Jhe ladies of the Luke household have a favorite old joke about the male of the species. It goes like this: Wally Witherspoon gets down on his knees and proposes marriage to his beautiful girlfriend. “Wally, honey,” she replies, “I like the simple things in life, but I wouldn’t marry one. Oh, how the ladies laugh. And yet, I have a lot of sympathy for Wally, especially as I get older and, like many of my peers, I try to make life as simple as possible, with the one resource I have in abundance: experience (what we veterans call the lessons of many mistakes).

This means that I particularly like “heuristics”, those mental shortcuts or rules of thumb that experienced physicians often use when juggling the daily demands of diagnosis, elimination, or distraction with the impulse to do a quick, important and sometimes a judgment of life or death. (By the way, I know being a “judge” is one of the cardinal sins of modern life, but I always think of the prehistoric hunter-gatherer who has to instantly judge whether those blinking things in the foliage are the eyes of a saber-toothed lion, or simply dappled sunlight. And I believe homo sapienss still has to make such quick decisions during each day).

The ‘3 D’s of Diagnosis’ have long been my favorite setting for the kind of speed-dating done in a crowded emergency ward: a triangulation of Distress, Upset and – in Cork – ‘De story’ offers a useful exercise before make a plan for any patient. An even simpler reflex check applies to hospital or office politics. In short, when a decision seems bizarre, undemocratic or unfair, Cicero’s legendary question, ‘Cui bono?‘, applies. Clearly, “for whose benefit” was this done?

Even when it comes to really big issues, like overcrowded emergency departments, delayed construction of maternity wards, or the manic culling of American schoolchildren, I resort to a trio of simplistic explanations. My ‘3 I’s of Misgovernance’ include incompetence, indifference and ideology.

Naturally, at the beginning of a career as a consultant or general practitioner, one tends to blame difficulties on a “totally useless” colleague, manager or civil servant, but I have come to believe that indifference towards those who are affected by bad policies is often the real problem. And the more I thought about it, and the more meetings I had with those responsible for questionable decisions, the more I realized that indifference usually stems from simple unconsciousness.

Policy makers often fail to really think about the consequences of their decisions for others. Of course, decision-makers can deliberately avoid putting themselves in others’ shoes, as this is often emotionally uncomfortable.

Call me naive, but I’m inclined to forgive incompetence and indifference. After all, “getting it wrong” and all that, and I remain eternally optimistic that incompetent or indifferent people – even those high up in the hierarchy – can learn to be more thoughtful or considerate, with a little humility and flexibility.

Alas, the same cannot be said of the “ideological”. Here I have a real problem. Stupidity, myopia, or recklessness rarely lead to the kind of epic misery produced by fanatical believers of an “-ism” or idea. To stick to the oversimplification with which I started, I tend to blame our chronic shortage of hospital beds (and the resulting misery for those waiting for one in the ER) on a “thatcherism” diffuse that prevailed in all these islands for a decade and a half after Margaret Thatcher became British Prime Minister in 1979.

This meant cuts in public spending and taxes, reliance on the free market, and a paradoxically centralized approach to decision-making, which marginalized unions (including those of doctors, nurses, and health care workers).

One of the hallmarks of this -ism was the deployment of dubious but politically useful economic doctrines, such as that which would have supported massive reductions in the number of hospital beds in Ireland, because “in the future so much health care will be provided in the community.

The initial factor was the financial difficulties of the 1970s, but the net result was a loss of 22% of all hospital beds in the Republic between 1980 and 1998; and, in the forty years (so far) of my medical career, we have failed to reverse these losses, despite our rapidly aging population.

Another -ism that seems to be at the heart of much misery here is the apparent militant atheism that has recently sought to delay, for yet another period of “re-engagement”, the relocation of the National Maternity Hospital (NMH) from intolerable inadequacy Holles Street at the Elm Park campus of St Vincent’s University Hospital, formerly a devout Catholic institution (where I was first trained).

This move, and the proposed physical and cultural architecture of the new hospital, has been enthusiastically supported by clinical and support staff in Holles Street, who are desperate to improve their working conditions, and those endured by the 7,000 mothers who give birth every year in the often dilapidated -NMH. And yet the move has been met with opposition from politicians who discern an ominous papal hand hovering over Elm Park, despite the growing invisibility of clergy and nuns in an impending post-Christian Ireland.

But despite everything – ignoring the paranoid delusions of the Kremlin maniac – surely the worst ideology affecting health care workers in the West is that which leads to the relentless slaughter of innocent people in American schools. I heard another Republican politician knot, on the radio, the morning after a “lonely bullied teenager” massacred 19 children and two adults in Uvalde, Texas in late May 2022.

The author and Conor Deasy in Cork.
Listen to their conversation on the IMT Podcast “Irish Medical Lives” – Search “Irish Medical Lives – Prof. Conor Deasy”

The interviewer asked the politician if he thought the shooter should have been able to buy two assault rifles a few days after his 18th birthday and – hesitating slightly – he suggested “maybe not if he had a background” criminals” or “mental health”. The problem was, the broadcaster pointed out, that the mass murderer was widely known to be “deeply troubled” and “violent”, but he had no criminal record or formal psychological diagnosis.

Yet even that conundrum was nothing compared to the one introduced by Texas Attorney General Ken Paxton, who reportedly “rejected the idea of ​​enacting gun restrictions – believing that shooters would not follow the law of anyway” – and said; “I would much rather see law-abiding citizens being armed and trained so they can react when something like this happens, because it won’t be the last time.”

So, again, an American politician is arguing that the cure for guns is, uh, guns. And teachers must become part-time soldiers in a school Wild West.

What ties all these scenarios together is a disregard for the healthcare workers who have pleaded for years for more beds to enable them to provide the care their patients need, who have begged to leave the utterly inadequate buildings in which they struggle to provide basic maternal care, or who argued that, while children in the United States are now more likely to die from gunshots than any other cause, and are twenty times more likely to die after being slaughtered than their peers in Europe, Australia and Japan. Good gun control would reduce this frightening toll.

In short, gun madmen have slaughtered people in England, Scotland, and Australia for decades, but ensuing gun access restrictions have massively limited their use in those countries ever since.

And, famously, the Japanese have nearly eradicated gun crime (in 2014, there were six gun deaths there, compared to 33,599 in the United States). Why? Well, for starters, to get a gun in Japan, you need to take a one-day course, pass a written exam, and pass a shooting range test with a mark of at least 95%. And then come controls for extremism, drug use or crime.
Here is another very simple idea.

The millions of dollars “given” to American politicians lobbying for the National Rifle Association are regularly published in the American media. And many years ago, American activist Upton Sinclair said, “It’s hard to get a man to understand something when his salary depends on him not understanding it.”

So for the 21st century, I would replace “man” with “politician” and add “status” to “salary”.
That sort of explains the public health challenges everywhere, doesn’t it, Wally?