rather than accept that someone has changed or wishes to change their gender. The rather unchristian unwillingness to see the pain behind the woman presenting for an abortion, or the person desperately struggling with their identity, deprives either activist of any possible heroism. The real heroes of Catholicism are hard to find, the media doesn’t look for them anymore. Neither do they tend to seek public recognition. Many (if not most of them) are passing away; alone, demented, childless in the convents and seminaries that have lately been transformed into nursing homes. Another scandal perhaps? If so then like the others, it too must await the sanction of the market.

    Former St Joseph’s Industrial School in Letterfrack.

    Child Protection?

    It is impossible to see into the future and as such many, or most, of the ills that beset our children today, were not anticipated by the most anxious, or even by the best of parents. My own, having come from the ‘lower’ classes, directly (and indirectly) instilled into me an inflated respect for the ‘class system’. When I left home in my late teens, I was determined to become a ‘somebody’ within that same system; as opposed to becoming self-sufficient and capable of thinking beyond it.

    My generation’s preoccupation with class may have come at the cost of an appreciation for the arts and for nature; the tools that might help us navigate an ubiquitous sense of inadequacy, an obsession with status and material consumption. We may have compounded the ambivalence towards nature and philosophy with an overemphasis on the importance of a certain kind of education for our own kids. Pushing them into universities, eschewing the arts and the ‘lowly’ trades for the ‘white collar’ of a college degree.

    For most young people a university degree (so valued by their parents) amounts to little more than a piece of paper and a pathway to barista work. Many of these young graduates have grown up surrounded by creature comforts. They remain oblivious or disinclined to ascend through the class system their parents have prioritised so much. Today their aspirations are often confined to the digital space; they are beset on all sides by addiction, depression, anxiety, identity, and a precarious social media image. Ills their parents could never have predicted.

    It seems as though each generation of parents is condemned to a similar fate of protecting their children from the wrong sorts of evils. Today’s school lunch scheme is a telling example; disempowering children, removing them from an engagement with their food and from the discipline and time needed to prepare and understand what a nutritious meal really is. There is no attention given to disempowerment, environmental impact, or even nutrition itself! Yet most parents seem to love the recently established ‘free lunch’ programme. My own kids get a hot ‘free lunch’ at their primary school in Annagassan, outside of which there is neither a footpath nor a speed bump.

    Today, across the country some 455 schools are teaching children in rented prefab accommodation. This comes in at a yearly cost to the state of some 23 million euro. At least this winter, one hopes that the chicken nuggets and pizza slices will be easier to heat than the prefabs.

    Had I known then what I know now I would have raised my older children differently. I might have pushed them into carpentry, and would have educated them daily on the twin evils of social media and drug dependence. On top of that I would have taught them how to lift a shovel, turn a sod and plant a seed, as I do now. I did try to teach them to read good literature, and where possible to think independently of the herd.

    Image: Daniele Idini

    Whistleblowers

    Shortly before the economic crash in 2007 economists, most notably David McWilliams and several others were critical of government economic policy and tried to blow the whistle. In 2007 the then Taoiseach Bertie Ahern dismissed the naysayers at a speech in Donegal saying:

    Sitting on the sidelines, cribbing and moaning is a lost opportunity. I don’t know how people who engage in that don’t commit suicide, because frankly the only thing that motivates me is being able to actively change something.

    When I think of a whistleblower, I think of an official who stands on the platform and informs people if and when it’s safe to get off the train. During the pandemic one such whistleblower was Dr Martin Feeley.

    A former Olympian and clinical director of the Dublin Midlands Hospital Group, Martin was part of a small cohort of physicians in Ireland who were critical of Covid policies, including nursing home deaths. He recognised from the outset that only the elderly and the very vulnerable needed protection, and that much of what was going on was not motivated by an interest in public health. Dr Feely was a physician and a gentleman, above and beyond anything the cliche might describe.

    We met each other many times and corresponded throughout the years of madness, I feel honoured to have known him. Having been compelled to resign his post as clinical director in 2020, Martin endured a torrid time as a consequence of speaking the truth and adhering to medical and scientific principles. Like the rest of our small group of naysayers, he was stunned and shunned by former ‘friends’ and colleagues. It was reported that Martin ‘died suddenly at his home’ in December 2023. Whilst I would not wish to burden his family with any speculations on his departure from this world, I have no doubt, (and personal experience informs) that the vitriol and invective he endured from within the medical profession, was a contributing factor to his untimely death.

    Ironically most of those medics who publicly contradicted Covid policy or questioned the administration of the vaccine to children or pregnant women, were either fired or placed under investigation by the regulator? In some cases, they were both fired and placed under investigation. The ongoing inquiries are now in their fourth year, at this stage they must be some of the longest investigations on record at the Irish Medical Council. One colleague, critical of NPHET policy, received his summons for investigation shortly after being discharged from hospital. Another colleague GP who refused to administer the vaccine, was summarily suspended from the register. In September of this year Dr Neville Wilson, a GP with a busy practice in Kilcock Co Kildare, was brought before a Fitness to Practise Hearing at the Medical Council for allegedly ‘making comments disapproving of the use of Covid Vaccines.’ He is presently awaiting a decision in respect of sanctions against him. Two weeks ago, another colleague (and a good friend), a GP with a busy practice in Adare was ordered (as part of his ongoing investigation) to travel to Dublin to attend an occupational health assessment, which includes an assessment of his mental health! In 2020 this same respected GP who runs a thriving and busy clinic in Adare, was compelled to resign from his role as Chairman of Shannon Doc (the out of hours service for the Midwest); after he publicly criticised Covid policy.

    Myself and several other GPs have yet to receive a date for our fitness to practise hearings. The purpose of these interminable prosecutions has an obvious historical precedent. It is a process little different to what those that contradicted the presiding dogma of the day experienced some fifty years ago. Then, as now, the collective injustice endured by Covid policy critics is largely ignored by the media because a majority were complicit in the embrace and execution of those policies. Not one of the doctors presently under investigation have caused harm to a single patient, instead, all are guilty, to a greater or lesser degree, of simply disagreeing with Covid policy, in a manner more benign than the prominent politicians and RTE presenters who publicly flouted the rules with impunity. Of course, there is an element of punishment in all of this, a punishment most acutely felt by the families of those who remain under investigation.

    Adverse Events

    Had I been inclined to inform someone of the harm that was being done by the bursar at my boarding school; where, or to whom could I have reported these adverse events? How would they have been received?

    Today, in order to record or report the adverse consequence or side effects of a Covid vaccine, one’s only recourse is to fill out a seven-page complaint form, obscurely buried on the HPRA website. If you don’t have a Medical Card, it will cost you sixty or seventy euro to bring a suspected side effect to the attention of your GP. If you do manage to get an appointment, he or she will probably dismiss your side effect as: ‘coincidental’ or ‘all in your head’.

    I suspect that Irish GPs are as ill-informed about potential side effects from Covid vaccines as they are (and were) ill-informed about the mechanism and mode of action of these novel genetic ‘vaccines.’ There are no posters in the waiting rooms, no mention of side effects anywhere, outside of some inaccessible small print on the back of a leaflet in the bottom of a box. Thus, one must complain about the medicine to the same people who are being handsomely paid to administer it.

    It is all easy to fall into the trap of becoming a conspiracy theorist or far-right supporter in Ireland. It is within these circles that criticism of almost all kinds is embraced.  The doctors who criticised Covid policy were described as ‘right-wing, anti-vaxxers’, a slur that has not yet lost its resonance. Today the man who was Minister for Health over much of the period of the Covid fiasco – including the period of the nursing home deaths – is presently Taoiseach. That observation alone should be enough to make the most reluctant conspiracy theorist pause and wonder: ‘Who are the king makers?’

    Those who objected during Harris’s term as Minister for Health are presently being prosecuted by the Regulator, or are deceased. To impressionable minds it might read like an episode from the HBO series Succession? Or a pulp fiction drama where behind an entertaining puppetry of politics, a few multinational corporations are in control of state and government. In Ireland truth is no stranger to fiction.

    My dad was reassured by my denial of being abused by the priests or the unchristian brothers at my boarding school in Moate. My abuse was to come in my adult life in a form I could never have predicted. It came not at the hands of the old priests, but at the hands of the new ones: my ‘colleagues’, and from a hopelessly failed and politically controlled Regulator.

    For less than obvious reasons, I fear many people in Ireland don’t want to look back on the Covid period. They would rather move forward towards a hopefully brighter future.  Perhaps the lack of a public outcry for a meaningful Covid inquiry reflects a deeper truth about the Irish public; one that suggests a broader culpability, beyond the pharmaceutical companies, the medical establishment and the political puppetry?

    I have no doubt, however, that a future generation will look back on the Covid years with the same level of disgust and anger that is readily applied today to those clergy that abused children.

    I desperately hope that history does not repeat itself. That fathers will not one day be nervously phone their sons and daughters, apologising for the consequences of decisions that for a time were coerced, mandated and unquestioningly endorsed by the medical hierarchy of today.

    Feature Image: Richard Tilbrook (wikicommons)

  • The Vanishing Cat

    When the day becomes the night and the sky becomes the sea, when the clock strikes heavy and there’s no time for tea; and in our darkest hour, before my final rhyme, she will come back home to Wonderland and turn back the hands of time.
    The Cheshire Cat.

    There are very good reasons why bathrooms are located at a remove from the dinner table: one should never defecate in the place where one eats. A barrister reminded me of this old adage one evening at dinner after I had bemoaned Ireland’s corrupt medico-legal system wherein plaintiffs (or more often their solicitors) pay their GPs handsomely to write medical reports for insurance claims. I’m sure my barrister friend would agree, however, that when the dining room has depreciated into the vandalised shell of an old tenement; it will inevitably become prone to unhygienic and antisocial usage.

    No doubt it will surprise some to read of a GP complaining about General Practice and biting the proverbial hand that feeds. However, my position within the establishment is ‘as safe as houses’ after my criticism of Covid policy and the role many of my colleagues played during the pandemic. This led to me closing my practice in North Dublin, having resigned my appointment to the Medical Council in 2020.

    I was subsequently placed under investigation for attending a public rally against lockdowns, and soon (three years later) the Medical Council is to decide upon my punishment, and that of the other doctors who failed in their duty to promote, unquestioningly, Government policy. Apparently, we were more influential and more of a danger to people than the Taoiseach or the TDs and judges in attendance at ‘Golf Gate’, ‘Party Gate’ and ‘Concert Gate’ etc.

    Today I have little invested in General Practice. In truth I have come to see it as a social ill rather than an overall benefit to society. I knew it was unwell prior to Covid, I had taken up my Ministerial appointment to the Council in 2018 in the vain hope of changing it. My experience and the silence of so many colleagues during the Covid years, suggests to me that the illness may be terminal. Its pathology is genetic and runs much deeper than the financial incentive brought to bear on General Practice throughout the pandemic.

    Myself and other Covid policy critics, have little left to lose, other than our licences, and a shared sense of disappointment in our profession. Realistically, I feel that disappointment could only be lifted by an unlikely paradigm shift; as such it will probably stay with us until the end. Having adhered to the Covid guidelines, yet being entirely guilty of the ‘crimes’, hopefully we will hold onto our licences and continue to be able to make a living. There are no guarantees. The establishment remains angered by dissent, and can be brutally vindictive when it wishes.

    Medicine is sometimes described as something of an ego trip. I have to admit that on occasion it has become one for me, but not in the manner you might think. What I mean by ego trip is that lately, should I glance at headlines on the shelves, or overhear the radio as I push my trolley down the supermarket aisles, I find myself nodding and even chuckling quietly to myself.

    The truth in respect of the Covid years remains as politically toxic as any virus. Occasionally however, it leaks into the air in flatulent forms of ‘I told you so’. I’m not alone in this mad little trip, the few doctors who spoke up against; nursing home deaths, masks, lockdowns and compulsory vaccines, also share in this little Pyrrhic victory.

    We continue to be gagged, pursued by a certain cabal who pull the strings from within the medical establishment. Excess deaths, missed cancers, suicides and vaccine related injuries cannot remain concealed indefinitely. To coin a hopeful phrase from the current ascendancy ‘tiocfaidh ár lá’. Given the hitherto impossibility of their day ever coming (as it might at the next General Election); so too might we hope that ‘our day will come’.

    In the Rare Auld Times

    I have been practising as a GP for more than twenty years, and regardless of current trends in a more progressive parlance, I don’t mind expressing a fondness for things like community, traditions, or even the old-fashioned notion of ‘the Family Doctor’. Some things are not ‘old fashioned’ at all. That’s just a term that is applied in the pejorative, for particular motives.

    In the olden-days (whenever they were), a reference to ‘years as a Doctor’, might have scooped some credibility from the idea that the longer one has practised at something, the better one performs in the role. Like poker or potty-training, practice means you are more likely to win, and less likely to ruin the carpet.

    Today, with the exception of less technologically dependent skills, like piano or pottery, the longer one has practised, the more likely one is to be outdated; married to ‘old fashioned’ or ‘primitive’ methods.

    Technology has become synonymous with progress towards the good. For many people, it has made the GP as redundant as the old notion of growing your own vegetables. In today’s world of instant food and information, people rarely visit the GP to dig up an ‘expert opinion’. Everybody’s got one of those – either in their head or at their fingertips. Many patients have already self-diagnosed, long before they’ve reached the waiting room. What they need is a signature, a scan, a test, a vaccine, or the usual panacea of the antibiotic. Augmentin has become a household brand-name, all too often (I am told) it is ‘the only one that works’.

    It is an important and relatively recent development in medicine that there is no longer a distinction between what we ‘want’ and what we ‘need’. The distinction remains a valid one, but there are few people we can trust to make it for us. Most antibiotics prescribed in General Practice are prescribed inappropriately, and more often, solely on the basis of demand.

    The internet has turned medicine into something of an amateur sport, one that everyone has a duty to participate in. I often hear people in the shops or passers-by on the pavement, applying diagnoses and medical terminology as though they were talking about cooking. Most people, with a rudimentary education, presume to know as much about a particular disease as the average GP. Often (but not always) the presumption is not too far off the mark.

    The General Practitioner, despite his oxymoronic designation as a ‘specialist’, has become a somewhat self-conscious ‘jack of all trades’; anxious to avoid complaints and keep his dwindling supply of private customers happy as Larry. Being an expert on nothing, he can be challenged on almost everything, except maybe golf or football?

    He does, however, remain slightly relevant to the average family as a sort of ‘medical handyman’; useful in the confirmation of a diagnosis, the issuing of prescriptions, or stamping forms. He’s not a real plumber or electrician, of course, but he can usually put you in touch with one and ‘get the ball rolling’ so to speak.

    The erosion of his standing within society may have added to his insecurity. Lately he must increasingly rely upon the government to validate his existence and to mandate the attendance and the dependence of his flock.

    By Trade I was a Cooper

    Present company excluded, GPs are (generally speaking) not stupid people, we are at least educated, and some (among the old-fashioned ones at least) might even supplement their phone usage with an occasional book.

    Many in the profession are not oblivious to the technological annexation of the lands that once belonged to the General Practitioner. Video and phone consultations are a cheaper and more accessible alternative to a waiting-room full of germs and viral pathogens. These types of consultations were becoming the ‘new-norm’, long before the current ‘new-norm’ replaced the older one.

    Impending social irrelevance is a bitter pill for any professional, but we humans are a resilient lot. When plastics and Tupperware made the tinkering of the travelling community redundant, they wisely moved into tarmacadam and power tools.

    Equally, General Practice must evolve as it struggles with its own increasing redundancy. During the pandemic, when the government invited GPs to an orgy of self-validation; saving the nation with a dirty cloth-mask and a syringe full of experimental vaccine; few of my colleagues asked any questions at all.

    Few resisted the temptation of becoming a ‘hero without a cape’. Fewer still were impervious to the largess and financial incentive, associated with logic-defying Covid Policies. Even the then Taoiseach Dr Varadkar, cashed in on the kudos. He rejoined the Medical Register, and flew to Halting Sites to test the travelling community. What a tragedy it took a pandemic for a Taoiseach to fly to a halting site.

    On the Corruption of the Youth

    Lately, when I work at the out-of-hours service in Dublin, I do so in the company of a junior Doctor; a GP registrar whom I am supposed to supervise and teach for the duration of my shift. They are fortunate enough when assigned to me, as I hardly know enough to practise medicine, never mind teach it to anyone.

    When I chat with these ‘newbies’ I am always surprised at the level of uncertainty they express in respect of their approaching identity as a fully qualified GP. In real terms what does that actually mean anymore? Most of them tell me they are seeking a ‘work life balance’, something very much at odds with the stubbornly persistent notion of what a family Doctor actually is, or perhaps was. A doctor who knows his patients and their families by name? Someone with a small efficient surgery in the heart of a community; a clinic where wounds are sutured, and lumps and bumps are removed or biopsied? Someone who does house calls, and stays for a cup of tea after the final palliative visit to the mum or dad who has just passed away?

    Or is the modern GP a youthful, tech-savvy doctor in a hospital scrub top? Someone who works three days per week at a large office block with a shiny glass frontage? A reticent and cautious professional type, who refers the dying to the palliative care team, house calls to the out of hours service, and anything requiring intervention to the relevant ‘specialist’ at the hospital?

    The former is an endangered species, confined to the fringes of rural Ireland.

    The latter, the GP who works on contract at the busy clinic with the impenetrable waiting list, and the unfriendly receptionist, he or she has become the aspiration and practical or empirical reality.

    Woke up one morning, looked out the window and I struggled for something to say, but you, you left me, just when I needed you most.
    Randy VanWarmer

    https://www.youtube.com/watch?v=1u06A-77TN4

    Not so long ago, my daughter interrupted some sage medical advice I was attempting to cast at her feet, by cooly stating: ‘Dad, who needs a GP when you have a smartphone?’ Her generation is an increasingly rare occurrence in the waiting room. Young adults have replaced most of what’s on offer at the GP, with a faster and cheaper consultation with Siri, Google, or Chat GPT.

    Pharmacists issue medical advice, along with; contraceptives, skin care, and a host of over the counter remedies for common ills. Alcohol, Red Bull, illicit drugs, and street-Xanax are self-applied to a real epidemic, currently plaguing a generation. That hidden disease of mental illness and drug dependence is managed by parents and barely registers on the busy radar of Irish General Practice.

    Young adults and teenagers have voted with their feet, unless they need a cert for school or for social welfare payments. The disengagement of young people (if they were ever engaged in the first place) is perhaps one of the sadder realities of General Practice. Arguably they are the cohort most in need of help in coping with; the porn, the drugs, the pressure, and the paradox of choice they must navigate alone, with a smartphone.

    At one extreme we have the absence (or abstention) of young people, at the other extreme we have the professional neglect of elderly people within the Nursing Homes. The space between these two demographics, contains some of the abysmal failures of General Practice as it exists today and that is to say nothing of the unique needs of a diverse immigrant population, one that GP’s are neither trained nor even encouraged to understand.

    What if the pharmacist could stamp forms or if patients could vouch for their own sick leave? Or if they could simply refer themselves for a routine blood test, or an appointment to see a consultant (as private patients often do); General Practice would be about as socially relevant as tits on a bull. If a couple of antibiotics were available over the counter (as they are in many countries), the meteor would impact and the dinosaurs would shuffle on towards oblivion.

    Arguably there is precious little that an average GP can or will do in the community that a competent Nurse could not accomplish quickly and efficiently. Today, almost all minor surgical procedures are referred into queues at the major hospitals. In north Dublin the Out of Hours Service will neither suture a wound nor syringe an ear, which seem to be risky interventions in these litigious times. Almost everything nowadays is referred to a ‘real doctor’ at the hospital.

    Ironically, the burgeoning bureaucracy of forms is not the bane of General Practice, it has become the umbilicus. A newly qualified GP can be as competent as he likes in respect of medicine yet, if he does not know how to use the practice software, to tick boxes and lodge claims for a myriad of HSE chronic-care payments, he or she is essentially unemployable.

    The traditional mythology surrounding General Practice, the institution’s relationship with the HSE, all mean that like the banks, it is ‘too big to fail’. For example, the training body responsible for the production of new GPs (the ICGP) has complex ties with, and is paid by the HSE.

    Like a recruiting agency, it supplies them with Doctors, who fill unattractive hospital posts around the country, as part of their ‘training’. These trainee GPs are also farmed out to provide free labour for select GPs around the country, whilst both the trainee and the ICGP are paid by the HSE. The ICGP is one of those illustrious quangos we Irish are in love with; a ‘registered charity’ with freebies for friends and financial investments as far afield as Saudi Arabia. Colleges and ‘non-profit’ medical organisations like the ICGP and the RCSI., pay no taxes, they share the spoils out in the form of benevolence, salaries and expense accounts.

    The entire system of medical training in Ireland is defined by deeply embedded and legitimate forms of nepotism and corruption. Beaumont Hospital freely provides almost everything from patients and teachers to the toilet paper, for the Royal College of Surgeons. The College is a private medical school and it charges students up to €58 thousand per year in tuition for the six year course, three years of which are conducted at Beaumont Hospital. Bizarrely (or perhaps not) this private medical college is sustained by the largest ‘public’ hospital in the country.

    Consultant Professors of this and that, can hardly find time to attend to surgeries or public clinics. They are often busy down the hall, at another theatre, lecturing to Saudi Princes and Emirs from Kuwait.

    The RCSI (another registered charity), owns and operates a second Private Medical School in Bahrain, where it offers private medical training to Canadian and American Medical Students, for around €44 thousand per annum for the six year degree.

    The Taoiseach’s leaking of contractual negotiations between the HSE and one of the rival GP organisations, is merely the tip of just one iceberg that has recently floated by. Off to melt away in warmer waters; like the long-forgotten intrigues and scandals at the IMO another quango who’s last CEO retired amid a teacup of controversy with a pension of ten million euro.

    Medicine in Ireland, particularly medical training might well be described as a fermenting vat of rot. We have no swamp; the water is too putrid for any genuine forms of life, reptilian or otherwise.

    The drugs don’t work, they just make you worse…
    Richard Ashcroft

    The vast majority of medicines consumed in Ireland are prescriptions issued by General Practitioners. The Pharmaceutical industry from the local Pharmacist to Pfizer itself, depends on GPs for those scripts. A need that is more prescient and influential than those of any particular patient cohort.

    This year, circa two billion euro in Exchequer funding was paid to a few pharma companies in return for drugs covered by the medical card scheme. That sum could be more than halved if a National Formulary of prescription drugs was put up for tender each year, as is the case in other countries like New Zealand for example.

    Pharmaceutical lobbying, however, discreetly maintains the status quo. In Ireland corporate lobbying will hardly be investigated by a mainstream media, dependent upon corporate payments for advertising revenues and the salaries of A-list celebrities. The general acceptance of corporate influence over the state broadcaster suggests that most Irish people think ‘lobbying’ is something that might pertain to Wimbledon or tennis.

    A prescription is often the most efficient way to end a consultation, it does not cost the Doctor a thought because they do not cost him a penny. In Irish Nursing Homes most residents have an extended shopping list of pointless medications, the phenomenon is referred to as ‘polypharmacy’. Many of the frail and emaciated are taking statins, in order to keep their cholesterol down; it’s a little bit like putting famine victims on diet pills. Sleeping pills, sedatives and expensive food supplements to compensate for an unpalatable diet of gruel are the norm for many.

    As a consequence of being interlaced with a political and pharmaceutical agenda, and in abeyance to a certain type of mythology associated with the family doctor; Government underwrites General Practice to the extent that it consumes as much, if not more exchequer funding, than the entire Public Hospital system. Last year it cost four billion Euro to pay for GPs and Medical Card Prescriptions, an increase of 49% since 2016.

    General Practice is a little bit like a religion in that it is sustained by some established patriarchal ideals. The notion of ‘doctor knows best’ or ‘just what the doctor ordered’ etc., is possibly more embedded in post-colonial or post Catholic societies.

    Following the collapse of the Church in Ireland, the GP has become something of a locum tenens, for the parish priest. His is an ‘evidenced based’ religion, one that promises a healthy life; in place of the immodest and unsubstantiated offer of an everlasting one.

    Despite a paucity of practical reasons for its preservation, General Practice is nonetheless sustained by popular demand, as a kind of impractical luxury. Like paying rent for a Lamborghini when a bicycle would be overkill. It is difficult to know whether the costly underwriting is motivated by the mythology; or whether it is mandated by the institution or the many others who gorge themselves upon a Health budget that knows no limits.

    Church & State

    The political preservation of General Practice is accomplished in several ways. You can be as sick as you like, but you will only get paid once the GP signs the IB1 form. Ironically if you are in hospital, a hospital Doctor will give you an IB1 form that you must then bring to your GP and pay for the pleasure of his or her signature.

    GPs are responsible for the care of every elderly resident within the depressing environs of the Nursing Home Sector. In Ireland a Nursing Home can neither open nor operate without the supervision of a registered GP, a supervision that is at best light-touch, but is heavily paid for.

    Illness benefit, driving licences, passports, nursing homes, access to the public hospital system, to the Emergency Department etc etc., are all stamped and signed by General Practice. These are the lands that belong to a post-colonial landlord, one who operates behind the general facade of a liberated Ireland.

    Pharmaceutical companies have an ever increasing need for community GPs to push an agenda of pharmaceutical dependence upon the entire population. Arguably this agenda has gone unchecked for over half a century. Pharma companies provide jobs in Ireland and advertising revenues for the mainstream media, they should never be questioned; and so the executive board of the HPRA is dominated by ex-pharma employees.

    Opiate dependence is barely a scratch on the surface; antidepressants, benzodiazepines, Lyrica, statins, antibiotics and polypharmacy in the elderly are more disturbing realities. Each of them are lucrative social tragedies, rarely spoken of in public. Like excess mortality or vaccine-related injuries they are confined to the realm of ‘conspiracy’.

    Learned and encouraged helplessness within Irish society in respect of basic health, fear mongering by pharma and state agencies in the guise of various ‘health promotion’ campaigns, means that there will always be the need for a Doctor in the community; one who is almost as skilled as a Nurse, but has all the power and influence of a mafia boss.

    I just checked in to see what condition my condition was in.
    Kenny Rogers

    Thirty years ago when I began to study medicine there was this crazy notion that Doctors would ‘cure’ or ‘fight’ disease, whenever possible. That same general expectation of ‘cure’ has all but disappeared from the everyday language of modern medicine. It is no longer expected of the GP to cure, or even to attempt to do so. Long-term illness and ‘chronic management schemes’ have become the ‘ne plus ultra’.

    Ironically, apart from cancer, the biggest killers in Ireland are indeed curable diseases; heart disease, type 2 Diabetes, vascular disease, obesity, depression etc. In recent years all of these conditions have evolved to be considered solely in the context of ‘chronic disease management’, associated with chronically diseased payments.

    The gaping irony hardly registers. When I mention it to the trainees they return a blank confused expression, as though I were suggesting something possible and impossible at the same time. There is no space within the establishment to discuss the question as to how or why GPs have become facilitators instead of healers? This is another conversation generally confined to the realm of conspiracy.

    In Ireland today illness is managed, no differently to a business, wherein profit is the bottom line. Tellingly, amid the mind-boggling array of payment types issued from the HSE to GPs, there is not a single payment or financial incentive in respect of ‘curing’ anything at all, never mind any of the curable diseases that actually kill most people.

    In New Zealand, where I completed my GP training some years ago, GPs were actually paid a bonus if their prescribing of antibiotics remained below the national average. Most disease was treated (and often cured) within the community setting. In Irish General Practice ‘cure’ has become an anathema and disease has become our raison d’être.

    Image Daniele Idini.

    Halcyon Days

    Any real or practical value that the GP brings to public health is (or was once) contingent upon the fading reality of the somewhat old-fashioned ‘Family Doctor’. That GP was (and occasionally is) part of a community of people living in close physical (as opposed to digital) proximity. People who are mutually dependent upon each other and the community, in small but positive ways. In the modern world of sprawling high-density estates, the notion of collective, integrative and supportive communities, is becoming little more than a sound-bite that estate agents use to sell houses.

    There was once a time when the GP knew all or most of his patients very well. That knowledge was an essential and fundamental clinical tool, as important as the stethoscope, and impossible to replicate through any amount of technology. It was that intimate knowledge that would often determine an intervention, and whether a referral to the specialist was immediately necessary, or necessary at all.

    Outside of the paperwork, most presentations in General Practice are motivated by some form of anxiety or worry. Intimate knowledge in respect of the family and the individual often allows the GP to distinguish between anxiety and pathophysiology.

    Sometimes he might have got it wrong, but more often, he or she was in the right place. This lack of distinction or inability to distinguish between anxiety and physical pathology, is one of the things that annually overwhelms the health service. It is almost never discussed and is expressed regularly in the unintelligent language of a: ‘shortage of hospital beds’ and a ‘shortage of doctors’. We may not have a shortage of Doctors, rather than a genuine shortage of doctors who know their patients well, or know their patients at all.

    The Doctor’s sometimes sage advice was an imperfect thing, derived from his unique knowledge of the person, from a love of learning and an understanding of science. He was also the victim and the enforcer of a particular zeitgeist and strict social paradigm; that aspect of medicine has never changed.

    Although it remains a rather lucrative enterprise to have one’s HSE-income, and share it with no one; single handed practice is taxed with an unhealthy level of responsibility. No newly qualified GP would dream of setting up alone in today’s Ireland. Few, if any, single-handed practitioners could provide the type of service that people now expect. Sole practice was the first limb of the cat to vanish. The once ubiquitous ‘walk-in’ surgery once had a financial incentive, supposedly socialist medicine however is strictly by an appointment, generally for sometime next week.

    Working for the Man

    Presently in Ireland a couple of large corporate entities are hoovering up what remains of the small suburban practices or those rural practices with profitable lists of Medical Card holders. These companies will buy a practice and keep the principal GP on as a paid employee in order to control his Medical Card list.

    For the most part, newly emerging GPs know nothing of the ‘halcyon days’, and are generally happy to start working for ‘the man’. They cannot be accused of selling their souls to the devil. In contemporary General Practice there is no place for old-fashioned things like souls, despite the overabundance of devils.

    Such corporations pay 12.5% in corporation tax; yet when I had my own practice I paid 52%; the profit margins are a no-brainer. They will then harvest the greatest possible return from the various Medical Card payments, and chronic disease schemes. They can afford to pay GPs good salaries, and hire a minimum number to do the husbandry. This type of corporate General Practice is entirely unregulated in respect of the service it provides (or doesn’t provide) for patients.

    These profit driven behemoths are presumed to function in the same way as the traditional Family Doctor. For the most part they are left to their own devices, sucking up a maximum amount of HSE payments and returning a token level of care. They conceal the inadequate service behind a rigid appointment system that keeps patients waiting, the workload at sustainable level, and profit margins as high as possible.

    For all their faults these centres are the inevitable future for General Practice, they are what people think they want, and what politicians are eager to give them.

    To interface with this industrial model, patients must increasingly learn to translate all of their pain into the unaccommodating language of medical pathology; human beings and their emotional realities become invisible and entirely medicalised. Deeper truths behind the pain, the fear, and the anxiety that are an increasing part of everyday life for all of us, evade this more sophisticated model of Primary Care. The emergent mystery becomes just another number on another waiting list.

    Of Human Bondage

    In my early twenties after reading Somerset Maugham’s novel Of Human Bondage, I thought about becoming a Doctor. I didn’t especially want to help people, but I wanted to be in a position whereby I could help them if I wished.

    I might have wanted to ‘help people’ in some vague way, but I wanted to help myself first. For a time I probably translated this notion into the more noble expression that many of my colleagues prefer to cling to. It is refreshing to hear honest medical motives expressed in the more acceptable language of a ‘work life balance’.

    Maugham’s novel is about all kinds of bondage, the one I wished to liberate myself from was poverty. Medicine has at least afforded me that compensation for the small price of my soul and at times my sanity. I never imagined that I would come to see the career itself as a kind of bondage; a darkening cave wherein we can no longer see the chains or the flickering shadows on the wall.

    Many Doctors know there is no need for the antibiotic, no need for the hospital referral, the scope or the scan, and yet we increasingly act according to our own benefit, or that of our employers. Convenience and fear of complaint are the other silent incentives.

    In Ireland and abroad, private obstetric care is more likely to result in a caesarean section, and a child with private health insurance is more likely to end up with grommets or a tonsillectomy. Medicine has always been an uncomfortable marriage between profit and compassion. Lately it seems that profit has separated, and is suing for divorce as well as damages.

    Image Daniele Idini.

    Hope Deferred?

    Perhaps the only thing worth saving in General Practice – the most beautiful and essential thing – is the thing that has almost disappeared; the unique nature of the relationship between the family Doctor and the families who attend him or her.

    That ‘thing’ is something many people may have once enjoyed and may still enjoy with some ‘old-fashioned’ GPs. It is the thing that saved many lives during the Pandemic, more so than; masks, vaccines or spending ten euro on a pint and a sandwich.

    Any future validity for General Practice would be contingent upon training GPs properly, educating them (and patients) to participate in that old partnership in an honest and meaningful way. For the moment however, the relationship is broken. The modern GP is not trusted in the manner that the family doctor once was, and he is wary of his patients or views them solely as a means to a private end. The problem is a million light years away from medical schools, training bodies or public health campaigns, all of whom have their heads in the trough.

    Before former Health Minister Mary Harney reformed the Medical Council in 2007, into a weapon for the indignant and a cosy club for political appointments; the family doctor might have been a man or woman with an honest opinion in respect of your health.

    An opinion that you could take or leave as you saw fit. Presently, Doctors are not trained to be honest or even candid with patients, quite the contrary in fact. Candidness was something that was permitted years ago. Often (but not always), it was a good and a welcome kind of honesty. The GP had the ‘power’ to tell you that you were ‘too fat’, ‘overly anxious’ or that you didn’t need to be immediately referred for a battery of tests or scans on demand. The GP was frank, candid and honest, and was even expected to be so. Some Doctors and GPs were lazy in their old-fashioned power, and things were sometimes missed, like cancers and physical disease. People were sometimes abused with insensitive words or beaten with the religious paradigm of the day.

    Today it is increasingly rare (if not impossible) to encounter a GP who would be willing to run the gauntlet of refusing a test or having a frank conversation with the newly emancipated patient turned consumer. Training bodies and the Medical Council indirectly insist upon an obsequious dishonesty as the gold standard. They advise Doctors to give ‘back pocket’ prescriptions, a euphemism for the unnecessary antibiotic on demand. Happy customers are presumed to equate with healthy patients. The universal goal is a consumer, pleased with the product they have purchased, or recently become entitled to.

    A GP might be sanctioned for using the word ‘fat’ inappropriately, and yet he or she will be rewarded in various ways should he provide an inappropriate prescription for a trendy weight loss injection; a diabetic drug currently in short supply as it is being over prescribed in the community for cosmetic purposes.

    As an institution, General Practice thrives upon; ignorance, compliance and government subsidy. Most consultations in primary care amount to a waste of time in respect of public health or genuine pathology. An increasing majority attend the GP simply because they have to, or because they have been encouraged or allowed themselves to become prescription drug addicts.

    Sometimes, disease becomes an identity; a form of socially sanctioned escape from an unpleasant and painful life. Illness is very often the veil that is worn to conceal a deeper unhappiness. Often, chronic illness becomes a persona with a social and financial incentive, one that can be as alluring and addictive as any drug.

    In my own experience far too many ‘sick’ people are simply very unhappy. General Practice in its current form is utterly ill-equipped to deal with, or even to recognise the unhappiness or anxiety that is its principal presentation.

    Increasingly, during my years in clinical practice, I found that telling a patient that they are ‘normal’ or that they have ‘normal results’ can cause a kind of disappointment. For some people, telling them they are normal is like denying their pain, barring them from Kafka’s Castle, refusing them a diagnosis and an entry into the legitimate world of the sick.

    Image: Daniele Idini

    To Italy

    “Are you the farmer? We’ve gone on holiday by mistake!”
    ‘Withnail and I’

    In many countries the expensive appendage of General Practice has already disappeared. Outside of the catchment area of ‘old victorian ways’, one attends an accident-clinic in the event of an accident, and almost everything else is self-referred to a specialist; a hospital consultant with rooms in the nearby town or city.

    In places like Northern Italy, the Middle East, the U.S. and many more, people do not need a magic letter from a GP to get to see a ‘real doctor’. One simply makes an appointment at the consultant clinic, the receptionist will assign the headache to the neurologist, or the gastritis to the gastroenterologist and so on. Sick children are brought to see paediatricians, those wishing to become more beautiful attend the plastic/cosmetic surgeon, and old people are brought to see a geriatrician before being dropped off at the nursing home. Friendly secretaries will triage and normally arrange a bed over the phone. The first consultation usually occurs with the patient in a bed on the hospital ward. The bill is sent to the state or the insurer.

    I am not suggesting for a moment that this is a better system, it is a system that was the principal cause of the horrific scenes in Lombardy during the Pandemic. Covid killed too many elderly people, that much is true, but it was the condition and organisation of the Italian health service in Northern Italy that allowed Covid to become the catastrophe that dominated the television networks.

    If we think about it, cholera and a few other diseases (rather than starvation) were responsible for half of all the deaths during the Irish Famine (1847-1851). Now, imagine the hue and cry that would emerge if some renowned British Epidemiologist tried to suggest that half of the total number of Famine victims did not die of the Famine, but died instead from a coincidental ‘pandemic’ of Asiatic Cholera? What remains of the IRA would undoubtedly issue a fatwa.

    Apparently when it comes to the Great Famine, we are quite capable of recognising that social conditions (poverty/famine) created the environment where disease festered and then killed exponentially. We don’t blame Cholera for the Famine, we blame the famine for Cholera. It was the Famine that created the conditions for Cholera to thrive, and it was English policy that created the conditions for the Famine itself.

    Equally, the Covid virus was not the principal cause of the terrible scenes in Northern Italy. It was the absence of community medicine that created the conditions necessary for the tragedy to unfold in the horrific manner that it did.

    There is, and was, no system of community medicine throughout much of Northern Italy when Covid arrived. In Lombardy; frail, elderly people with Covid, had no one to call, other than consultants and specialists, who then flooded their hospitals with Covid and transformed them into the geriatric hotbeds of disease and mortality that provided the horror show, and fuelled the fear-frenzy. That same frenzy soon transformed Covid from a cohort specific disease, into a pandemic that requires universal vaccination, lockdowns and allegedly kills almost everyone it touches.

    At home the Italian mistakes were coarsely imitated by the Irish Government as they cleared the public hospitals and transferred a mass of untested, convalescing hospital patients, into all available beds in the Nursing Homes. They introduced Covid into the sector en masse, firmly and strictly locked it in, and thereby caused (or at least facilitated) a wave of death that has yet to be investigated.

    The truth about Italy was opined in an article that appeared in the NYT in November 2020 entitled ‘Why Covid Caused Such Suffering in Italy’s Wealthiest Region’.

    In 2016, Lombardy — home to more than 10 million people — saw only 90 medical school graduates go on to pursue specialised studies toward becoming general practitioners. They received annual scholarships of 11,000 euros (nearly $13,000), less than half those secured by people preparing for specialties like cardiology. The numbers have grown in recent years, but not enough to replace retiring general practitioners, medical associations say.

    The point I am making here, is that despite the fact that General Practice might well be an overall pathology in Ireland; that is not to say that the institution does not accomplish some purely accidental good. A broken clock will tell the right time twice a day.

    Many Irish lives were inadvertently saved by the fact that patients had a relationship with a Doctor (their Family Doctor). One whom they could call and who would tell them what they should or should not do.

    Despite the fact that medical advice from the oracle of General Practice amounted to little more than: ‘stay at home and suffer on’; it was the simple fact of having a relationship with a contactable GP that reassured and ultimately saved lives.

    Needless to say, (proportionally at least) far more lives were saved by GPs like Dr Pat Morrissey in Adare, and several others – some of whom who became part of a covert network who insisted (despite threats from the IMC president) upon doing more for very sick patients – than simply telling them to ‘stay at home until they turned blue’.

    Public health officials were quick to see the value of this old-relationship and offered GPs an unvouched blank cheque, to the tune of €30 per reassuring phone call. However, beyond a phone consultation, Irish GPs by and large did not provide any interventional ‘care’ for those whom they advised to ‘stay at home’.

    Nonetheless they saved lives and avoided an Italian-type tragedy simply because those lives had access to a Doctor within their own community. During Covid, it did not matter if GPs were wilfully useless; it only mattered that people had access by phone, by video-link or smoke signal. They were not entirely alone.

    The miracle of science was with them, and they stayed in the safest place, far away from established medicine. Whilst Covid patients were in contact with their GP,  they were cared for at home by their families. This was not the case in Northern Italy where even a token degree of Community Medicine was non-existent. A passage from the NYT article states the following:

    When the first wave hit, Milan — a city of more than 1.3 million — had only five doctors expert in public health and hygiene, said Roberto Carlo Rossi, president of Milan’s Doctors’ and Dentists’ Guild. They were responsible for setting up a testing and contact tracing regimen.

    Where most Irish GPs did in fact care for patients in practical terms, was in the Nursing Home. We were the responsible physicians and were the only ones allowed in.

    As a consequence of our careless ‘care’, combined with political ineptitude; over a thousand died alone, and in truly horrible conditions, all within a matter of months. During that time Covid payments in respect of their care were doubled, trebled and quadrupled, in spite of the death rate and the abject failure to deliver what might be described (in third world terminology) as ‘the very basics’.

    The survival of honest medicine may depend upon an old-fashioned relationship with a different type of Doctor. One who is often found to be ‘non-compliant’ at Medical Council Hearings. Yet, to paraphrase an old philosopher: ‘there may be a different court, one that is higher than the Courts of men; one where a great many of the judgements of this world, will doubtlessly be overturned.’

  • Diary of Pandemic Doctor: Nursing Home Chaos

    It’s Saturday morning and I stand exhausted in line for my weekly shop, having left home without breakfast to get ahead of the despondency that might otherwise keep me indoors all day, despite the incongruent sunshine. I know at heart I am mostly there in hopes of some semblance of normal human contact. The phone rings as I wait. I answer to the now familiar voice of the coroner detailing the latest coronavirus-related death at the nursing home where I work as a doctor. My mind races through the expanding catalogue of names residing in the hastily fashioned ‘COVID wing’ and fixes upon her sunken face and heaving chest.

    Last I saw her, rendered unrecognisable behind sheets of dehumanising plastic, she clutched at my hand with her failing limbs and begged me not to leave. But in every room, each now unadorned with the usual ersatz trappings of home and identity one finds in nursing homes – photographs, homespun blankets, love letters from grandchildren – fellow residents lie awaiting their rushed assessments. Oxygen saturations, pulse and respiratory rate, a survey of existing co-morbidities, and finally resuscitation and transfer status to be revisited and revised: who might possibly be saved by hospital transfer, and whose last comfort would be the inevitable cocktail of morphine and midazolam, slipped quietly under the skin at intervals until death arrives.

    I have some forty patients to see before resuming my main function back at the practice in the afternoon. There I will take calls from many of those caring for the residents and triage their symptoms, almost inevitably caused by the virus that has taken hold in this seemingly forgotten corner of society.

    Across the hall, the atmosphere is suddenly lifted by the wit and humour of a ninety-odd year-old who has somehow escaped the dementia and delirium that pervades here. Unlike his fellow residents, this is a man who never wears his breakfast and is more recognisable to me in crisp shirt and tie, top button fastened. When we first met some months ago I doubted his cognition on hearing him shouting instructions to ‘Alexa’ across the room, but it turns out that I was the one that was out of touch. I look at his records – not for resuscitation, not for transfer. Despite his joviality, the oxygen levels already look poor. Given that it is still early on in the course of his infection, it is only a matter of time before he will crash and be gone.

    As the nation scrambled to prepare itself for the deluge of demand on ventilators, this was the kind of man who was never to have been deemed eligible. Yet in spite of the full newspaper spread photos of busy intensive care units, I know there is room for him, and that he has the will to live. Despite his age, were he to defy the admittedly poor odds, he has a quality of life to return to. We embark on the conversation that echoes a distant role-play from medical training which treads gently but directly on taboo. How is it you wish to die, and what interventions might be acceptable or worthwhile to try to prevent that?

    I tell him I feel he should at least consider a hospital assessment, and he accuses me of looking for the remaining half of the president’s cheque that he had promised to his doctor following his last successful visit to hospital some months previously. The next time I am at the home he is no longer there and I hope to God I have made the right decision in encouraging him to leave.

    On and on it goes, as the moisture accumulates under my mask and the goggles steam over. The delicate exercise of balance between connection and scientific detachment as I pass from room to room. Gaping mouths and vacant faces paint a poor prognosis, but even the most frail have surprised us to somehow come out the other side of this infection. To what quality of life, one may well ask. Does dementia provide some sweet oblivion to the horror of all of this? It is an ugly and brutalising process, despite best efforts from nurses and carers.

    Almost entirely recruited en masse from India, these are the compassionate and cheerful bearers of what society now refuses, at poor return to themselves. Let’s not forget that it is a business after all. Living on site in groups of eight or ten, they are simultaneously the protectors of residents and also the vectors by which many will now die. Left to their own devices by a distracted state and a self-preserving management structure (inevitably homegrown), they continued over recent months to meet their duties without full awareness or being properly equipped, and so the virus spread its wings to envelope the entire campus.

    Care facilities always tell a story with their decor. I remember a private hospital from training where a self-playing grand piano sat in the lobby. It was possibly the last place in the country I would recommend anyone actually falling ill. This centre is steeped in a dubious faux-heritage atmosphere of fake mahogany and red carpets. At one point there was even a Leeson Street nightclub type velvet cordon rope placed outside the entrance. Perhaps more than anything else these finishes are there to assuage the guilt families inevitably feel as they break a certain human code by consigning a loved one to an institution. Such is the society we have organised for ourselves. But in this situation the contrast between decor and reality is one of the utmost dissonance; all is well, while everything is falling apart.

    The airwaves and print media are bursting with opinion, analysis and occasional outrage as the crisis unfolds and consumes the institutionalised elderly. The great and the good understand and discuss, sounding wise and all-knowing. But week after week we are alone. Where is the calvary? Where are the boots on the ground? Who is going to help?

    I cease to sleep. I withdraw from friends and family, unable to explain how this has all come to affect me. On the telephone, I struggle to contain the emotion of the distressed families who have been kept away from their loved ones for months at this stage. Meanwhile, the underclass of cleaners, carers, assistants and nurses struggle on, now considered heroes without capes, but shorter staffed and more at risk than ever. Simultaneously caring for and infecting those they seek to serve.

    I break the rules and cross the city from odd to even postcode to visit my widowed mother at a remove. The atmosphere is a languid scene of early summer as dogs are walked and the dividends of lockdown are embraced. Garden parties are heard over walls and milestones of self-development and Zoom yoga classes are considered. It’s a different world. But perhaps it always was. On leaving I check my phone and see another two missed calls from the coroner.

    This is the third in a series of diaries written by different doctors confronting aspects of the Covid-19 Pandemic. If you are interested in contributing an entry drop us a line to admin@cassandravoices.com. Anonymity is guaranteed.