An Cailín Rua
Medicine is not my area of expertise, nor is management of large, unwieldy organisations. Unless you count the time in my childhood spent trying to rear three poorly orphaned lambs simultaneously (they all survived to adulthood; I can’t vouch for their fate thereafter). But of late, we are seeing a lot of attention on both the public health system and public health medicine, and in the throes of a pandemic, both merit some discussion.
I say both, because there is an alarming lack of awareness of the difference between our public health system, and public health medicine as a discipline.
The former could be defined a combination of all entities – public, private and voluntary – that contribute to the delivery of health services. A network of various bodies with different roles and responsibilities that contribute to the health and wellbeing of everyone.
So, while government entities and organisations like the HSE are major players, they don’t actually represent the full spectrum of those contributing to public health. The public health system is a debate for another day.
Public health medicine, on the other hand, is that discipline or art within medicine that focuses primarily on ensuring the good physical and mental health of the public. It is the science of preventing and combating disease, prolonging life and ensuring that good health is promoted throughout society. Never has the work of our public health specialists been thrown into relief like this.
In recent weeks, you will probably have heard that public health specialists were due to go on strike last January, but deferred their action in light of the dire Covid-19 situation.
What drives doctors to threaten strike action at such a time? You may be surprised to hear that despite their undisputed importance to all of us, public health specialists are just that: specialists, not consultants.
Their role as frontline workers combating Covid-19 – trying to manage outbreaks, working on complex contact tracing, trying to ensure that all of us stay healthy – is essential, you might think. However, their roles are not deemed worthy of consultant status and the discipline is not consultant-led. This is entirely at odds with international practice. In addition, the discipline has been historically hugely under-resourced.
There are only 90 or so public health specialists in Ireland. Their lack of consultant status restricts the work they can do in terms of proactively improving health, despite being qualified.
Several public health specialists in Ireland have taken to social media to speak up about the conditions under which they are working. They speak of long hours, feeling overwhelmed and exhausted, having little support and having to work with poor, outdated technology. This results in a high attrition rate; loss of talented doctors to equivalent roles overseas, or to other disciplines, or to early retirement.
Even the HSE acknowledges the risk. Earlier this month, the Medical Independent reported that on the HSE corporate risk register, the risk to the ongoing and effective management of Covid-19 is acknowledged because of ‘inadequate and sustained resourcing of public health teams’.
The register also acknowledges the risk of failure to control the spread of the virus, due to an inability of the service ‘to respond in a sufficiently robust and agile way across the end-to-end service pathway to the evolving capacity demands of the Covid-19 pandemic’. We have seen this play out in front of our own eyes this year as our contact tracing system became overwhelmed, resulting in significant loss of life.
The struggle for parity and resourcing by public health specialists has been ongoing long before we ever dreamed a pandemic could happen. For nearly two decades, they have been fighting this battle.
Given that they are there to protect us, we owe our public health doctors, at the very least, the respect to ensure they are properly recognised and remunerated for the work they do. They also deserve to not have to waste valuable energy fighting for the resources they need to do their jobs.
But if the government cannot see the value of public health doctors now, during an actual pandemic, it remains to be seen whether they ever will. And in the end, it’s we who will lose out.