It seems to me that a number of factors present in Ireland have lethally come together in the health area. For a start we have run out of nuns. A hundred years ago, you had these driving women setting up hospitals and managing them. The caricature of the old hospital nun giving out yards because you couldn't roll a penny across a coverlet - ergo it wasn't smooth and tight enough - carried a healthy grain of truth in it.
Those women had standards and by being rigid control freaks and monopolists and because they treated their standards like they were the Word of God they got thousands of people working within those hospitals to abide by the rules and ensure levels of cleanliness and hygiene which, frankly, are unequalled today.
Right now, in some hospitals, we're slipping back towards Victorian or Third-World standards of cleanliness while the other half of us is expensively in the 21st century with high-tech procedures and equipment.
So the nuns are dying off, and the hospitals are, for the most part, transferring into State hands. Now, when something passes from a culture and tradition as ingrained as religious healthcare into a radically different culture and tradition, the period of changeover is a massive challenge to all concerned.
At the same time, the globalisation of travel and business means that only a closed society can keep out some diseases and even a relatively closed society like China can't keep those diseases out for long.
That's the next challenge.
At the same time, the old behavioural controls - "Do that and you'll go blind . . . go to hell . . . die young or be found out by your mother" have all fallen away in a generation - at a time when health is more behaviour-related than at any time in the past. Challenge number three.
At the same time, funding systems have changed so radically that the privatisation and outsourcing of previously centralised activities are a necessity. Yet another challenge.
Add to all that the fact that social problems, whether of poverty or drug-taking, sooner or later (usually sooner) impinge on the health system.
In order to meet these challenges the Department of Health should be the pride and joy, the pioneering thinker among government departments. World-class ideas should be its hallmark, fast flexible responses should be emerging from it. But to this eye, at least, they appear to be thin on the ground.
But there again, some departments get lucky - Education got O'Rourke and Martin, both in their very different ways, fine ministers, one a kicker-into-shape, the other a consolidator and innovator. Health, on the other hand, got John O'Connell, a visionary of another time but perhaps a little too inflexible for the complexity of the task, and then Brendan Howlin.
Of the two, Howlin probably had the worst long-term impact, because he seems to have spent most of his time working on his strategy document, the most tangible end result of which has been a complete absence of strategic thinking by that Department thereafter.
The document seems to have been used mostly as a kind of checklist system when people were being interviewed for health service posts. If you could prove you matched paragraph x on page Y, you were OK. Michael Noonan followed the document as if it was the Holy Grail and as a result walked into Hep C like a man walking into a wall.
And then we got Brian Cowen. The brightest and best of minds, his period in Health has been the ministerial equivalent of radiation poisoning. You can't see it or hear it or smell it, but it's not making you feel great, either.
The leadership/management problem does not stop there. In the past, there have been Department managements of such moral or intellectual force that even with a mild-mannered minister or one without much innovation there was a sense that there was a hell of an engine running in the Department. There has been no sense of this in recent years. It could be argued that the range and complexity of problems facing the health services are so great and increasing at such a rate that no one could manage all of it. But what the crisis over smear tests has proved is that the Department isn't even handling old-established problems.
False smear test results are not without precedent in other countries. And still the lessons learned repeatedly elsewhere have been ignored here. Health boards have been allowed so much latitude that they can sub-contract a delicate set of tests, in which the time factor is as pivotal as the accuracy factor, not to a laboratory properly accredited to do these tests, but to one that specifically doesn't do these tests.
It's like being told your obstetrician is away and they've sub-contracted his work to a chiropodist but don't worry, the chiropodist has further sub-contracted to some really reputable guy. For my part, I would much prefer to be in more direct control, and a system like that operated by a health board worries me.
And, in turn, the fact that the Department seems to have been perfectly happy with this system is even more worrying. It gives the impression that the Department of Health has decided that it will just look after funding and abrogate its responsibility to patients. Not acceptable. Not acceptable in any way whatsoever.
The final problem about the smear tests is that they will bring the usual calls for resignations, preferably the Minister's. While I am all for ministers taking responsibility for the problems within their departments, in this case a resignation would not help solve the problem.
The Department of Health requires a long "reading-in" period precisely because it faces so many challenges. Appointing a new minister will inhibit the work of the Department until that learning process is complete. Also, the present Minister is one of the brightest available. A better replacement would be difficult to find.
But what cannot happen is for this crisis to be muddled through and for nothing to change. As a first step the control systems that have so obviously failed must be overhauled. Not to create new layers of bureaucracy but to create systems that work, that include self-testing mechanisms and that reassure the public by eliminating basic errors. This would surely be an ideal test for the Government's much-vaunted strategic management initiative.