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• Gladwell and Minister Harney

  April 28, 2010 @ 11:55 pm | by Bryan

  I really like Malcolm Gladwell. I had the privilege of listening to him speak when UCD hosted the writer a little over a year ago. On that occasion, he even kindly answered a question I put before him as he signed my copy of Outliers. Days later, while reading the book, I remember disagreeing with something he had written (the first and only time that I’ve seriously disagreed with Gladwell). Mixed in with stories about Mozart, Steve Jobs, and Korean pilots, while defending his 10 000 hour thesis, Gladwell makes the case for charter schools.

  Charter schools seem to me to be a particularly American solution to poverty. A testimony to the mastery of the market, they demonstrate what can be accomplished given the right incentives. Typically, inner-city American children fall behind their better-off cohorts academically. The root problem is that social issues keep these children from devoting as much time to their studies as others. Charter schools therefore start early in the morning and end late in the day. They also offer shorter vacations since they aim to keep their pupils in active learning for as long as possible. The idea is that if these children are in school for a sufficient period of time, they will cover as much ground as children in better social circumstances and will therefore be more likely to succeed academically. And they do just that, making the schools very popular in poor areas, despite being almost cruelly taxing on their pupils.

  I don’t like the idea of charter schools. An old paediatrician once called me a bleeding heart liberal, but on this issue, I think we would agree. Charter schools, in my opinion, treat the symptom rather than the underlying pathology. If poverty is the issue, I don’t see how allowing a few to keep up academically can be thought of as anything but a temporary bandage. Reading Gladwell hold up this bandage as a potential solution makes me more than a little uncomfortable.

  That same feeling was evoked in me by the minister for health, who wrote:

  …The critical question is how we use all resources, particularly public resources, to help people stay healthy and to get best outcomes for patients from healthcare…

  …It’s a critical question for all developed countries because the hospitalisation model of healthcare is financially unsustainable…

  …I invite people to recognise that it’s more important how money is spent than how it is raised from the public…

  …Our policy is equity of access to publicly-funded health services. We are open to using all providers who meet quality and value for money standards to contribute to public services…

  A comparison between Gladwell and Minister Harney isn’t quite fair. I generally tend to agree with the former while I mostly disagree with the latter. I just don’t share her faith in the market. Gladwell believes in charter schools because he believes that if you spend long enough at something (10 000 hours), you’ll do well at it given some aptitude. Minister Harney on the other hand, from what I can gather, believes in the market.

  But even before we get to the question of service delivery, an important question must be answered. What does ‘equity of access to publicly-funded health services’ mean? We can even simplify that. What is equity? Does it mean that people get what they pay for, such that those who are willing to pay extra are entitled to more or better or faster services? Does it mean that absolutely no distinctions should be drawn between patients, so that regardless of one’s ability to pay, or how expensive one’s treatment may be, each will be treated ‘equally’? Or does it mean that each citizen will be allocated a fixed sum of money, health credits so to speak, and will be entitled only to their fair share such that when those credits run out, they are no longer eligible for state health services? Or that the state’s health services will be structured so as to serve the greatest number; meaning that those whose ailments are expensive to treat will have to access their healthcare elsewhere?

  And what about the suggestion that ‘the hospitalisation model of healthcare is financially unsustainable’? Isn’t it only unsustainable if one holds to a certain set of values? The Cubans (I know, this example is well worn now), seem to value healthcare above modern consumer goods. I imagine that the idea that the hospitalisation model is unsustainable, on a budget of €15 billion, when far greater sums can be found to prop up the financial services sector, would make no sense to them.

  Doesn’t the question of what is or isn’t financially sustainable then really rest on what we take as our foundational principles? Isn’t the same true of what we mean by the word ‘equitable’?

  I suppose what worries me most about the minister’s article isn’t so much the matter of our ideological differences, or my fear that, as Dr Christine O’Malley suggested on radio today, the subtext is a desire to privatise health. No, the real worry for me is that we make Gladwell’s mistake and fight over which bandage to apply rather than engaging in debate over the real underlying issue. What are our views on justice? What does equity look like? Who should get what and why?

  The only way €15 billion isn’t enough to sustain the health of less than 5 million people is when there is an attempt to throw money at the issue instead of directly addressing those difficult core issues.

• Obama a year on

  January 21, 2010 @ 5:09 pm | by Bryan

  

  A year ago I wrote the following:

  …I think Obama’s role is largely symbolic … I think the biggest ‘thing’ he gives his nation and the rest of the world is a sense of hope and possibility. Having lived in places where hope literally sustains people, I would be the last person to belittle the importance of that quality… Tied in to that hope, I think he inspires people to strive for more and better. Again, you can’t quantify the importance of that. But even I, an unashamed Obama fan, have begun to feel that the level of expectation on him in some quarters has gone way beyond the ridiculous.

  It has only been twelve months, but things have changed dramatically. I’m not an Obama fan anymore, and I certainly don’t think that he inspires universal hope. As for ‘Yes We Can’, I personally feel betrayed.

  Why betrayed? Barack Obama ran as more than just a ‘change candidate’. He ran as a man who wanted to ‘transcend politics’; an ordinary human being in high political office. The idea was that the political process in the United States would be simplified, and ordinary people would get to dictate to government and the political establishment, not the other way around – government of the people, for the people, and all of that. I think that’s what galvanised so many people: the idea that the masses would get to call the shots. That of course, hasn’t happened.

  The example that most stands out is the so-called healthcare debate. Even before the ‘debate’ was opened to people, a settlement was supposedly reached with the health insurance industry. A pragmatic move? Maybe, but to then characterise the so-called healthcare reform as a means of ‘sticking it to the man’ was deceitful. And having begun with the health insurance industry in mind, is it any wonder that word of bill being successfully passed resulted in stock-market gains for those same companies? Worst of all, the closest that the public – the ‘we’ in ‘Yes We Can’ – came to a crafting their own healthcare legislation, was being campaigned to by politicians with their own ideas about how to go about things. Not exactly rule of and for the people.

  According to today’s editorial:
  The constant management of expectations, the brokering of compromise after compromise in Congress over health, the recommitment to the war in Afghanistan, the deferral of action on jobs while bankers were “rescued”, and delays in closing Guantánamo, have contributed to [President Obama’s] gradual alienation from his Democratic base.

  True, but more than those things, I think it is the feeling that though he may be a decent man with good intentions, the president is still at heart a politician in the mould of other politicians. His decine in popularity has to do with the fact that there will be no earthshaking change under his tenure, that as things stand, really, ‘we can’t’.

• Delusions of grandeur

  July 16, 2009 @ 9:06 pm | by Bryan

  I haven’t read the entire ‘Bord Snip’ report. I just looked through the sections that interest me most – Foreign Affairs and Health. I’ll save foreign affairs for another day because that’s a long rant in itself. For now, I’m going to limit myself to health.

  I can’t imagine how difficult a task Colm McCarthy had. The country is essentially broke, living off borrowed funds. It makes sense that something has to give. And it’s also important to point out the fact that it’s so much easier to spectate and comment from the sidelines than it is to have to take the kinds of measures that the government have been forced into. The, ‘they wrecked the economy in the first place’ argument isn’t completely without merit. But because no-one benefits if the government fails, it’s probably best, at least for now, to focus on the actions taken since the ESRI told us we were in recession.

  With all of that out of the way and my position clear, I disagree with some of the suggestions for health in the report. In some ways they don’t go far enough, while in others, I think they go way too far.

  The single biggest problem with the health system here is that it suffers from delusions of grandeur. I’m serious. Ireland has a population of somewhere in the region of 4.5 million people. Why isn’t there just a single entity responsible for health? Zimbabwe, a country with more problems than most, with a population of over 10million people, managed to have a single department look after health and child welfare. The NHS is a wonderful system, but Britain can afford it. With the size of their population, they may even need it. Ireland doesn’t.

  Another manifestation of the delusions of grandeur is the preoccupation with centres for excellence. The country needs a solid primary health care (PHC) model. To strive for world class cancer centres without an adequate PHC system is like … it’s like buying a fancy door knob for the house you’re going to build one day. Great if you can afford it, but if you’re struggling to pay the rent…

  I’m no economist. I’m certainly no Colm McCarthy, who I think is an incredibly intelligent, brilliant man. But getting rid of jobs and merging a few departments together isn’t very imaginative. And if Ireland needs something right now, may I humbly suggest that it’s imagination. Keep those people in jobs, but reassign them. Redisign the entire system to serve the most people at their most basic needs. If that means people need to go to Belfast for specialist treatment because they can’t get world class attention for some rare conditions here, so be it. But if you get the basics right, if you effectively get vaccines to children, have a solid health education program, motivate the staff and reassure them of their continued employment, who knows…

• Owning stuff

  May 13, 2009 @ 1:21 pm | by Bryan

  A colleague of mine, Katie, is a committed advocate of intellectual property rights. Coming from a musical background, she sympathises with those who, in the absence of vigourous protection of their intellectual property, could find it very difficult to make a living. Katie and I disagree.

  I’m not sure where I stand on the liberal concept of private property. I don’t own very much, but I am grateful for the fact that my things cannot be arbitrarily taken from me. That said, I think the idea of the protection of private property as the foundation of individual freedom is fatally flawed. And this flaw is reproduced in almost all of our institutions and our thinking.

  Article 17 of the Universal Declaration of Human Rights (UDHR), for example, affirms the right to private property. Great … if you own property. Article 17 ignores people who don’t own any property. It is lopsided in that it protects those who have without discussing whether or not something should be done for those who haven’t, in order that they too may have. Although one could argue that the rest of the UDHR address those who don’t have and that article 17 protects those who don’t own property in the event that they eventually accuire some, I’m not convinced. I still maintain that the UDHR protects me, most of you, and even the likes of Bill Gates who could raise their own armies if they needed to. It doesn’t address the poor in parts of the developing world who don’t own any capital and therefore don’t have not the means to produce for themselves.

  An interesting development in the property rights debate is the notion of intellectual property rights. While I’m not sure exactly where I stand on private property, I think the idea that knowledge can be owned is ludicrous. Katie argues that it incentivises research, development and innovation. My response to that is, “Humbug!” Nowhere is the folly of that thinking shown up as clearly as in the debates around genetically modified seeds, and now, in the patenting of the human genome!

  There are cancer patients who cannot get genetic testing because some firm owns the patent on those particular genes. The means by which these patients can find out the sequence of a short strip of their DNA, present in almost every cell in their bodies, is withheld because of a ridiculous belief in the value of private ownership. Worse, the fact that another firm is praised for licensing out (for money) its knowledge of a differnet gene goes to show the magnitude of the problem. Ownership of knowledge isn’t being questioned. Rather, this issue is being dealt with, in the mainstream, as a question of whether that knowledge should be kept and developed by one owner, or a few more.

  I think Katie and I ultimately disagree because she is concerned about the potential consequences, for everybody, of denying those with property or knowledge benef from their ownership. I, on the other hand, am more concerned about the immediate consequences of the barriers erected by private ownership – barriers to the means of a producing food as well as those to finding out if you’re more likely to get cancer.

• Swine flu

  April 30, 2009 @ 4:32 pm | by Bryan

  I don’t mean to trivialise a very serious problem, or to appear insensitive to the families of those who are ill and those who have died. That said, I don’t understand the hysteria around swine flu that is emanating from a lot of media outlets.

  All potentially fatal illnesses must be taken seriously. Communicable diseases should also raise public concern. But outside of Mexico, swine flu has resulted in one mortality. I understand the need for monitoring, the need to keep the public informed, and the need for a public awareness campaign to limit the risks of further transmission. But hospital acquired MRSA is far more significant in Ireland than swine flu. In fact, even in Ireland, the spread of HIV between heterosexual, white non-i.v. drug users is a growing problem that isn’t given the time of day outside of the medical community.

  So why all the panic about swine flu? Is it a reflection of modern culture? Maybe we have all watched so many episodes of shows like 24 that we have been conditioned to expect global disasters that have the potential to wipe out the whole race. Or maybe, we just like ‘excitement’ and a developing story. That 3000 people die each day of malaria in Africa, while lamentable, is something we have come to expect. It’s no longer news. And it’s something that is happening far away. Swine flu on the other hand is exciting! There have probably been less than 3000 cases in total (and that probably becomes definitely once you exclude Mexico), but it could happen to you! Swine flu might be coming after you! If it does, statistics show you’ll probably be fine after a few days’ treatment. But the fact that it might land on your doorstep is enough for this virus to be a top story.

  I never cease to be amazed by how the world works.

• Doctors’ strike?

  February 27, 2009 @ 10:58 am | by Bryan

  99% of non-consultant hospital doctors (NCHDs) voted in favour of industrial action yesterday. Interestingly, nothing was left off the table, including an all out strike.

  I remember being involved in a doctor’s strike in Zimbabwe. It’s never a good thing when people who work in hospitals are unhappy. Patient care can only suffer. In a Zimbabwean context, a doctors’ or nurses’ strike meant that some people, who under different circumstances would have survived their illness, died.

  So why did we go on strike? We were dealing with a system that refused to respond to any but the most extreme actions. It was the only way to ensure that health personnel were earning just enough to be able to live above the poverty datum line. The fact that the country’s social fabric had been completely ripped apart made it much easier to take that kind of action. And we always saw it as action taken against the government as opposed to patients. I guess when times are desperate, people generally try to use whatever power they have to ensure that they have the best chances of getting by. But having said all of that, even though we were convinced we weren’t in the wrong, I think we all felt guilty about the consequences of our actions.

  Here in Ireland, The NCHDs are being unfairly targeted by the HSE (Health Service Executive). They are significantly weaker than the nurses, who have powerful unions backing them, and they have less leverage and options than consultants. Despite the fact that NCHDs do most of the doctoring in hospitals, it has been proposed that they take what amounts to a 49% pay cut. Can you imagine a 49% pay cut being proposed for consultants or nurses? It just wouldn’t happen … unless similar cuts were imposed across the board.

  That said, the environment in Ireland is different to that in Zimbabwe. For starters, in many ways, the strike vote is primarily a show of power. The Irish Medical Organisation is in talks with the HSE and the industrial action vote will bolster the union’s position.

  The politics and the socio-economic situation are also very different. Public opinion counts for a lot more here than it does in Zimbabwe. There is also more social cohesion. I can’t see doctors walking out en masse. This dispute will probably be decided by public opinion and after all the posturing is done (on both sides), some form of compromise will be reached.

  To echo the sentiments expressed in Monday’s editorial in this newspaper, the real issue here is that people need to feel that the burden of the recession is being shared justly. At some stage, severe cuts are probably going to have to be made, and the standard of living in Ireland will have to drop.

  I wonder if any mainstream political party will be able to endure the political fall-out from saying that and making cuts across the board. The cynic in me thinks that most political parties the world over are much more likely to try to spare those with the power to keep them in power, or precipitate their demise.

• A&E

  February 6, 2009 @ 7:00 am | by Bryan

  You sometimes hear horrific stories about people spending dreadful hours in A&E. But there is nothing like having it happen to you to get you to realize that there really is an urgent need for health reform.

  At around midnight, a friend developed severe abdominal pain and his wife called an ambulance. She later phoned me and I decided to tag along. Hours later, the two of us had to leave him in the A&E department. He had been looked over once and had been given some pain medication which hadn’t done him much good. We still had no idea whether or not he would be admitted or even the working diagnosis. But because there were children at home alone, and a hospital is supposed to be a safe place for the ill, we left him. I’m yet to hear what eventually happened.

  The whole thing got me thinking. I started comparing the A&E services in that Irish regional hospital to those in Zimbabwe three years ago. In fairness, the Irish hospital won the contest pretty easily, but the fact that I had to think about it, considering that the competition was a hospital in a failing state, is telling. And although I normally reserve my strongest criticism for managers and politicians, I think there is enough blame for everyone to have a share.

  We can argue over who is responsible for the fact that a visit to A&E is often much worse than it needs to be, but that may miss the point. The big question for me is this: are the people who work at the various levels of health delivery conscious of the experience of patients as they go about their day-to-day jobs? If the patient experience is not their primary concern (and I’m talking about everyone – consultants, government officials, nurses, hospital security, etc…), shouldn’t that be where ‘reform’ starts?

• HSE planning to review A&E services in 2009

  December 16, 2008 @ 1:50 pm | by Bryan

  When Finance Minister, Brian Lenihan, said that the country was living beyond its means, I agreed with him. That being the case, it made perfect sense that there be some painful budget cuts. But I was under the impression that health and education were going to be spared of any reductions to their front-line staff. If anything, both need a serious recruitment drive.

  I guess I was wrong. It now appears that the entire health delivery system is under review and some A&E departments may be sacrificed. Am I the only person who thinks this might not be the smartest idea the government has come up with this year?

  I thought that having patients spend hours on trolleys in A&E departments across the country was something we were going to try to address. Granted, most of that is because of bed shortages in the rest of the hospital. But if you decrease the number of functional A&E departments, surely the numbers on trolleys in those hospitals will just escalate. Won’t that pressure just worsen service delivery in those hospitals? This is the sort of thing that happens, I think, when the person responsible for the Health Ministry is not from the health sector, and worse, they believe that business strategies can be translated seamlessly to health care delivery.

  It’s really easy to sit there and be critical when you aren’t looking at the figures and being told to make cuts. I may have serious differences of opinion with the Health Minister and her team with respect to health policy, but I don’t doubt her intentions and commitment to do the best with what’s available. That said, of all the strategies she has announced that I have disagreed with, this one is near the top of the list.

• Recycled Food

  December 9, 2008 @ 9:20 am | by Bryan

  

  Millstream Recycling, Clohamon Mills, Co Carlow, the plant at the centre of the contamination scare, which supplies pig food to farmers

  Recently, one of my closest friends called me a ‘soft socialist.’ I’m not too moved because not too long ago, a colleague called me a ‘right wing extremist’. In fairness, it was at the end of a pretty heated debate. But she is convinced that my views lie way to the right of centre. Hopefully the fact that two people who know me well can have such different views on me and on my own views means that I am capable of being objective.

  The objective person that I am is more than a little surprised about the source of our bacon and sausages. I feel terrible for the farmers who have lost buckets of money since it was announced that Irish pork was contaminated with the dioxin, a potentially carcinogenic toxin. What people may not know is that the source of that toxin was a food recycling plant.

  This is where my surprise and confusion kicks in. Pigs, which become the pork chops, rashers and sausages we eat, are fed recycled food? Who decided that was a good idea? Unless I’m mistaken, that is what contributed to the foot and mouth disease outbreak in Britain a few years ago.

  Remember, I’m not an unhinged ‘leftie’. But I am disgusted at the extent our society goes to make an extra buck. Rather than feeding livestock recycled food, or bits of other livestock, why not feed those animals proper natural food? If that means having the whole system go organic, then why not? If recycling animal feed can lead to contamination with a substance that is routinely tested for, who is to say that there aren’t many other undetected substances that we ingest daily? The sad thing is it all comes down to greed. I’m not talking about the farmers here. Most of them are probably struggling to get by. It’s the whole food industry that is twisted. Raj Patel’s Stuffed and Starved, a brilliant book, paints a depressing picture about the state of that industry.

  I’m not a tree hugging plant lover or anything like that. But maybe one of the great tragedies is that we tend to dismiss people with concerns about things like the food cycle or the environment as tree hugging loonies.

  Recycled food?

• HSE chain-saw massacre?

  November 18, 2008 @ 9:04 am | by Bryan

  I understand the outrage about HPV vaccines being dropped to save costs. But that’s just a symptom, I think, of a much larger problem. Think about it, a full blown screening program was floated at about the same time as the vaccine. Many dirt poor countries in the developing world have functioning screening programs. Why there was a push to establish “centres of excellence” for cancer treatment before there was one for proper cancer screening programs is beyond me.

  While everyone has demanded that the civil service be reformed, I don’t think that what the HSE (Health Service Executive) has in mind is the way to go. As reported by Martin Wall in today’s paper, the HSE is looking at saving hundreds of millions of euros, not by getting rid of and background staff and trimming unnecessary layers of health managers, but by trimming down various “layers of on-call cover”.

  I think the HSE is taking the path of least resistance here. Non-consultant hospital doctors (NCHDs) have less political clout than consultants, but are probably more important to the system. NCHDs probably contribute a lot more to the health system than most realise. What may look like frivolous benefits that the HSE has proposed removing from them are anything but that. Just about all of them are currently putting in hours of unpaid overtime work, almost daily, because of the staff shortages. Restricting recruitment of front-line medical staff is not a smart way of saving money.

  When all is said and done, it sometimes feels as though there is an ad-hoc campiagn to save as much money as possible. The current situation reminds of of an 80s horror film with a crazed man swinging his chain-saw wildly in a crowed room. The results can’t possibly be pretty – especially in the long run.

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