Medical Independent
27 March 2017
Clinicians warn that urgent action is required to ensure that carbapenem-resistant Enterobacteriaceae (CRE) do not become endemic in the Irish health system.
Catherine Reilly reports
A 'national emergency’ that is ‘spiralling out of control’.
Clinicians are describing the spread of carbapenem-resistant Enterobacteriaceae (CRE) in Ireland’s acute hospital system in such unequivocal terms.
Recent outbreaks of gram-negative bacteria resistant to the carbapenem class of antibiotics – the ‘drugs of last resort’ for life-threatening infections – have seriously impacted several acute hospitals and long-term care facilities (LTCFs) in Ireland.
The CRE subset carbapenemase-producing Enterobacteriaceae (CPE) – which are Enterobacteriaceae non-susceptible to carbapenem via production of a carbapenemase enzyme, and are of huge concern globally – have been implicated in Irish and international outbreaks. These carbapenemases include Klebsiella pneumoniae Carbapenemase (KPC), Verona Integron-encoded Metallo-β-lactamase (VIM), Oxacillinase-48-type carbapenemases (OXA-48) and New Delhi Metallo-β-lactamase (NDM).
On 24 August 2016, Tallaght Hospital notified a CRE outbreak to the HSE Department of Public Health-East. This CRE outbreak has constituted Ireland’s largest to date and involves OXA-48 CRE. In November 2016, an internal HSE document described the scale of the outbreak as “unprecedented” in Ireland. In the 18 months to February 2017, Tallaght says it treated 528,077 adult patients – 142 of whom were identified as carriers of CRE. Most affected patients were aged in their seventies, the Medical Independent (MI) understands.
Since 2015 there have been three invasive cases and no deaths “directly attributable” to CRE, according to the hospital. Cases are still occurring but the hospital says they have reduced substantially.
In December 2016 an outbreak of VIM CRE was notified by Mayo University Hospital (outbreak status has been since ‘stood down’). There were 11 colonisations and five invasive CRE cases over a period of 27 months, according to the Saolta University Health Care Group. Two patients died where CRE was identified as a contributing factor to their death. “None of them were acquired in Mayo University Hospital. The first case in 2014 with sepsis and the second case in November 2016 with multi-organ failure,” said the spokesperson.
In January 2017 St Luke’s Hospital, Kilkenny notified a “small contained outbreak” in a surgical ward (“it has ended”, stated Ireland East Hospital Group). University Hospital Waterford also experienced an outbreak in 2016, involving OXA-48 and NDM CRE, while an increase in CPE incidence is under investigation at St James’s Hospital Dublin as of March 2017.
Sporadic KPC CPE cases have continued to be identified in the midwest, where CRE may have become endemic (see panel page 5). There are also two LTCFs actively dealing with outbreaks: one in the northwest and the other in west Dublin. The latter is directly related to the Tallaght Hospital outbreak. Various types of CRE have circulated and not all of the recent outbreaks in Ireland would be inter-related.
Confirmed CPE cases have increased almost 10-fold from 2013 to 2016, according to statistics from the National Carbapenemase Producing Enterobacteriaceae Reference Laboratory(48 confirmed CPE cases in 2013; 81 in 2014; 140 in 2015; and 369 in 2016).CRE outbreaks in Irish healthcare have principally involved colonisation (typically termed ‘CRE cases’); yet carriers serve as a reservoir that facilitate proliferation and increased risk of infection. Healthy people colonised with CRE would not usually suffer ill-effects. However, vulnerable patients in hospitals and other care facilities are at risk of bloodstream infection, particularly those requiring invasive medical devices, and CRE invasive infection is associated with mortality of over 50 per cent. In Ireland there have been deaths associated with CRE. The HSE, however, did not respond conclusively on a query as to whether it held such figures.
Records obtained by MI following a Freedom of Information (FoI) request to the HSE show that major manpower deficits, insufficient infrastructure and equipment, and a highly under-resourced and uncoordinated national response, brought Tallaght Hospital to the brink of effective closure as an acute care service.
The documentation also revealed laborious and complicated reporting lines within the upper echelons of the HSE and acute hospital network, limiting the capability for urgent and effective response.
Some three weeks after notification of the outbreak, Minister for Health Simon Harris was moved to ask Department officials – in an email sent on the night of 14 September – to find out “if there is an outbreak” of CRE at Tallaght Hospital. The hospital did not inform the Dublin Midlands Hospital Group (DMHG) about the outbreak until 14 September.
On 16 September, a note came through to the Department of Health, via HSE Acute Hospitals, from the Group. Two adult wards had been closed to admissions, the Group stated, and this would have a “temporary impact” on bed availability and elective admissions at the hospital.
Yet the impact at Tallaght was anything but temporary. Over the coming weeks, the hospital faced a huge battle to contain the rapidly evolving crisis. The hospital stated that there were eight CRE cases in August 2016; this rose to 31 in September (and one invasive case) and 37 in October. In November, there were 25 cases (and one invasive case), 11 in December and nine in both January and February. Thousands of screenings have been undertaken: 9,891 from August 2016 to February 2017 inclusive, hitting a peak of 1,929 in November.
‘Major patient safety issue’
Irish health authorities have been well aware of the threat posed by CRE for several years, but it has not been high on an agenda dominated by more visible and relatable problems such as the trolley crisis and long hospital waiting lists. However, leading figures in Irish microbiology warn that this country is fast running out of time.
Dr Eleanor McNamara, President of the Irish Society of Clinical Microbiologists (ISCM), said the window of opportunity to stop CRE from becoming endemic in the hospital system is “diminishing rapidly”. The Society wrote to Minister Harris in July and October of 2016 requesting a meeting to discuss, update and advise him on the threat posed by CRE and risk mitigation interventions, but this request has not yet been realised.
Dr McNamara said there were recent ongoing outbreaks which were “nearly crippling” acute services. She said outbreak incidents can effectively “bring a hospital to its knees, and affect its ability to deliver the acute services that it is mandated to do”.
She added: “Overall, this is a major patient safety issue. As one of my colleagues had said, if we had an outbreak of blood-borne virus infections, acquired in hospitals, there would be a national outcry, and yet here we are having healthcare-associated infections occurring with an almost untreatable organism, and there isn’t an emergency national outbreak team being pulled together with dedicated resources.”
Dr McNamara emphasised that a longer-term strategic focus in parallel to an emergency response is equally as important. A national action plan on antimicrobial resistance (AMR) that is resourced, actioned and auditable is also an essential requirement, added Dr McNamara.
“We have had emergencies, like a few years ago, with Ebola and novel strains of influenza, and everybody knew about it. And plans were implemented. However, CRE is a global emergency of even greater significance in some respects than Ebola, because it is affecting everybody now – in health sectors across the world – and basically we are not getting that level of energy, attention and focused reaction to it,” said Dr McNamara.
“We need to have coordinated action – unfortunately at the moment it is all very uncoordinated,” added Dr McNamara on the current national efforts.
Prof Martin Cormican, Professor of Bacteriology at NUI Galway, told MI that “if we are to have any chance of controlling this, we need much more effective leadership from the Minister for Health and the Department of Health than we have seen to date”.
A number of Irish hospitals experiencing major outbreaks have “managed to limit spread” but at “considerable cost and disruption of service”.
More broadly, measures taken to date to control CPE “have not been effective overall”, he said.
“Although spread in hospitals is almost certainly the biggest problem at present, there has been spread in some nursing homes and it is likely that spread in homes and in the wider community and the environment are likely to become increasingly common as the problem continues to spiral out of control.”
Consultant Microbiologist Dr Rob Cunney, Clinical Lead for the HSE/RCPI Clinical Programme on Healthcare Associated Infections (HCAI) and AMR, agrees with colleagues that an urgent response is needed to prevent CRE becoming endemic, certainly in the hospital system. The problem requires “a properly focused and resourced response”, along the lines of that adopted in Israel some years ago, when local measures failed.
A HSE spokesperson told MI there is a “work plan” produced by its Multi-Drug Resistant Organisms Taskforce [aka AMR/HCAI Taskforce] and a “proposal” to the HSE senior management team around “resource requirements for addressing CRE”. A national action plan on AMR is also being developed by the Department of Health and the Department of Agriculture, Food, and the Marine.“[CRE] is something that is being taken very seriously by the [HSE] Leadership Team, much more than we have seen before. I am hoping that will translate into a properly resourced response,” Dr Cunney commented.
Communication
The crucial importance of clear lines of communication and escalation, and prompt access to emergency resourcing at a national level, are writ large when surveying the Tallaght crisis.
Several weeks after the outbreak notification, on 9 November 2016, a HSE Public Health report described Tallaght Hospital as “overwhelmed”.
It stated: “The hospital has been overwhelmed by this organism and efforts to contain it have been hindered by the contagiousness of this plasmid, the prolonged duration of colonisation, the inadequate number of single rooms, the lack of dedicated equipment, the inadequate [number of] clinical microbiologists, laboratory staff, infection control nurses and general nursing staff…”
Many hospitals throughout the country “have even fewer resources to deal with a situation like this and the country as a whole is extremely vulnerable”, it added.
In the early days following outbreak notification, finding funding for replacement mattresses for those that failed an audit was proving difficult. It was also recommended that dedicated staff provide care for CRE patients but this was “not possible due to financial and staff shortages”, according to a report from the HSE Department of Public Health-East on 23 September. Some agency staff were also refusing to work at Tallaght Hospital.
Remit
There are numerous entities involved in tackling AMR/HCAI, but no single responsible body with a clear, and adequately resourced, lead operational remit in the case of outbreak.
The HSE’s Multi-Drug Resistant Organisms Taskforce does not have an operational role in response to outbreaks. The HSE/RCPI Clinical Programme, clinically led by Dr Cunney, devises quality improvement projects focused on hand hygiene, device related infection and antibiotic stewardship.
The HPSC is responsible for coordinating national surveillance of CRE (including CRE outbreaks), and providing operational support for the management of outbreaks where required. HSE Departments of Public Health are responsible for coordinating regional surveillance, providing operational support for management of outbreaks or, in some cases, leading outbreak control teams depending on the outbreak setting.
The Clinical Programme sits under the HSE Quality Improvement Division, while the HPSC and public health departments are under the remit of the HSE Health and Wellbeing Division.
The HSE said there are two separate reporting mechanisms in the public hospital network for escalation of CRE outbreaks. Firstly, all hospital outbreaks are required to be notified to the local HSE Department of Public Health and, from there, to the HPSC. Secondly, hospitals and community healthcare institutions “can escalate issues relating to CRE, or other HCAI, via the HSE Accountability Framework” (eg, from hospital to Hospital Group to HSE Acute Care Division to HSE Senior Management Team). Therefore, in the case of a hospital outbreak, the corporate line of accountability runs from the hospital CEO/general manager reporting to the CEO of the Hospital Group reporting to the divisional lead of Acute Hospitals.
Neither the HSE National Office for Health and Wellbeing nor Quality Improvement Division have a formal role in the escalation or reporting of outbreaks, according to the HSE. By press time, the HSE had not confirmed when Director General Mr Tony O’Brien was informed of the Tallaght Hospital outbreak by HSE managers*.
‘Not under control’
On 22 September 2016, just over a week on from Minister Harris’s internal Department enquiry as to whether there was an outbreak at Tallaght Hospital, Consultant Microbiologist at the HPSC Dr Karen Burns informed senior HSE managers: “We all need to be clear that this outbreak is not under control.”
The hospital was detecting approximately one new patient per day, with around 40 patients to date and 14 inpatients affected at the time of Dr Burns’s note. It was likely to “go on for a protracted period of time” and there was a “significant risk that a similar situation to Limerick is likely to evolve, whereby screening will continue to detect patients returning to the hospital who picked up CRE on an earlier admission”.
Dr Burns made reference to stretched manpower in crucial areas at Tallaght Hospital and in the HPSC, which has only 0.5 WTE consultant microbiologists (the recruitment process is still “ongoing” for a 0.5 WTE consultant microbiologist to cover a seconded staff member, according to the HSE. The HPSC is also still attempting to fill the position of Director following the retirement of Dr Darina O’Flanagan in May 2016).
In his reply to Dr Burns, and HSE colleagues, HSE Director of Quality Improvement Dr Philip Crowley said the situation showed “how thin the national resource is in this area”.
After visiting Tallaght Hospital, Dr Burns reported on 27 September that there were 16 inpatients with known CRE: nine were accommodated in a ward that was fully single en-suite and six were in isolation on a second ward.
“One patient was transferred to ICU last night and is being treated for CRE infection. Contacts of known CRE cases are being screened for CRE carriage. There are approximately 47 confirmed patients with CRE in the year to date…we suspect that this issue may have started in the hospital during Q4 2015 and grumbled on at a low level, prior to being identified and notified as an outbreak this August.”
Throughout the crisis, there appeared to be a complicated chain of escalation and information sharing among senior HSE management. On 28 September, for example, Director of Health and Wellbeing Dr Stephanie O’Keeffe, referred to “a lot of traffic on this and need to be careful it is being directed in the right way”.
On 5 October, Dr Burns of the HPSC reported to senior HSE management of further concerns following a visit to the hospital. She wrote that there was nothing to indicate to the general public visiting the hospital that there was an ongoing outbreak. “There has been no formal media communication from the hospital to advise people to attend only if absolutely necessary,” she added. Moreover it was not always clear to healthcare professionals, including doctors, which patients had CRE.
On 27 October, as the hospital examined alternatives to ensure patients could access scheduled care, a CRE Outbreak Meeting at Tallaght Hospital – which included hospital management, HSE, DMHG and HPSC representatives – heard that private hospitals had raised concerns regarding accepting CRE patients. It was also noted at this meeting that “other hospitals are not following national guidelines”, which MI understands as a reference to the Guidelines for the Prevention and Control of Multi-drug resistant organisms (MDRO) excluding MRSA in the healthcare setting, which outlines screening protocols.
At this meeting, CEO of the hospital Mr David Slevin advised of the need to screen five nursing homes (as of mid-March 2017, the HSE has commenced screening in one of these nursing homes. Tallaght Hospital’s laboratory has facilitated this by processing the samples).
The HSE Public Health report of 9 November 2016 noted that there had been 79 cases of CRE at Tallaght Hospital from July to the end of October 2016 (and 91 in total for 2016). There were 32 CRE positive inpatients on six wards, all in isolation as of 9 November, according to the HSE document. Furthermore, there were 52 CRE contacts cohorted on 12 wards. Eight beds were blocked due to cohorting of CRE contacts.
The HSE report noted that many patients had tested positive for more than one OXA-48-like positive bacterial species. “As a result there is no defined bacterial species or antiobiogram associated with this outbreak which hindered the initial recognition of the situation.” Another characteristic that contributed to the spread “was the time taken for contacts to become culture positive which can take up to four weeks”. Of the CRE cases when first positive samples were taken (January 2015-October 2016), most were on the Crampton, Gogarty and Lynn wards. Five were in the ITU and four in the CCU.
The infection control nurse staffing levels were 3.3 whole-time equivalents for 430 beds. They were at “breaking point”, according to the HSE document, and there did not appear to be qualified staff available to hire. The hospital had just 1.7 WTE consultant microbiologists. Furthermore, the most recent hand hygiene audits for September 2016, during the outbreak, did not achieve 90 per cent compliance (the HSE-mandated KPI).
There had been instances of more than three days to isolate a CRE patient, while there were regularly more than 10 beds blocked due to cohorting and isolation and, on one day, 45 beds were blocked. Moreover, while weekly screen of high risk patients (ICU, haematology, oncology, renal, dialysis, major GI or vascular surgery, trauma and orthopaedics) was recommended as a control measure “it is not yet in place for all areas due to the burden of testing”.
According to the report, the only way to prevent the spread of CRE nationally would be to follow the Israeli example (Schwaber et al, 2011) of a “properly funded national taskforce along with a plan and the funding to improve the national hospital infrastructure and bring it in line with HIQA standards for the prevention of healthcare associated infections”.
‘National concern’
By the middle of November, it appeared that HSE Acute Hospitals was managing to commit to, and coordinate, a number of measures to assist Tallaght, and the exhaustive efforts of key hospital staff were making some headway. The DMHG said its management team “helped secure funding for essential diagnosing equipment and works”.However, towards the end of 2016, Mayo University Hospital notified an outbreak involving a different type of CRE.
On 19 December, in an email to HSE Director of Health and Wellbeing Dr O’Keeffe, Director of Quality Improvement Dr Crowley and Director of Acute Hospitals Mr Liam Woods, and colleagues, Dr Burns of the HPSC described the “evolving situation” in Mayo as highlighting that “CRE is a public health emergency of national concern”.
Dr Burns was providing advice to the hospital’s recently appointed consultant microbiologist.
The outbreak may have begun much earlier than the date it was notified to Public Health on 2 December, she reported. There had been cases in the ICU, orthopaedic ward, a medical ward, a paediatric case and a dialysis patient. Screening had been limited to the ICU, haematology and oncology, with resourcing issues involved. "It is a VIM type, which is unusual in Ireland to date and indicates that there may be a significant local VIM problem which has evolved unchecked,” wrote Dr Burns.
Meanwhile, by early 2017, CRE remained an ongoing concern at Tallaght Hospital. According to the hospital, the HSE made a “significant contribution” to its additional funding requirements to manage this situation in 2016. Discussions to provide additional funding for 2017 are ongoing with the HSE.
Tallaght Hospital said it had two WTE consultant microbiologists in early August 2016, increasing to 2.7 later that month. Troublingly, the current figure is “temporarily” at 1.8 WTE “due to a full-time retirement”, with a replacement due to begin in June. “A consultant working 0.1 WTE has been appointed to help with clinical work and antimicrobial stewardship.”
The number of WTE infection control nurses in August 2016 was 3.3 and is now 4.1, according to the hospital.
Tallaght Hospital now has two molecular systems running for the detection of CRE – the Genexpert system, which gives a result in about an hour, has been used for new patient admissions since 28 November 2016. The Flowflex system, which can process 96 samples every five hours, has been run every day at a set time since 19 December 2016 “as part of routine screening of patients”.
The hospital requires specialised software to manage hospital infections and is using a temporary in-house IT solution for tracking CRE cases. It also “has plans to develop a new 72-bed unit, which will assist staff in managing such infections in the future”.
Prescribing
MI understands that Tallaght Hospital has high use of third generation cephalosporins, fluoroquinolones and carbapenems. Experts agree that appropriate antibiotic prescribing is a key feature of tackling AMR. Some hospitals have invested more than others in antimicrobial stewardship, noted Dr Cunney of the Clinical Programme.
In May, the HPSC will coordinate a national point prevalence survey (PPS) of hospital-acquired infections and antimicrobial use, as part of a European-wide PPS. The recently published PPS for LTCFs found that, of 10,044 LTCF residents who were counted, some 981 were prescribed antibiotics.
Dr Cunney said there are high levels of antibiotic use in Irish nursing homes, and the indication is often not clear. He emphasised the need for establishment of resourced antimicrobial stewardship teams in the community.
At the ISCM, Dr McNamara agrees that both stewardship teams and consultant microbiologists overseeing infection control/AMR activities in the community are badly needed.
Dr McNamara also underlined that Ireland needs to develop its eHealth national capabilities urgently. She said it was difficult to fathom that national e-prescribing is not in place in the acute hospital system, given its capability of real-time monitoring of antibiotic prescribing and the wider issue of reducing medication-related errors.
Dr McNamara said patients are being transferred between acute hospitals and also from primary care settings without knowledge of their CRE carrier status. She said it is essential to find out which patients are affected by CRE.
“However the whole issue of CRE screening is challenging, labour intensive and costly,” she continued. “The laboratories haven’t been resourced for it, and methods are complex. The logistics of identifying the patients for screening, then resourcing to do the screen, and communicating of the results, particularly across hospitals, is really difficult.”
A national electronic healthcare record (EHR) would assist significantly with surveillance and management of issues such as CRE, the HSE’s Chief Information Officer Mr Richard Corbridge told MI. The EHR business case is still with the Department of Health for consideration after approval by the HSE last summer.
Response
In response to the increased incidence of CRE in Ireland and associated outbreaks during 2016, voluntary enhanced CRE surveillance scheme was discontinued at the end of last year. Effective from January 2017, all Irish microbiology labs are required to report information directly to the HPSC on a quarterly basis (the HPSC will be publishing quarterly reports).
Meanwhile, HIQA intends to “continue to closely monitor this situation during 2017, through the undertaking of a revised approach to monitoring against the National Standards for the Prevention and Control of Healthcare Associated Infection and we will be publishing a guidance document on this in the coming months”.
Longstanding CRE problem in midwest
A “particular problem” with CRE exists in the midwest region “at large”, which is reflected in the hospital population, according to the HSE. There were 31 new CRE detections across the UL Hospitals Group in 2016, and no invasive bloodstream infections, stated the Group. There were 60 new CRE detections across the Group during 2015.
“With large ‘Nightingale’ wards the norm in the older parts of the building, managing contacts between patients carrying CRE and others remains a challenge.”
The UL Hospitals Group refurbished an inpatient ward at a cost of €400,000 to facilitate an infection prevention and control “cohort ward”; it refurbished another ward, at a cost of €300,000, at UHL due to infection prevention and control “concerns”, including replacement of infrastructure such as sinks; it says it has also invested in additional cleaning and deep cleaning measures.
“ULH has developed a quality improvement plan in regard to CRE, which incorporates much of the NHS Toolkit for the Control of CRE 2013. This includes an intensive screening programme; use of an isolation ward for newly detected or known positive patients to reduce the risk of cross-transmission; flagging all CRE positive and CRE contacts through the management, surveillance and reporting software ICNet; and reporting new cases appropriately through the microbiology team.”
More complex antibiotics are referred to the microbiology team before being prescribed, says the Group. Nevertheless, there have been concerns expressed about management of CRE at UHL. In summer 2015, Clinical Lead for the HSE/RCPI Clinical Programme on HCAI/AMR Dr Rob Cunney visited the hospital. He reported to senior HSE management about “issues relating to resources, clinical and corporate governance, and cross-divisional governance that appear to be contributing to the ongoing outbreak”.
The report by Dr Cunney and a colleague, dated July 2015, described how “the current CRE outbreak in UHL and surrounding areas is already a major patient safety issue”. The report noted that there had been 87 cases of CRE colonisation detected at UHL, of which 22 had resulted in CRE infection, with at least two deaths related to CRE infection.
The outbreak was being sustained due to transmission in community settings, with further transmission in UHL facilitated by infrastructural, staffing and procedural issues. The infection prevention and control team at UHL had made huge efforts to put in place control measures and their workload was “immense”.The report also referred to high levels of broad spectrum antibiotic use and “lack of ownership” of the CRE response by clinicians and senior management.
It noted that the extent of CRE may be underestimated across other acute and non-acute settings due to limitations in surveillance and screening in line with national guidance. In response to the paper, CEO of UL Hospitals Group, Prof Colette Cowan outlined the measures taken to date and said it continued to “utilise every opportunity to stem the spread of CRE”.
*After the Medical Independent (MI) went to press, the HSE provided the following comment on when growing concerns about CRE were escalated to HSE DG Mr Tony O’Brien: "The National Directors of Health and Wellbeing and Acute Services proposed, on behalf of the National HCAI/AMR Taskforce, the need for a national coordinated response to CPE outbreaks at the January meeting of the Leadership Team. A paper prepared by the Clinical Programme for HCAI/AMR in December 2016 informed these discussions.
“The Leadership Team requested a detailed report on the actions required to address CPE in the healthcare system, along with relevant costings, for consideration at a further Leadership Team meeting. A report outlining a series of priority actions was presented to the Leadership Team at their meeting in March 2017. This proposed response was approved subject to some further work on costings.”
Clinicians are describing the spread of carbapenem-resistant Enterobacteriaceae (CRE) in Ireland’s acute hospital system in such unequivocal terms.
Recent outbreaks of gram-negative bacteria resistant to the carbapenem class of antibiotics – the ‘drugs of last resort’ for life-threatening infections – have seriously impacted several acute hospitals and long-term care facilities (LTCFs) in Ireland.
The CRE subset carbapenemase-producing Enterobacteriaceae (CPE) – which are Enterobacteriaceae non-susceptible to carbapenem via production of a carbapenemase enzyme, and are of huge concern globally – have been implicated in Irish and international outbreaks. These carbapenemases include Klebsiella pneumoniae Carbapenemase (KPC), Verona Integron-encoded Metallo-β-lactamase (VIM), Oxacillinase-48-type carbapenemases (OXA-48) and New Delhi Metallo-β-lactamase (NDM).
On 24 August 2016, Tallaght Hospital notified a CRE outbreak to the HSE Department of Public Health-East. This CRE outbreak has constituted Ireland’s largest to date and involves OXA-48 CRE. In November 2016, an internal HSE document described the scale of the outbreak as “unprecedented” in Ireland. In the 18 months to February 2017, Tallaght says it treated 528,077 adult patients – 142 of whom were identified as carriers of CRE. Most affected patients were aged in their seventies, the Medical Independent (MI) understands.
Since 2015 there have been three invasive cases and no deaths “directly attributable” to CRE, according to the hospital. Cases are still occurring but the hospital says they have reduced substantially.
In December 2016 an outbreak of VIM CRE was notified by Mayo University Hospital (outbreak status has been since ‘stood down’). There were 11 colonisations and five invasive CRE cases over a period of 27 months, according to the Saolta University Health Care Group. Two patients died where CRE was identified as a contributing factor to their death. “None of them were acquired in Mayo University Hospital. The first case in 2014 with sepsis and the second case in November 2016 with multi-organ failure,” said the spokesperson.
In January 2017 St Luke’s Hospital, Kilkenny notified a “small contained outbreak” in a surgical ward (“it has ended”, stated Ireland East Hospital Group). University Hospital Waterford also experienced an outbreak in 2016, involving OXA-48 and NDM CRE, while an increase in CPE incidence is under investigation at St James’s Hospital Dublin as of March 2017.
Sporadic KPC CPE cases have continued to be identified in the midwest, where CRE may have become endemic (see panel page 5). There are also two LTCFs actively dealing with outbreaks: one in the northwest and the other in west Dublin. The latter is directly related to the Tallaght Hospital outbreak. Various types of CRE have circulated and not all of the recent outbreaks in Ireland would be inter-related.
Confirmed CPE cases have increased almost 10-fold from 2013 to 2016, according to statistics from the National Carbapenemase Producing Enterobacteriaceae Reference Laboratory(48 confirmed CPE cases in 2013; 81 in 2014; 140 in 2015; and 369 in 2016).CRE outbreaks in Irish healthcare have principally involved colonisation (typically termed ‘CRE cases’); yet carriers serve as a reservoir that facilitate proliferation and increased risk of infection. Healthy people colonised with CRE would not usually suffer ill-effects. However, vulnerable patients in hospitals and other care facilities are at risk of bloodstream infection, particularly those requiring invasive medical devices, and CRE invasive infection is associated with mortality of over 50 per cent. In Ireland there have been deaths associated with CRE. The HSE, however, did not respond conclusively on a query as to whether it held such figures.
Records obtained by MI following a Freedom of Information (FoI) request to the HSE show that major manpower deficits, insufficient infrastructure and equipment, and a highly under-resourced and uncoordinated national response, brought Tallaght Hospital to the brink of effective closure as an acute care service.
The documentation also revealed laborious and complicated reporting lines within the upper echelons of the HSE and acute hospital network, limiting the capability for urgent and effective response.
Some three weeks after notification of the outbreak, Minister for Health Simon Harris was moved to ask Department officials – in an email sent on the night of 14 September – to find out “if there is an outbreak” of CRE at Tallaght Hospital. The hospital did not inform the Dublin Midlands Hospital Group (DMHG) about the outbreak until 14 September.
On 16 September, a note came through to the Department of Health, via HSE Acute Hospitals, from the Group. Two adult wards had been closed to admissions, the Group stated, and this would have a “temporary impact” on bed availability and elective admissions at the hospital.
Yet the impact at Tallaght was anything but temporary. Over the coming weeks, the hospital faced a huge battle to contain the rapidly evolving crisis. The hospital stated that there were eight CRE cases in August 2016; this rose to 31 in September (and one invasive case) and 37 in October. In November, there were 25 cases (and one invasive case), 11 in December and nine in both January and February. Thousands of screenings have been undertaken: 9,891 from August 2016 to February 2017 inclusive, hitting a peak of 1,929 in November.
‘Major patient safety issue’
Irish health authorities have been well aware of the threat posed by CRE for several years, but it has not been high on an agenda dominated by more visible and relatable problems such as the trolley crisis and long hospital waiting lists. However, leading figures in Irish microbiology warn that this country is fast running out of time.
Dr Eleanor McNamara, President of the Irish Society of Clinical Microbiologists (ISCM), said the window of opportunity to stop CRE from becoming endemic in the hospital system is “diminishing rapidly”. The Society wrote to Minister Harris in July and October of 2016 requesting a meeting to discuss, update and advise him on the threat posed by CRE and risk mitigation interventions, but this request has not yet been realised.
Dr McNamara said there were recent ongoing outbreaks which were “nearly crippling” acute services. She said outbreak incidents can effectively “bring a hospital to its knees, and affect its ability to deliver the acute services that it is mandated to do”.
She added: “Overall, this is a major patient safety issue. As one of my colleagues had said, if we had an outbreak of blood-borne virus infections, acquired in hospitals, there would be a national outcry, and yet here we are having healthcare-associated infections occurring with an almost untreatable organism, and there isn’t an emergency national outbreak team being pulled together with dedicated resources.”
Dr McNamara emphasised that a longer-term strategic focus in parallel to an emergency response is equally as important. A national action plan on antimicrobial resistance (AMR) that is resourced, actioned and auditable is also an essential requirement, added Dr McNamara.
“We have had emergencies, like a few years ago, with Ebola and novel strains of influenza, and everybody knew about it. And plans were implemented. However, CRE is a global emergency of even greater significance in some respects than Ebola, because it is affecting everybody now – in health sectors across the world – and basically we are not getting that level of energy, attention and focused reaction to it,” said Dr McNamara.
“We need to have coordinated action – unfortunately at the moment it is all very uncoordinated,” added Dr McNamara on the current national efforts.
Prof Martin Cormican, Professor of Bacteriology at NUI Galway, told MI that “if we are to have any chance of controlling this, we need much more effective leadership from the Minister for Health and the Department of Health than we have seen to date”.
A number of Irish hospitals experiencing major outbreaks have “managed to limit spread” but at “considerable cost and disruption of service”.
More broadly, measures taken to date to control CPE “have not been effective overall”, he said.
“Although spread in hospitals is almost certainly the biggest problem at present, there has been spread in some nursing homes and it is likely that spread in homes and in the wider community and the environment are likely to become increasingly common as the problem continues to spiral out of control.”
Consultant Microbiologist Dr Rob Cunney, Clinical Lead for the HSE/RCPI Clinical Programme on Healthcare Associated Infections (HCAI) and AMR, agrees with colleagues that an urgent response is needed to prevent CRE becoming endemic, certainly in the hospital system. The problem requires “a properly focused and resourced response”, along the lines of that adopted in Israel some years ago, when local measures failed.
A HSE spokesperson told MI there is a “work plan” produced by its Multi-Drug Resistant Organisms Taskforce [aka AMR/HCAI Taskforce] and a “proposal” to the HSE senior management team around “resource requirements for addressing CRE”. A national action plan on AMR is also being developed by the Department of Health and the Department of Agriculture, Food, and the Marine.“[CRE] is something that is being taken very seriously by the [HSE] Leadership Team, much more than we have seen before. I am hoping that will translate into a properly resourced response,” Dr Cunney commented.
Communication
The crucial importance of clear lines of communication and escalation, and prompt access to emergency resourcing at a national level, are writ large when surveying the Tallaght crisis.
Several weeks after the outbreak notification, on 9 November 2016, a HSE Public Health report described Tallaght Hospital as “overwhelmed”.
It stated: “The hospital has been overwhelmed by this organism and efforts to contain it have been hindered by the contagiousness of this plasmid, the prolonged duration of colonisation, the inadequate number of single rooms, the lack of dedicated equipment, the inadequate [number of] clinical microbiologists, laboratory staff, infection control nurses and general nursing staff…”
Many hospitals throughout the country “have even fewer resources to deal with a situation like this and the country as a whole is extremely vulnerable”, it added.
In the early days following outbreak notification, finding funding for replacement mattresses for those that failed an audit was proving difficult. It was also recommended that dedicated staff provide care for CRE patients but this was “not possible due to financial and staff shortages”, according to a report from the HSE Department of Public Health-East on 23 September. Some agency staff were also refusing to work at Tallaght Hospital.
Remit
There are numerous entities involved in tackling AMR/HCAI, but no single responsible body with a clear, and adequately resourced, lead operational remit in the case of outbreak.
The HSE’s Multi-Drug Resistant Organisms Taskforce does not have an operational role in response to outbreaks. The HSE/RCPI Clinical Programme, clinically led by Dr Cunney, devises quality improvement projects focused on hand hygiene, device related infection and antibiotic stewardship.
The HPSC is responsible for coordinating national surveillance of CRE (including CRE outbreaks), and providing operational support for the management of outbreaks where required. HSE Departments of Public Health are responsible for coordinating regional surveillance, providing operational support for management of outbreaks or, in some cases, leading outbreak control teams depending on the outbreak setting.
The Clinical Programme sits under the HSE Quality Improvement Division, while the HPSC and public health departments are under the remit of the HSE Health and Wellbeing Division.
The HSE said there are two separate reporting mechanisms in the public hospital network for escalation of CRE outbreaks. Firstly, all hospital outbreaks are required to be notified to the local HSE Department of Public Health and, from there, to the HPSC. Secondly, hospitals and community healthcare institutions “can escalate issues relating to CRE, or other HCAI, via the HSE Accountability Framework” (eg, from hospital to Hospital Group to HSE Acute Care Division to HSE Senior Management Team). Therefore, in the case of a hospital outbreak, the corporate line of accountability runs from the hospital CEO/general manager reporting to the CEO of the Hospital Group reporting to the divisional lead of Acute Hospitals.
Neither the HSE National Office for Health and Wellbeing nor Quality Improvement Division have a formal role in the escalation or reporting of outbreaks, according to the HSE. By press time, the HSE had not confirmed when Director General Mr Tony O’Brien was informed of the Tallaght Hospital outbreak by HSE managers*.
‘Not under control’
On 22 September 2016, just over a week on from Minister Harris’s internal Department enquiry as to whether there was an outbreak at Tallaght Hospital, Consultant Microbiologist at the HPSC Dr Karen Burns informed senior HSE managers: “We all need to be clear that this outbreak is not under control.”
The hospital was detecting approximately one new patient per day, with around 40 patients to date and 14 inpatients affected at the time of Dr Burns’s note. It was likely to “go on for a protracted period of time” and there was a “significant risk that a similar situation to Limerick is likely to evolve, whereby screening will continue to detect patients returning to the hospital who picked up CRE on an earlier admission”.
Dr Burns made reference to stretched manpower in crucial areas at Tallaght Hospital and in the HPSC, which has only 0.5 WTE consultant microbiologists (the recruitment process is still “ongoing” for a 0.5 WTE consultant microbiologist to cover a seconded staff member, according to the HSE. The HPSC is also still attempting to fill the position of Director following the retirement of Dr Darina O’Flanagan in May 2016).
In his reply to Dr Burns, and HSE colleagues, HSE Director of Quality Improvement Dr Philip Crowley said the situation showed “how thin the national resource is in this area”.
After visiting Tallaght Hospital, Dr Burns reported on 27 September that there were 16 inpatients with known CRE: nine were accommodated in a ward that was fully single en-suite and six were in isolation on a second ward.
“One patient was transferred to ICU last night and is being treated for CRE infection. Contacts of known CRE cases are being screened for CRE carriage. There are approximately 47 confirmed patients with CRE in the year to date…we suspect that this issue may have started in the hospital during Q4 2015 and grumbled on at a low level, prior to being identified and notified as an outbreak this August.”
Throughout the crisis, there appeared to be a complicated chain of escalation and information sharing among senior HSE management. On 28 September, for example, Director of Health and Wellbeing Dr Stephanie O’Keeffe, referred to “a lot of traffic on this and need to be careful it is being directed in the right way”.
On 5 October, Dr Burns of the HPSC reported to senior HSE management of further concerns following a visit to the hospital. She wrote that there was nothing to indicate to the general public visiting the hospital that there was an ongoing outbreak. “There has been no formal media communication from the hospital to advise people to attend only if absolutely necessary,” she added. Moreover it was not always clear to healthcare professionals, including doctors, which patients had CRE.
On 27 October, as the hospital examined alternatives to ensure patients could access scheduled care, a CRE Outbreak Meeting at Tallaght Hospital – which included hospital management, HSE, DMHG and HPSC representatives – heard that private hospitals had raised concerns regarding accepting CRE patients. It was also noted at this meeting that “other hospitals are not following national guidelines”, which MI understands as a reference to the Guidelines for the Prevention and Control of Multi-drug resistant organisms (MDRO) excluding MRSA in the healthcare setting, which outlines screening protocols.
At this meeting, CEO of the hospital Mr David Slevin advised of the need to screen five nursing homes (as of mid-March 2017, the HSE has commenced screening in one of these nursing homes. Tallaght Hospital’s laboratory has facilitated this by processing the samples).
The HSE Public Health report of 9 November 2016 noted that there had been 79 cases of CRE at Tallaght Hospital from July to the end of October 2016 (and 91 in total for 2016). There were 32 CRE positive inpatients on six wards, all in isolation as of 9 November, according to the HSE document. Furthermore, there were 52 CRE contacts cohorted on 12 wards. Eight beds were blocked due to cohorting of CRE contacts.
The HSE report noted that many patients had tested positive for more than one OXA-48-like positive bacterial species. “As a result there is no defined bacterial species or antiobiogram associated with this outbreak which hindered the initial recognition of the situation.” Another characteristic that contributed to the spread “was the time taken for contacts to become culture positive which can take up to four weeks”. Of the CRE cases when first positive samples were taken (January 2015-October 2016), most were on the Crampton, Gogarty and Lynn wards. Five were in the ITU and four in the CCU.
The infection control nurse staffing levels were 3.3 whole-time equivalents for 430 beds. They were at “breaking point”, according to the HSE document, and there did not appear to be qualified staff available to hire. The hospital had just 1.7 WTE consultant microbiologists. Furthermore, the most recent hand hygiene audits for September 2016, during the outbreak, did not achieve 90 per cent compliance (the HSE-mandated KPI).
There had been instances of more than three days to isolate a CRE patient, while there were regularly more than 10 beds blocked due to cohorting and isolation and, on one day, 45 beds were blocked. Moreover, while weekly screen of high risk patients (ICU, haematology, oncology, renal, dialysis, major GI or vascular surgery, trauma and orthopaedics) was recommended as a control measure “it is not yet in place for all areas due to the burden of testing”.
According to the report, the only way to prevent the spread of CRE nationally would be to follow the Israeli example (Schwaber et al, 2011) of a “properly funded national taskforce along with a plan and the funding to improve the national hospital infrastructure and bring it in line with HIQA standards for the prevention of healthcare associated infections”.
‘National concern’
By the middle of November, it appeared that HSE Acute Hospitals was managing to commit to, and coordinate, a number of measures to assist Tallaght, and the exhaustive efforts of key hospital staff were making some headway. The DMHG said its management team “helped secure funding for essential diagnosing equipment and works”.However, towards the end of 2016, Mayo University Hospital notified an outbreak involving a different type of CRE.
On 19 December, in an email to HSE Director of Health and Wellbeing Dr O’Keeffe, Director of Quality Improvement Dr Crowley and Director of Acute Hospitals Mr Liam Woods, and colleagues, Dr Burns of the HPSC described the “evolving situation” in Mayo as highlighting that “CRE is a public health emergency of national concern”.
Dr Burns was providing advice to the hospital’s recently appointed consultant microbiologist.
The outbreak may have begun much earlier than the date it was notified to Public Health on 2 December, she reported. There had been cases in the ICU, orthopaedic ward, a medical ward, a paediatric case and a dialysis patient. Screening had been limited to the ICU, haematology and oncology, with resourcing issues involved. "It is a VIM type, which is unusual in Ireland to date and indicates that there may be a significant local VIM problem which has evolved unchecked,” wrote Dr Burns.
Meanwhile, by early 2017, CRE remained an ongoing concern at Tallaght Hospital. According to the hospital, the HSE made a “significant contribution” to its additional funding requirements to manage this situation in 2016. Discussions to provide additional funding for 2017 are ongoing with the HSE.
Tallaght Hospital said it had two WTE consultant microbiologists in early August 2016, increasing to 2.7 later that month. Troublingly, the current figure is “temporarily” at 1.8 WTE “due to a full-time retirement”, with a replacement due to begin in June. “A consultant working 0.1 WTE has been appointed to help with clinical work and antimicrobial stewardship.”
The number of WTE infection control nurses in August 2016 was 3.3 and is now 4.1, according to the hospital.
Tallaght Hospital now has two molecular systems running for the detection of CRE – the Genexpert system, which gives a result in about an hour, has been used for new patient admissions since 28 November 2016. The Flowflex system, which can process 96 samples every five hours, has been run every day at a set time since 19 December 2016 “as part of routine screening of patients”.
The hospital requires specialised software to manage hospital infections and is using a temporary in-house IT solution for tracking CRE cases. It also “has plans to develop a new 72-bed unit, which will assist staff in managing such infections in the future”.
Prescribing
MI understands that Tallaght Hospital has high use of third generation cephalosporins, fluoroquinolones and carbapenems. Experts agree that appropriate antibiotic prescribing is a key feature of tackling AMR. Some hospitals have invested more than others in antimicrobial stewardship, noted Dr Cunney of the Clinical Programme.
In May, the HPSC will coordinate a national point prevalence survey (PPS) of hospital-acquired infections and antimicrobial use, as part of a European-wide PPS. The recently published PPS for LTCFs found that, of 10,044 LTCF residents who were counted, some 981 were prescribed antibiotics.
Dr Cunney said there are high levels of antibiotic use in Irish nursing homes, and the indication is often not clear. He emphasised the need for establishment of resourced antimicrobial stewardship teams in the community.
At the ISCM, Dr McNamara agrees that both stewardship teams and consultant microbiologists overseeing infection control/AMR activities in the community are badly needed.
Dr McNamara also underlined that Ireland needs to develop its eHealth national capabilities urgently. She said it was difficult to fathom that national e-prescribing is not in place in the acute hospital system, given its capability of real-time monitoring of antibiotic prescribing and the wider issue of reducing medication-related errors.
Dr McNamara said patients are being transferred between acute hospitals and also from primary care settings without knowledge of their CRE carrier status. She said it is essential to find out which patients are affected by CRE.
“However the whole issue of CRE screening is challenging, labour intensive and costly,” she continued. “The laboratories haven’t been resourced for it, and methods are complex. The logistics of identifying the patients for screening, then resourcing to do the screen, and communicating of the results, particularly across hospitals, is really difficult.”
A national electronic healthcare record (EHR) would assist significantly with surveillance and management of issues such as CRE, the HSE’s Chief Information Officer Mr Richard Corbridge told MI. The EHR business case is still with the Department of Health for consideration after approval by the HSE last summer.
Response
In response to the increased incidence of CRE in Ireland and associated outbreaks during 2016, voluntary enhanced CRE surveillance scheme was discontinued at the end of last year. Effective from January 2017, all Irish microbiology labs are required to report information directly to the HPSC on a quarterly basis (the HPSC will be publishing quarterly reports).
Meanwhile, HIQA intends to “continue to closely monitor this situation during 2017, through the undertaking of a revised approach to monitoring against the National Standards for the Prevention and Control of Healthcare Associated Infection and we will be publishing a guidance document on this in the coming months”.
Longstanding CRE problem in midwest
A “particular problem” with CRE exists in the midwest region “at large”, which is reflected in the hospital population, according to the HSE. There were 31 new CRE detections across the UL Hospitals Group in 2016, and no invasive bloodstream infections, stated the Group. There were 60 new CRE detections across the Group during 2015.
“With large ‘Nightingale’ wards the norm in the older parts of the building, managing contacts between patients carrying CRE and others remains a challenge.”
The UL Hospitals Group refurbished an inpatient ward at a cost of €400,000 to facilitate an infection prevention and control “cohort ward”; it refurbished another ward, at a cost of €300,000, at UHL due to infection prevention and control “concerns”, including replacement of infrastructure such as sinks; it says it has also invested in additional cleaning and deep cleaning measures.
“ULH has developed a quality improvement plan in regard to CRE, which incorporates much of the NHS Toolkit for the Control of CRE 2013. This includes an intensive screening programme; use of an isolation ward for newly detected or known positive patients to reduce the risk of cross-transmission; flagging all CRE positive and CRE contacts through the management, surveillance and reporting software ICNet; and reporting new cases appropriately through the microbiology team.”
More complex antibiotics are referred to the microbiology team before being prescribed, says the Group. Nevertheless, there have been concerns expressed about management of CRE at UHL. In summer 2015, Clinical Lead for the HSE/RCPI Clinical Programme on HCAI/AMR Dr Rob Cunney visited the hospital. He reported to senior HSE management about “issues relating to resources, clinical and corporate governance, and cross-divisional governance that appear to be contributing to the ongoing outbreak”.
The report by Dr Cunney and a colleague, dated July 2015, described how “the current CRE outbreak in UHL and surrounding areas is already a major patient safety issue”. The report noted that there had been 87 cases of CRE colonisation detected at UHL, of which 22 had resulted in CRE infection, with at least two deaths related to CRE infection.
The outbreak was being sustained due to transmission in community settings, with further transmission in UHL facilitated by infrastructural, staffing and procedural issues. The infection prevention and control team at UHL had made huge efforts to put in place control measures and their workload was “immense”.The report also referred to high levels of broad spectrum antibiotic use and “lack of ownership” of the CRE response by clinicians and senior management.
It noted that the extent of CRE may be underestimated across other acute and non-acute settings due to limitations in surveillance and screening in line with national guidance. In response to the paper, CEO of UL Hospitals Group, Prof Colette Cowan outlined the measures taken to date and said it continued to “utilise every opportunity to stem the spread of CRE”.
*After the Medical Independent (MI) went to press, the HSE provided the following comment on when growing concerns about CRE were escalated to HSE DG Mr Tony O’Brien: "The National Directors of Health and Wellbeing and Acute Services proposed, on behalf of the National HCAI/AMR Taskforce, the need for a national coordinated response to CPE outbreaks at the January meeting of the Leadership Team. A paper prepared by the Clinical Programme for HCAI/AMR in December 2016 informed these discussions.
“The Leadership Team requested a detailed report on the actions required to address CPE in the healthcare system, along with relevant costings, for consideration at a further Leadership Team meeting. A report outlining a series of priority actions was presented to the Leadership Team at their meeting in March 2017. This proposed response was approved subject to some further work on costings.”
Irish medicine and the House of Saud
Medical Independent
8 December 2016
The activities of Irish postgraduate training bodies in countries with poor human rights records, notably Saudi Arabia, are prompting questions within the medical profession.
Catherine Reilly reports
The surgeon is depicted in theatre making an incision. The scene moves to her office where certificates adorn the walls. Her phone vibrates with a message: “Invitation to speak at a cardiac conference in London”, it reads.
She types a text while sitting at her desk: “Son, please grant me permission to travel.” At home on the couch playing a computer game, her son responds: “I don’t feel like it. I’m busy.”
Human Rights Watch (HRW) produced this animation arising from its investigation into Saudi Arabia’s male guardianship system, which imposes a range of legal and societal restrictions on women. Under Saudi law, women must obtain permission from a male guardian to travel abroad.
One wonders, though, if this really extends to a senior medical professional; a distinguished surgeon? “Yes, the travel restrictions are imposed on all women,” Dr Hala Aldosari, a Saudi women’s rights activist and social affairs expert, informs the Medical Independent (MI).
Women also cannot study abroad on a government scholarship without guardian approval and, while not always enforced, “officially require a male relative to accompany them throughout the course of their studies”, according to HRW’s in-depth investigative report into the male guardianship system, Boxed In, which was published in July.
The system includes measures not in law or regulation but tacitly permitted by government, such as guardian permission for women to work. There are no penalties for employers who impose this restriction, says HRW.
Damning
Saudi Arabia has made “a series of limited changes” over the last 10 years to ease restrictions on women, such as allowing them to participate in the country’s “limited political space”, states HRW. However, these reforms are “partial and incomplete”.
The country’s human rights record is disturbing: Minors are on death row; homosexuality is illegal; women are not legally permitted to drive. The most elementary freedoms are shorn bare.
“On the basic rights, expression, peaceful assembly, peaceful association, I mean, their record couldn’t possibly be worse,” Mr Adam Coogle, Middle East Researcher at HRW tells MI. “All dissidents pretty much get locked up; you are not really free to form associations; public demonstrations are banned and people are prosecuted for doing them. So, in terms of those basic rights, there is absolutely nothing on the horizon that would suggest that Saudi Arabia is changing its position.”
A harsh form of Sharia law is imposed in Saudi Arabia, where over 150 executions are reported to have taken place in 2015 including for nonviolent drug crimes. Beheadings are the most common form of execution. Allegations of a flawed justice system are recurrent.
Presently, a military coalition led by Saudi Arabia stands accused of unlawful and deadly airstrikes on markets, hospitals and schools in Yemen.
The travel advisory for Saudi Arabia on the website of the Irish Department of Foreign Affairs and Trade has a distinctly dystopian feel. “Under Saudi Arabia’s customs, in the event of a marriage to a Saudi national, the family has strong power over the individual. If a woman wants her right of movement or to work guaranteed, she must insist on a premarital settlement, stipulating this right,” is one of many jarring sections.
Nevertheless, Ireland and Saudi Arabia have diplomatic relations. Saudi Arabia is a “designated priority market for Ireland” under this country’s trade, tourism and investment strategy, Minister for Foreign Affairs Charlie Flanagan recently told the Dáil.
Irish medicine has set its sights on Saudi Arabia, too.
‘Global presence’
International linkages and partnerships are viewed as important by Western medical training colleges, notably for financial reasons. Like counterparts elsewhere in Europe, and in North America, Irish postgraduate medical colleges continue to develop partnerships internationally, including in countries with dubious human rights records – such as Saudi Arabia.
The RCPI’s Strategic Plan 2015-2020 cites the development of a “global presence” as one of five strategic aims. The College’s 2015/6 annual report said that “strong relationships” were developing at “governmental and institutional level” in Malaysia, India, Saudi Arabia, Oman, Kuwait, Bahrain, and the United Arab Emirates.
It reported that a “high-level” Memorandum of Understanding (MoU) was signed between the RCPI and a Saudi governmental body called the Saudi Commission for Health Specialties to develop a “Joint Residency Training Programme”.
“It is proposed that this programme will be delivered partly in the Kingdom of Saudi Arabia and partly in Ireland. Participants take both the Saudi Board examinations and the MRCPI examinations and the programme will be recognised by both the Saudi Commission and RCPI,” stated the annual report.
Already, some overseas doctors including from Saudi Arabia are sponsored by their governments to train in Ireland under the auspices of RCPI and other postgraduate institutions through the International Medical Graduate (IMG) Training Initiative.
Many will be practising medicine in an altogether new environment.
The Saudi Commission for Health Specialties is responsible for supervising and evaluating training programmes in Saudi Arabia, as well as setting “controls and standards” for the practice of health professions in the country. Some stipulations in the Commission’s Professionalism and Ethics Handbook for Residents (2015) significantly conflict with guidance on medical ethics in Ireland.
According to the guide, the availability of safe and easily obtainable contraception “removes the fear of pregnancy and encourages sexual promiscuity and temporary sexual unions devoid of childbearing responsibilities”. The physician “must exercise due judgment before prescribing contraceptives to make sure that there are no immoral consequences”.
It continues: “Widespread use of contraception in the community has other undesirable consequences. Population imbalances by age and by gender may result. Widespread acceptance of contraception is a slippery slope that may make it easier for the community to accept genocide due to decreased respect for human life.”
A Medical Council spokesperson tells MI that doctors coming to work and train in Ireland under these programmes are registered in the Supervised Division and must meet “strict criteria”. The Council has established guidelines for employers of doctors registered in the Supervised Division in supervised posts. According to these guidelines, there should be a programme of orientation and induction for doctors newly registered in the Supervised Division. The programme should include an introduction to the Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners.
Dangerous liaisons?
Writing recently in MI (‘Stand up and fight’, 16 November 2016), Consultant Gastroenterologist Dr Anthony O’Connor stated that “we again need to question why Irish medical training colleges, registered charities who by act of Government command the compulsory membership, subscription, and patronage of all Irish doctors, are engaging with governments in countries like Bahrain and Saudi Arabia”, due to their very poor human rights records and state interference with the practise of medicine.
“Quite where engaging with these regimes fits into their missions is beyond my understanding. The Colleges of Physicians and Surgeons have proven themselves in the domestic and international realms in recent years as being progressive, innovative and thoughtful institutions, taking on admirable public health work and developing their educational facilities to a standard unimaginable a short time ago….
“Regarding international engagement, if this is desirable then there are vast tracts of the developing world that would benefit from their expertise without plying the wares of Irish medical training in countries richer than we could ever hope to be.”
Dr O’Connor’s commentary was typically robust and composed. However, while there are many doctors who share his concerns, few wish to raise their heads above the parapet.
Dr Ronan Collins, Consultant in Geriatric and Stroke Medicine, is an exception. He feels strongly about the situation.
“A lot of the colleges have been struggling for funding, and seeking new funding opportunities, and some of those funding opportunities are about offering educational opportunities abroad to other governments,” he tells MI. “I suppose you could be very purist and say, what government would be acceptable? Should we deal with India, for example, that has a caste system; should we deal with China, which has its own problems with human rights?”
Given factors such as Saudi Arabia’s wealth, extremely poor human rights record, its conduct in Yemen and support for fundamentalist groups, he has “huge discomfiture” about the situation. His concern has nothing to do with the training of doctors who happen to be Saudi Arabian, but the nature of the governmental regime with which the RCPI is engaging, he explains.
“I would very firmly be not in favour of this, full stop. Well, actually, that is not true. If Saudi Arabia agrees to implement the UN charter of human rights fully, then I am fully in agreement with it. Until then, I am not.”
Dr Collins continues: “The problem is when I raised this with colleagues, most colleagues didn’t know. And I think there is a big disconnect between the business arm of the College and, if you like, the academic, medical arm of the College.”
He acknowledges that doctors under the College’s jurisdiction are “duty bound to read the annual report”, which references its agreement with the Saudi Commission for Health Specialties and other international initiatives. Nevertheless, he believes further information should be published by the RCPI.
“I would like to know, for example, how much money we have taken, and where has it come from [within the Saudi government]? I think that should be public knowledge.”
Principles
He acknowledges that there is no embargo with Saudi Arabia and the two countries have huge business ties in agriculture and the equine industry. “But medicine is different. I am very uncomfortable with the notion that the College would take funding from a government that would routinely stone women, and punish and execute people because they are gay.”
Medicine occupies “a different space” and “has to worry about human rights”.
MI understands that concerns have been raised internally by doctors within RCPI. This newspaper contacted for comment the three candidates for RCPI President – Prof Hilary Hoey, Prof Conor O’Keane, and Prof Mary Horgan- but none had responded by press time.
A motion carried at this year’s IMO AGM reflected the concern doctors feel about some of the partnerships their colleges are entering into.
The motion from the IMO Consultants Committee called on RCPI and RCSI to ensure that “funding received from overseas governments in support of postgraduate training of doctors does not legitimise regimes that actively support international terrorism, sectarianism, misogyny, homophobia or have laws enshrining such ideals”.
A spokesperson for RCPI told MI: “The College has a long involvement in providing medical training and education in Ireland and other countries including Malaysia, Oman, Zambia, Saudi Arabia and India. Many of our Members and Fellows will have worked and trained in many other countries around the world bringing that expertise back to benefit the Irish health system. RCPI’s focus overseas is to improve health care provision, through the delivery of training programmes and examinations. International Medical Graduates training with us are doing so in specialties in which there is a recognised deficit in their home country, and each doctor is contracted to return to their home country upon completion of training to develop and deliver services in their communities.
“It has been the position of the College over many years that where we believe that we can make a difference to the quality of care to the people of these countries, we will do so. We are not alone in this and many other Irish organisations have taken the same approach.
“Our overseas activities include the provision of examinations, training, training consultancy programmes and Continuing Professional Development activities.”
The Joint Residency Training Programme with Saudi Arabia is scheduled to commence in 2017. “The primary focus of the MoU is the structure of the training programme, curriculum, rotations, assessments and certification requirements. Participants will undertake their training on the same basis as all other national and international doctors currently in training in Ireland,” said RCPI’s spokesperson.
“Doctors in training in Ireland under the Joint Residency Training Programme will be provided with the same clinical training that is currently provided to all RCPI SHOs. All of these activities will lead to improved healthcare provision for the citizens of these countries.”
RCPI provided figures in respect of doctors enrolled in the International Clinical Fellowship Programme, which sits under the IMG Training Initiative. “We currently have 46 trainees on this Programme; 22 males and 24 females.”
Specific questions on the financial aspects of the training programmes, and whether the MoU with the Saudi Commission for Health Specialties included any human rights principles including access for women and employment opportunities for women during and post-training, were not answered. In addition, RCPI did not comment on whether other agencies of the Saudi government sponsored trainees.
RCSI
Down the road from Kildare Street, on Stephen’s Green, the RCSI has been engaged in work in Saudi Arabia for a number of years. Most recently, its School of Nursing and Midwifery received a delegation from the King Abdullah Medical City (KAMC), Saudi Arabia.
During the visit in May, Prof Hannah Magee, Dean of the Faculty of Medicine and Health Sciences, signed a MoU on behalf of RCSI with regard to the provision of postgraduate education to KAMC’s 1,000-strong nursing workforce.
“The School will be providing MSc and Postgraduate Diploma programmes in areas such as wound care and tissue viability, respiratory nursing and a range of clinical specialities. Prof Zena Moore and her team will be commencing the provision of these programmes in the academic year 2016/17,” stated the RCSI website.
In 2014, RCSI Bahrain’s School of Nursing and Midwifery “successfully completed a BSc Bridging programme with Saudi Aramco and Johns Hopkins”.
Also in 2014, RCSI’s Institute of Leadership announced that it had won a competitive tender to provide 46 training workshops over the following twelve months in Riyadh and Jeddah. “Over the past 18 months, the Institute has established a positive working relationship with the Central Board for Accreditation of Healthcare Institutions (CBAHI), a department of the Ministry of Health in Saudi Arabia that accredits all 5,000 healthcare organisations in the Kingdom. The Institute has also formed a successful partnership with Knowledge Source Centre (KSC), a healthcare training organisation, based in Riyadh,” according to the announcement on the RCSI’s website.
MI put a number of questions to RCSI on these initiatives.
For example, MI asked RCSI whether it insisted on any human rights principles in its MoU with KAMC, in respect of dress code, freedom of expression, access to further education/employment opportunities and indiscriminate treatment of patients irrespective of their gender, sexuality, and marital status.
The MoU is “ongoing” and the College does “not comment on the details of such MoUs or agreements”.
“Our primary responsibility is to contribute, by providing a high-quality education, based on internationally recognised ethical principles in a safe and supportive environment, allowing students and trainees in Ireland and internationally to reach their potential and maximise their opportunities,” stated RCSI’s spokesperson.
Meanwhile, as part of the IMG Training Initiative, there are 29 doctors undertaking training in Ireland in conjunction with RCSI. There are 23 male trainees and six female trainees; they come from Pakistan (24) and Saudi Arabia (five). “All are in Ireland with the support of relevant government agencies in their home country,” said RCSI.
Asked what government agencies were sponsoring the Saudi trainees and how many were female, RCSI’s spokesperson said it had “no further comment”.
RCSI’s most controversial foray internationally has been the establishment of its multi-million campus in Bahrain. Its medical school depends on clinical training sites that human rights activists allege discriminate against political activists, as well as patients and healthcare professionals from the Shia majority.
In 2011, the medical press reported that senior staff at the RCSI Bahrain “asked three medical students attending its college to swear an oath of loyalty to the Bahraini Royal Family and to sign a declaration that they would not participate in further protests” against the Bahraini government. Subsequently, RCSI issued an unreserved apology for this incident.
RCSI has always emphasised its role as a specialist health sciences institution and even maintained that it is employing ‘soft power’ or seeking to exert influence behind-the-scenes. But even some of those who believe RCSI was right to remain in Bahrain feel that there is more it could do – and say – publicly.
RCSI and RCPI also undertake Membership exams internationally, including in the Middle East. Both Colleges were keen to emphasise their philanthropic endeavours in developing world countries, of which there are many fine examples.
‘Meaningful’
Dr Aldosari, the Saudi women’s rights advocate, tells MI that “meaningful engagement” in training health workforces “according to universal standards is rewarding more than refraining from interaction”.
Colleges must be mindful to ensure that issues such as gender-based discrimination, patients’ rights, and social determinants of women’s health are imparted to Saudi doctors during this training, she outlines. “This is crucial,” she says.
Dr Aldosari says Irish doctors and healthcare providers can influence the next generation of Saudi physicians and healthcare providers by showing them the potential of working in gender equal environments in practice.
The number of female doctors in Saudi Arabia is low, she says, and they usually practice in areas where most of their encounters are with paediatric or adult female patients, such as family medicine, paediatrics, and obstetrics and gynaecology. While male guardian permission is not required to hire a woman, many employers enforce this. There is “no punitive action” for those who do so, says Dr Aldosari.
Female patients can face problems accessing various procedures without guardian permission, despite the fact that this is not required by law (with the exception of abortion), outlines Dr Aldosari.
There are “a plethora of western institutions that are happy to take Gulf money” to establish partnership programmes and “we see it in all the European countries and the US”, says Mr Coogle at HRW.
HRW don’t adopt a blanket position on whether these engagements are right or wrong. Mr Coogle says each programme needs to be examined individually.
“So, for example, if the Saudi doctors are going over and being taught in Ireland that it is absolutely wrong to require anyone to approve a medical procedure for a person, if that person has the legal ability to make the (decision) for themselves – if they are teaching that, then that is good, right? The idea that women’s healthcare should be a private matter between them and their doctors, that is good….”
However, in the absence of more detailed information from Colleges surrounding their engagements with countries like Saudi Arabia, questions will abound in medical circles.More widely, the area of business and human rights is coming under greater focus internationally.
Business and human rights
According to Dr Shane Darcy, lecturer at the Irish Centre for Human Rights in NUI Galway, there has been greater attention at the UN recently around business and human rights.
“The UN Human Rights Council has adopted what are called the guiding principles on business and human rights. The idea is that when it comes to business activities, states have to make sure that companies respect human rights, and companies themselves also have a responsibility to respect human rights throughout their operation…. Each country is encouraged to adopt a national action plan that puts this into practice.”
Ireland has signalled support for these guiding principles but has dragged its heels on the action plan. It is anticipated that the plan will be published in the first quarter of next year.
“The idea is that your human rights obligations should follow you irrespective of where you operate. There is a big push for that now internationally and nationally, but governments are not overly enthusiastic… they give it lip service but they don’t really oblige companies.”
At the UN, some countries are pushing for a binding treaty on business and human rights whereby states would have clear obligations. “Ireland is opposed to that treaty, the EU is not a big fan of that treaty, it is being led by poorer countries, developing world countries, Ecuador and South Africa in particular are pushing it, because they and countries like them come out of the wrong end of globalisation.”
On universities, Dr Darcy acknowledges that many look at opportunities abroad due to restricted funding at home. But when such institutions say they are “building bridges and engaging on these issues overseas, that is not the purpose of having a campus overseas, it is sort of effectively a business arm. If they made human rights a part of it that would be a separate issue.”
ICGP ‘not currently deriving income’ from MVI
The ICGP has said it “currently derives no income” from its involvement in Medical Validation Ireland (MVI), an RCSI-led consortium of Irish postgraduate medical and dental training bodies that undertakes consultancy work abroad. The College has been involved in a medical revalidation project in Qatar through MVI.
The ICGP did not answer questions on whether its members were consulted about its decision to join MVI, which offers a “range of bespoke assessment, accreditation and consultancy services”.
MVI was not explicitly referenced in the ICGP’s most recent annual reports. However, the annual report for 2013 states: “The College, along with the other Irish Post Graduate Medical Training Bodies (PGTB), embarked on a medical revalidation project in Qatar. This project is very innovative and allows all the PGTBs to collaborate and gain experience in the area of medical revalidation. It is certainly something that is on the horizon for Irish doctors.”
A College spokesperson told MI: “ICGP became involved in MVI following an approach from the RCSI in 2013. ICGP currently derives no income from its involvement in this organisation and has no involvement in the day-to-day running of MVI. Queries relating to MVI should be directed to RCSI or MVI.
“ICGP was involved in an MVI led project (the Assessment and Revalidation Programme, Qatar) for a period of two years, along with a number of other Postgraduate Training Bodies. This project involved the revalidation of Family Physicians in Qatar through MVI. This project is now concluded.”
MI understands that the exercise was on behalf of Hamad Medical Corporation, which describes itself as “the main provider of secondary and tertiary healthcare in Qatar and one of the leading hospital providers in the Middle East”.
The ICGP did not respond to questions on how it approaches the differing sociocultural/religious norms in respect of general practice delivery in Ireland and in other countries when undertaking this work. It also did not make any comment on whether it had plans to hold MICGP exams or undertake any ventures in the Middle East or develop overseas chapters akin to other training bodies.
In the UK, the RCGP has an international strategy which it adopted in 2011.
It has a MoU with the Health and Family Planning Commission, Zhejiang province, China. This agreement has seen RCGP provide training to doctors from the province, and it is also active in India. RCGP offers an international Fellowship and runs international Membership exams.
She types a text while sitting at her desk: “Son, please grant me permission to travel.” At home on the couch playing a computer game, her son responds: “I don’t feel like it. I’m busy.”
Human Rights Watch (HRW) produced this animation arising from its investigation into Saudi Arabia’s male guardianship system, which imposes a range of legal and societal restrictions on women. Under Saudi law, women must obtain permission from a male guardian to travel abroad.
One wonders, though, if this really extends to a senior medical professional; a distinguished surgeon? “Yes, the travel restrictions are imposed on all women,” Dr Hala Aldosari, a Saudi women’s rights activist and social affairs expert, informs the Medical Independent (MI).
Women also cannot study abroad on a government scholarship without guardian approval and, while not always enforced, “officially require a male relative to accompany them throughout the course of their studies”, according to HRW’s in-depth investigative report into the male guardianship system, Boxed In, which was published in July.
The system includes measures not in law or regulation but tacitly permitted by government, such as guardian permission for women to work. There are no penalties for employers who impose this restriction, says HRW.
Damning
Saudi Arabia has made “a series of limited changes” over the last 10 years to ease restrictions on women, such as allowing them to participate in the country’s “limited political space”, states HRW. However, these reforms are “partial and incomplete”.
The country’s human rights record is disturbing: Minors are on death row; homosexuality is illegal; women are not legally permitted to drive. The most elementary freedoms are shorn bare.
“On the basic rights, expression, peaceful assembly, peaceful association, I mean, their record couldn’t possibly be worse,” Mr Adam Coogle, Middle East Researcher at HRW tells MI. “All dissidents pretty much get locked up; you are not really free to form associations; public demonstrations are banned and people are prosecuted for doing them. So, in terms of those basic rights, there is absolutely nothing on the horizon that would suggest that Saudi Arabia is changing its position.”
A harsh form of Sharia law is imposed in Saudi Arabia, where over 150 executions are reported to have taken place in 2015 including for nonviolent drug crimes. Beheadings are the most common form of execution. Allegations of a flawed justice system are recurrent.
Presently, a military coalition led by Saudi Arabia stands accused of unlawful and deadly airstrikes on markets, hospitals and schools in Yemen.
The travel advisory for Saudi Arabia on the website of the Irish Department of Foreign Affairs and Trade has a distinctly dystopian feel. “Under Saudi Arabia’s customs, in the event of a marriage to a Saudi national, the family has strong power over the individual. If a woman wants her right of movement or to work guaranteed, she must insist on a premarital settlement, stipulating this right,” is one of many jarring sections.
Nevertheless, Ireland and Saudi Arabia have diplomatic relations. Saudi Arabia is a “designated priority market for Ireland” under this country’s trade, tourism and investment strategy, Minister for Foreign Affairs Charlie Flanagan recently told the Dáil.
Irish medicine has set its sights on Saudi Arabia, too.
‘Global presence’
International linkages and partnerships are viewed as important by Western medical training colleges, notably for financial reasons. Like counterparts elsewhere in Europe, and in North America, Irish postgraduate medical colleges continue to develop partnerships internationally, including in countries with dubious human rights records – such as Saudi Arabia.
The RCPI’s Strategic Plan 2015-2020 cites the development of a “global presence” as one of five strategic aims. The College’s 2015/6 annual report said that “strong relationships” were developing at “governmental and institutional level” in Malaysia, India, Saudi Arabia, Oman, Kuwait, Bahrain, and the United Arab Emirates.
It reported that a “high-level” Memorandum of Understanding (MoU) was signed between the RCPI and a Saudi governmental body called the Saudi Commission for Health Specialties to develop a “Joint Residency Training Programme”.
“It is proposed that this programme will be delivered partly in the Kingdom of Saudi Arabia and partly in Ireland. Participants take both the Saudi Board examinations and the MRCPI examinations and the programme will be recognised by both the Saudi Commission and RCPI,” stated the annual report.
Already, some overseas doctors including from Saudi Arabia are sponsored by their governments to train in Ireland under the auspices of RCPI and other postgraduate institutions through the International Medical Graduate (IMG) Training Initiative.
Many will be practising medicine in an altogether new environment.
The Saudi Commission for Health Specialties is responsible for supervising and evaluating training programmes in Saudi Arabia, as well as setting “controls and standards” for the practice of health professions in the country. Some stipulations in the Commission’s Professionalism and Ethics Handbook for Residents (2015) significantly conflict with guidance on medical ethics in Ireland.
According to the guide, the availability of safe and easily obtainable contraception “removes the fear of pregnancy and encourages sexual promiscuity and temporary sexual unions devoid of childbearing responsibilities”. The physician “must exercise due judgment before prescribing contraceptives to make sure that there are no immoral consequences”.
It continues: “Widespread use of contraception in the community has other undesirable consequences. Population imbalances by age and by gender may result. Widespread acceptance of contraception is a slippery slope that may make it easier for the community to accept genocide due to decreased respect for human life.”
A Medical Council spokesperson tells MI that doctors coming to work and train in Ireland under these programmes are registered in the Supervised Division and must meet “strict criteria”. The Council has established guidelines for employers of doctors registered in the Supervised Division in supervised posts. According to these guidelines, there should be a programme of orientation and induction for doctors newly registered in the Supervised Division. The programme should include an introduction to the Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners.
Dangerous liaisons?
Writing recently in MI (‘Stand up and fight’, 16 November 2016), Consultant Gastroenterologist Dr Anthony O’Connor stated that “we again need to question why Irish medical training colleges, registered charities who by act of Government command the compulsory membership, subscription, and patronage of all Irish doctors, are engaging with governments in countries like Bahrain and Saudi Arabia”, due to their very poor human rights records and state interference with the practise of medicine.
“Quite where engaging with these regimes fits into their missions is beyond my understanding. The Colleges of Physicians and Surgeons have proven themselves in the domestic and international realms in recent years as being progressive, innovative and thoughtful institutions, taking on admirable public health work and developing their educational facilities to a standard unimaginable a short time ago….
“Regarding international engagement, if this is desirable then there are vast tracts of the developing world that would benefit from their expertise without plying the wares of Irish medical training in countries richer than we could ever hope to be.”
Dr O’Connor’s commentary was typically robust and composed. However, while there are many doctors who share his concerns, few wish to raise their heads above the parapet.
Dr Ronan Collins, Consultant in Geriatric and Stroke Medicine, is an exception. He feels strongly about the situation.
“A lot of the colleges have been struggling for funding, and seeking new funding opportunities, and some of those funding opportunities are about offering educational opportunities abroad to other governments,” he tells MI. “I suppose you could be very purist and say, what government would be acceptable? Should we deal with India, for example, that has a caste system; should we deal with China, which has its own problems with human rights?”
Given factors such as Saudi Arabia’s wealth, extremely poor human rights record, its conduct in Yemen and support for fundamentalist groups, he has “huge discomfiture” about the situation. His concern has nothing to do with the training of doctors who happen to be Saudi Arabian, but the nature of the governmental regime with which the RCPI is engaging, he explains.
“I would very firmly be not in favour of this, full stop. Well, actually, that is not true. If Saudi Arabia agrees to implement the UN charter of human rights fully, then I am fully in agreement with it. Until then, I am not.”
Dr Collins continues: “The problem is when I raised this with colleagues, most colleagues didn’t know. And I think there is a big disconnect between the business arm of the College and, if you like, the academic, medical arm of the College.”
He acknowledges that doctors under the College’s jurisdiction are “duty bound to read the annual report”, which references its agreement with the Saudi Commission for Health Specialties and other international initiatives. Nevertheless, he believes further information should be published by the RCPI.
“I would like to know, for example, how much money we have taken, and where has it come from [within the Saudi government]? I think that should be public knowledge.”
Principles
He acknowledges that there is no embargo with Saudi Arabia and the two countries have huge business ties in agriculture and the equine industry. “But medicine is different. I am very uncomfortable with the notion that the College would take funding from a government that would routinely stone women, and punish and execute people because they are gay.”
Medicine occupies “a different space” and “has to worry about human rights”.
MI understands that concerns have been raised internally by doctors within RCPI. This newspaper contacted for comment the three candidates for RCPI President – Prof Hilary Hoey, Prof Conor O’Keane, and Prof Mary Horgan- but none had responded by press time.
A motion carried at this year’s IMO AGM reflected the concern doctors feel about some of the partnerships their colleges are entering into.
The motion from the IMO Consultants Committee called on RCPI and RCSI to ensure that “funding received from overseas governments in support of postgraduate training of doctors does not legitimise regimes that actively support international terrorism, sectarianism, misogyny, homophobia or have laws enshrining such ideals”.
A spokesperson for RCPI told MI: “The College has a long involvement in providing medical training and education in Ireland and other countries including Malaysia, Oman, Zambia, Saudi Arabia and India. Many of our Members and Fellows will have worked and trained in many other countries around the world bringing that expertise back to benefit the Irish health system. RCPI’s focus overseas is to improve health care provision, through the delivery of training programmes and examinations. International Medical Graduates training with us are doing so in specialties in which there is a recognised deficit in their home country, and each doctor is contracted to return to their home country upon completion of training to develop and deliver services in their communities.
“It has been the position of the College over many years that where we believe that we can make a difference to the quality of care to the people of these countries, we will do so. We are not alone in this and many other Irish organisations have taken the same approach.
“Our overseas activities include the provision of examinations, training, training consultancy programmes and Continuing Professional Development activities.”
The Joint Residency Training Programme with Saudi Arabia is scheduled to commence in 2017. “The primary focus of the MoU is the structure of the training programme, curriculum, rotations, assessments and certification requirements. Participants will undertake their training on the same basis as all other national and international doctors currently in training in Ireland,” said RCPI’s spokesperson.
“Doctors in training in Ireland under the Joint Residency Training Programme will be provided with the same clinical training that is currently provided to all RCPI SHOs. All of these activities will lead to improved healthcare provision for the citizens of these countries.”
RCPI provided figures in respect of doctors enrolled in the International Clinical Fellowship Programme, which sits under the IMG Training Initiative. “We currently have 46 trainees on this Programme; 22 males and 24 females.”
Specific questions on the financial aspects of the training programmes, and whether the MoU with the Saudi Commission for Health Specialties included any human rights principles including access for women and employment opportunities for women during and post-training, were not answered. In addition, RCPI did not comment on whether other agencies of the Saudi government sponsored trainees.
RCSI
Down the road from Kildare Street, on Stephen’s Green, the RCSI has been engaged in work in Saudi Arabia for a number of years. Most recently, its School of Nursing and Midwifery received a delegation from the King Abdullah Medical City (KAMC), Saudi Arabia.
During the visit in May, Prof Hannah Magee, Dean of the Faculty of Medicine and Health Sciences, signed a MoU on behalf of RCSI with regard to the provision of postgraduate education to KAMC’s 1,000-strong nursing workforce.
“The School will be providing MSc and Postgraduate Diploma programmes in areas such as wound care and tissue viability, respiratory nursing and a range of clinical specialities. Prof Zena Moore and her team will be commencing the provision of these programmes in the academic year 2016/17,” stated the RCSI website.
In 2014, RCSI Bahrain’s School of Nursing and Midwifery “successfully completed a BSc Bridging programme with Saudi Aramco and Johns Hopkins”.
Also in 2014, RCSI’s Institute of Leadership announced that it had won a competitive tender to provide 46 training workshops over the following twelve months in Riyadh and Jeddah. “Over the past 18 months, the Institute has established a positive working relationship with the Central Board for Accreditation of Healthcare Institutions (CBAHI), a department of the Ministry of Health in Saudi Arabia that accredits all 5,000 healthcare organisations in the Kingdom. The Institute has also formed a successful partnership with Knowledge Source Centre (KSC), a healthcare training organisation, based in Riyadh,” according to the announcement on the RCSI’s website.
MI put a number of questions to RCSI on these initiatives.
For example, MI asked RCSI whether it insisted on any human rights principles in its MoU with KAMC, in respect of dress code, freedom of expression, access to further education/employment opportunities and indiscriminate treatment of patients irrespective of their gender, sexuality, and marital status.
The MoU is “ongoing” and the College does “not comment on the details of such MoUs or agreements”.
“Our primary responsibility is to contribute, by providing a high-quality education, based on internationally recognised ethical principles in a safe and supportive environment, allowing students and trainees in Ireland and internationally to reach their potential and maximise their opportunities,” stated RCSI’s spokesperson.
Meanwhile, as part of the IMG Training Initiative, there are 29 doctors undertaking training in Ireland in conjunction with RCSI. There are 23 male trainees and six female trainees; they come from Pakistan (24) and Saudi Arabia (five). “All are in Ireland with the support of relevant government agencies in their home country,” said RCSI.
Asked what government agencies were sponsoring the Saudi trainees and how many were female, RCSI’s spokesperson said it had “no further comment”.
RCSI’s most controversial foray internationally has been the establishment of its multi-million campus in Bahrain. Its medical school depends on clinical training sites that human rights activists allege discriminate against political activists, as well as patients and healthcare professionals from the Shia majority.
In 2011, the medical press reported that senior staff at the RCSI Bahrain “asked three medical students attending its college to swear an oath of loyalty to the Bahraini Royal Family and to sign a declaration that they would not participate in further protests” against the Bahraini government. Subsequently, RCSI issued an unreserved apology for this incident.
RCSI has always emphasised its role as a specialist health sciences institution and even maintained that it is employing ‘soft power’ or seeking to exert influence behind-the-scenes. But even some of those who believe RCSI was right to remain in Bahrain feel that there is more it could do – and say – publicly.
RCSI and RCPI also undertake Membership exams internationally, including in the Middle East. Both Colleges were keen to emphasise their philanthropic endeavours in developing world countries, of which there are many fine examples.
‘Meaningful’
Dr Aldosari, the Saudi women’s rights advocate, tells MI that “meaningful engagement” in training health workforces “according to universal standards is rewarding more than refraining from interaction”.
Colleges must be mindful to ensure that issues such as gender-based discrimination, patients’ rights, and social determinants of women’s health are imparted to Saudi doctors during this training, she outlines. “This is crucial,” she says.
Dr Aldosari says Irish doctors and healthcare providers can influence the next generation of Saudi physicians and healthcare providers by showing them the potential of working in gender equal environments in practice.
The number of female doctors in Saudi Arabia is low, she says, and they usually practice in areas where most of their encounters are with paediatric or adult female patients, such as family medicine, paediatrics, and obstetrics and gynaecology. While male guardian permission is not required to hire a woman, many employers enforce this. There is “no punitive action” for those who do so, says Dr Aldosari.
Female patients can face problems accessing various procedures without guardian permission, despite the fact that this is not required by law (with the exception of abortion), outlines Dr Aldosari.
There are “a plethora of western institutions that are happy to take Gulf money” to establish partnership programmes and “we see it in all the European countries and the US”, says Mr Coogle at HRW.
HRW don’t adopt a blanket position on whether these engagements are right or wrong. Mr Coogle says each programme needs to be examined individually.
“So, for example, if the Saudi doctors are going over and being taught in Ireland that it is absolutely wrong to require anyone to approve a medical procedure for a person, if that person has the legal ability to make the (decision) for themselves – if they are teaching that, then that is good, right? The idea that women’s healthcare should be a private matter between them and their doctors, that is good….”
However, in the absence of more detailed information from Colleges surrounding their engagements with countries like Saudi Arabia, questions will abound in medical circles.More widely, the area of business and human rights is coming under greater focus internationally.
Business and human rights
According to Dr Shane Darcy, lecturer at the Irish Centre for Human Rights in NUI Galway, there has been greater attention at the UN recently around business and human rights.
“The UN Human Rights Council has adopted what are called the guiding principles on business and human rights. The idea is that when it comes to business activities, states have to make sure that companies respect human rights, and companies themselves also have a responsibility to respect human rights throughout their operation…. Each country is encouraged to adopt a national action plan that puts this into practice.”
Ireland has signalled support for these guiding principles but has dragged its heels on the action plan. It is anticipated that the plan will be published in the first quarter of next year.
“The idea is that your human rights obligations should follow you irrespective of where you operate. There is a big push for that now internationally and nationally, but governments are not overly enthusiastic… they give it lip service but they don’t really oblige companies.”
At the UN, some countries are pushing for a binding treaty on business and human rights whereby states would have clear obligations. “Ireland is opposed to that treaty, the EU is not a big fan of that treaty, it is being led by poorer countries, developing world countries, Ecuador and South Africa in particular are pushing it, because they and countries like them come out of the wrong end of globalisation.”
On universities, Dr Darcy acknowledges that many look at opportunities abroad due to restricted funding at home. But when such institutions say they are “building bridges and engaging on these issues overseas, that is not the purpose of having a campus overseas, it is sort of effectively a business arm. If they made human rights a part of it that would be a separate issue.”
ICGP ‘not currently deriving income’ from MVI
The ICGP has said it “currently derives no income” from its involvement in Medical Validation Ireland (MVI), an RCSI-led consortium of Irish postgraduate medical and dental training bodies that undertakes consultancy work abroad. The College has been involved in a medical revalidation project in Qatar through MVI.
The ICGP did not answer questions on whether its members were consulted about its decision to join MVI, which offers a “range of bespoke assessment, accreditation and consultancy services”.
MVI was not explicitly referenced in the ICGP’s most recent annual reports. However, the annual report for 2013 states: “The College, along with the other Irish Post Graduate Medical Training Bodies (PGTB), embarked on a medical revalidation project in Qatar. This project is very innovative and allows all the PGTBs to collaborate and gain experience in the area of medical revalidation. It is certainly something that is on the horizon for Irish doctors.”
A College spokesperson told MI: “ICGP became involved in MVI following an approach from the RCSI in 2013. ICGP currently derives no income from its involvement in this organisation and has no involvement in the day-to-day running of MVI. Queries relating to MVI should be directed to RCSI or MVI.
“ICGP was involved in an MVI led project (the Assessment and Revalidation Programme, Qatar) for a period of two years, along with a number of other Postgraduate Training Bodies. This project involved the revalidation of Family Physicians in Qatar through MVI. This project is now concluded.”
MI understands that the exercise was on behalf of Hamad Medical Corporation, which describes itself as “the main provider of secondary and tertiary healthcare in Qatar and one of the leading hospital providers in the Middle East”.
The ICGP did not respond to questions on how it approaches the differing sociocultural/religious norms in respect of general practice delivery in Ireland and in other countries when undertaking this work. It also did not make any comment on whether it had plans to hold MICGP exams or undertake any ventures in the Middle East or develop overseas chapters akin to other training bodies.
In the UK, the RCGP has an international strategy which it adopted in 2011.
It has a MoU with the Health and Family Planning Commission, Zhejiang province, China. This agreement has seen RCGP provide training to doctors from the province, and it is also active in India. RCGP offers an international Fellowship and runs international Membership exams.
Managing the message in Irish healthcare
Medical Independent
9 June 2016
The public hospital system has acquired layers of separate arrangements for PR/communications provision, with a multitude of PR firms under contract. Catherine Reilly reports
Last October, the HSE’s Leadership Team gathered for a workshop with an intriguing focus: Storytelling and narrative development skills. The workshop was delivered by communications company Make Yourself. The tagline on its website encourages prospective clients to “experience how great you can be”.
A HSE spokesperson told the Medical Independent (MI) that a “storytelling session” was provided to the Leadership Team.
The workshop was designed to provide the techniques required for “effective storytelling” to help the HSE “improve its ability to communicate effectively the story of the developments taking place across the health services”. It cost €3,200 and was delivered by Make Yourself’s Managing Director Mr Graham Singleton.
Communications training for the Leadership Team is largely provided by the HSE National Communications Division, but “from time to time” the HSE engages “external experts to provide specialist training”.
The story of change in the health service is an undeniably complex narrative, testing the most gifted of ‘storytellers’. Under Government policy (set in motion by its predecessor administration) the public health system is being restructured into Hospital Groups (eventually Trusts) and Community Healthcare Organisations that will work in tandem with a ‘Health Commission’. This epic change-management exercise has been unfolding at a slow pace.
Yet an early chapter in this developing story surrounds the separate and significant payments to PR firms by many voluntary hospitals and embryonic Hospital Groups, as they seek to protect and assert their identities.
Information obtained by MI shows that, in 2015, over €730,000 was spent on PR agencies by five Hospital Groups and ten voluntary hospitals.
Additionally, communications staff are employed by numerous hospitals and Groups while the HSE National Communications Division has 29 staff (such roles largely extend beyond media/public relations).
In this article, MI presents a compilation of expenditure gathered through Freedom of Information (FOI) requests to the HSE, Hospital Groups and their constituent hospitals. In a number of cases, MI sought information administratively, after the hospital/Group indicated that the request had not been received or where a decision was not issued (in these cases, information on expenditure and recipient was sought).
MI also asked hospitals and Groups via FOI for “any performance reports or updates” on the “PR strategy authored by the PR/communication companies/personnel” during 2015 to March 2016; and any correspondence between hospital chiefs, Group CEOs and the HSE Director of Acute Hospitals on PR provision. Beaumont Hospital was the only entity to locate relevant records (a power point presentation to its board by Drury Porter Novelli in March 2015).
THE PR DOSSIER • HSE National Communications Division – 29 staff.
Headed by a National Director on a €136,282 salary.
Annual salaries of staff combined are minimum of €1.7 million using the lowest points in salary scales
The HSE National Communications Division has 29 staff (as of March 2016). Its remit includes media relations, crisis communications, staff communications training, social media strategy/management, website development and internal/staff communications as well as work on public health campaigns.
It delivers its work programme through four teams: Client services; digital; news and media; and programmes and campaigns.
“We work with HSE division teams to deliver over 500 communications projects annually,” it stated.
In 2015 the HSE’s four regional communications offices – comprising 16 staff – were discontinued in light of the emergence of Hospital Groups. “The Groups will become separate legal agencies. As part of the transition to this new model, Hospital Group CEOs are developing in-house capability for managing their own communications.”
Each CHO is developing its communications function and this is managed and co-ordinated by CHO management locally, stated the HSE.
The news and media team in the Communications Division has internal and external communications duties. It handles approximately 5,000 media queries annually. The team consists of seven staff (including one staff member on maternity leave).
In a power point presentation (on the HSE website), the Communications Division outlined how its news and media team gains positive coverage for the health services, “as well as expertly handling negative stories”.
Asked about the essential ingredients of handling a ‘negative’ story, a HSE spokesperson referred MI to a paper on crisis management by Dr W Timothy Coombs on the website of the Institute of Public Relations, US. (www.instituteforpr.org/crisis-management-communications/).
This paper states that the primary concern in a crisis has to be public safety: “A failure to address public safety intensifies the damage from a crisis.” It also outlines concepts such as “stealing thunder”, describing how “research consistently demonstrates that a crisis does less reputational damage if the organisation is the first to report the crisis”.
The staff numbers and grades in the HSE Communications Division are listed below:
National Director, salary €136,282.
Assistant National Director, salary scale: €90,514-€110,183.
Six General Managers, salary scale: €65,376-€79,481.
Nine staff at Grade VIII, salary scale: €64,812-€74,551.
Four staff at Grade VII, salary scale: €47,015-€61,417.
Six staff at Grade VI, salary scale: €44,849-€55,032.
One staff member at Grade V, salary scale: €40,209-€48,496.
One staff member at Grade IV, salary scale: €25,752-€42,891.
• RCSI Hospitals Group – €96,684 to Q4 PR in 2015
In 2015, under a tendered contract, RCSI Hospitals Group paid €96,684 to Q4 PR (€73,314 for PR; €23,370 for “direct communications”). From 1 January-10 March 2016, the Group paid €27,582 to Q4 PR (€24,507 for PR; and €3,075 for direct communications). In its FOI response, the Group said it had no employees with a specific media communications/PR remit. The arrangement for “direct communications” support (ie, when Q4 responded to media queries) was discontinued in February 2016, according to the Group’s FOI response.
Asked what the “PR” arrangement entails, the Group said PR/media “support”.
• Beaumont Hospital, Dublin (RCSI Hospitals Group) – €100,945 to Drury Porter Novelli in 2015
In 2015, Beaumont’s spend was €100,945 to Drury Porter Novelli; for January and February 2016, the spend was €11,712. The contract is to be renewed shortly following a tender process. Beaumont, in its FOI response, provided a presentation by the firm to the hospital board in March 2015, on its PR function and strategy (see further in main body of article).
• Rotunda Hospital, Dublin (RCSI Hospitals Group) – €28,102 to Strand Communications in 2015
The Rotunda “expended through revenue” €28,102 on communications/PR in 2015 when Strand Communications held the contract. In November 2015, the Rotunda tendered for PR/communications advisors. In February 2016 the contract was awarded to Heneghan PR. The company is not on a retainer, nor was Strand Communications.
“To date there have been no charges from Heneghan PR to the Rotunda Hospital,” according to the hospital’s FOI response on 21 March. There were no staff employed by the Rotunda with a PR/media communications remit.
• Dublin Midlands Hospital Group – €18,810 to PR 360 and Q4 PR in 2015
In 2015, this Group paid €18,810 to PR 360 and Q4 PR for press and communications support. From January-March 2016, €17,500 was paid to PR 360, according to the Group’s FOI response.
In November 2015, PR 360 won a tender for provision of communications/PR services. The contract duration is for a maximum of four years. PR 360 are required to provide services either to the Group or to individual hospitals within the Group “as the need arises or collaborating with any existing communications provider in individual hospitals”.
Communications/PR activities include managing the relationship between the Group and the media, to include “protecting the reputation” of the Group. Strategic PR advice is provided.
The Group also has a communications manager at Grade VIII (salary scale: €64,812-€74,551). This role involves internal and external communications. A Group communications strategy is being developed.
• St James’s Hospital, Dublin (Dublin Midlands Hospital Group) – it engages Q4 PR
Details were still awaited through FOI at the time of going to press.
• Coombe Women and Infants University Hospital, Dublin (Dublin Midlands Hospital Group) – €25,552 to FTI Consulting in 2015
FTI Consulting is retained by the Coombe (following a tender) to provide PR on an ongoing basis at €2,942 per month including VAT, according to its FOI response. In 2015, the amount paid was €25,552. From 1 January-10 March 2016, €10,333 was paid for PR. The hospital employs an information/communications officer at Grade VII (salary scale: €47,015-€61,417) who, as part of the role, acts in a liaison capacity with the HSE, external organisations including PR firms, and the general public in relation to requests for information.
• Tallaght Hospital, Dublin (Dublin Midlands Hospital Group) – €92,400 to Drury Porter Novelli in 2015
Since 2012, Tallaght Hospital has used the services of Drury Porter Novelli for “proactive communications support, press office services and consultancy advice”. The services include a “24/7/365 press office function and support for communications campaigns on hospital initiatives relating to clinical developments and community relations, amongst others”.
These services are “contractual and provided on an hours incurred basis and the hospital has paid €21,881 for these services, year to date May 2016”. Tallaght paid an average of €7,700 per month in 2015 (equating to €92,400).
The hospital employs 1.5 WTEs to manage internal communications across campus and to meet online/social media requirements, event management, community engagement and “manage the liaison” between Tallaght Hospital, the Dublin Midlands Hospital Group, Children’s Hospital Group and Drury Porter Novelli on any related media issues.
The full-time communications officer at Grade VII (salary scale: €47,015-€61,417) was appointed in early 2015; the temporary part-time administrative post was put in place to support this role in September 2015. This information was sought administratively after Tallaght indicated the FOI request from MI had not been received.
• Ireland East Hospital Group (IEHG) – €21,848 to PSG Communications (September-December 2015)
From September to December 2015, IEHG paid €21,848 to PSG Communications, stated the Group’s FOI response.
In May 2015 IEHG put out to tender a contract for a communications agency to act as communications advisors, help manage a press office, and advise the Group “and the 11 hospitals which are part of IEHG”. Following a “robust” tender process, PSG Communications was awarded the contract with a retainer fee of €5,000 per month “plus projects to cover media training and other special services as required”.
The contract with PSG came into effect in September 2015 and runs until 31 August 2019. From January-March 2016, €11,781 was paid to PSG by IEHG.
IEHG’s response noted that, in the later part of 2015, communications functions started to transition from the HSE to the Group communications department. As of January 2016, all communications needs for its HSE statutory hospitals are met by the Group.
IEHG hired a Group communications manager in August 2015 to help develop its internal and external communications. The post is at Grade VIII (salary scale: €64,812-€74,551).
A press office and communications manager was hired to deal with press queries for statutory hospitals within the Group and to support the Group communications manager in development and implementation of communications requirements, stated IEHG.
The post is at Grade VII (salary scale: €47,195-€61,417).
• St Vincent’s University Hospital, Dublin (IEHG) - €48,000 to MKC Communications in 2015
St Vincent’s University Hospital has a retainer with MKC Communications for €4,000 per month.
In 2015 the hospital spent €48,000 and year-to-date expenditure is €12,000, according to the FOI response issued via the IEHG on 11 April.
• Mater Hospital, Dublin (IEHG) – €25,433 to PSG Communications from January-September 2015
In 2015 the Mater Hospital retained PSG Communications from January-September 2015 when its PR and communications requirements were absorbed into the Group. Spend up to September 2015 was €25,433, according to the FOI response issued via the IEHG.
• National Maternity Hospital, Holles Street (IEHG) – €4,804 to Murray Consultants in 2015
According to an administrative response from the National Maternity Hospital, PR costs in 2015 were €4,804; costs from 1 January-10 March 2016 were €3,484.
It is not a retainer but an ‘as used’ arrangement, according to the hospital’s response (issued by Murray Consultants). An administrative response was requested after the FOI request was not progressed.
NMH has no staff specifically employed to deal with media/PR.
• Saolta University Health Care Group – €134,316 to Setanta Communications in 2015
Saolta paid €134,316 to Setanta Communications in 2015. From 1 January-31 March 2016, the Group paid €33,579 to Setanta. The contract runs from 1 January 2015 to 31 December 2016. According to the Group’s FOI response, external support was instigated by the former Galway Roscommon University Hospital Group and subsequently Saolta. This resource was put in place as the HSE West Communications Office was providing part-time support to the Hospital Group between January 2013 and August 2014.
The HSE communications support ceased from August 2014 until the Group made an internal appointment in April 2015. The support is necessary to manage internal and external communications requirements, including the newsletter, website, events etc, for a Group of six hospitals, employing 9,000 staff and serving a catchment in excess of 700,000 people, it said.
Saolta employs two internal communications staff at Grade V (salary scale: €40,209-€48,496) and Grade VIII (salary scale: €64,812-€74,551).
• South/South West Hospital Group – issued a tender for PR services
Group PR/communications requirements are handled by the HSE Press Office. The Group tendered for a “specialist communications service” last year.
• Mercy University Hospital (South/South West Hospital Group) – €24,300 to Mills Public Relations in 2015
Since June 2011, Mercy University Hospital (MUH) has engaged Mills Public Relations. It is on a monthly retainer. The contract is “in accordance with procurement rules” incorporating a “review process” managed by the hospital CEO. Some €24,300 was spent in 2015; total amount spent from 1 January-30 April 2016 was €8,100.
MUH does not employ staff with a PR/media communications remit, according to information supplied administratively by the hospital (via the PR firm) after MI received no acknowledgement of an FOI request.
• Children’s Hospital Group (CHG) – €70,110 to Q4 PR in 2015
The CHG engages Q4PR and has internal communications resources (one internal communications manager since October 2015). The total amount paid for services provided by Q4 PR from April 2015-3 June 2016 was €76,445. In 2015 alone CHG expenditure with Q4 PR was €70,110.
• Temple Street, Children’s University Hospital (Children’s Hospital Group) – €16,583 to Q4 PR in 2015
According to an administrative response from Temple Street (sought after the FOI request attracted search and retrieval fees), Q4PR was appointed to provide communications support for Temple Street in April 2015. Support is provided on an hourly basis depending on the hospital’s needs.
“If and when Temple Street commissions Q4PR to do work on its behalf, this is completely separate to Q4’s contract with the CHG and NPHDB [National Paediatric Hospital Development Board],” stated a hospital spokesperson.
Q4PR provides a range of services including media relations support, advocacy campaigns, internal communications, messaging development and event management. Temple Street paid €16,583 in 2015 and €1,272 in 2016 (year-to-date to the end of March 2016) to Q4PR.
Temple Street has a part-time communications manager who handles both internal and external communications.
• Our Lady’s Children’s Hospital, Crumlin (Children’s Hospital Group) – €22,140 to Setanta and Fleishman Hillard in 2015
Setanta Communications provided out-of-hours PR services from January 2014 to June 2015. Fleishman Hillard commenced providing out-of-hours PR services from July 2015 to date. Total spend to Setanta Communications for the period January 2015 to June 2015 was €11,070. This was an annual contract, according to the hospital’s response under FOI. Total payment to Fleishman Hillard for the period July-December 2015 was €8,364 (total fees due were €11,070). Expenditure from 1 January-10 March 2016 was €1,845. The contract is due for renewal in July 2016.
The hospital has one Grade VII (salary scale: €47,015-€61,417) staff member employed for PR/Communications.
• UL Hospitals Group – three-person in-house communications team
UL Hospitals and its hospitals do not engage PR companies, according to the Group’s FOI response. The Group has three employees in its communications team, one at Grade VIII (salary scale: €64,812-€74,551) and two at Grade VI (salary scale: €44,849-€55,032). The latter two appointments were made in May 2015. Media coverage is reported on a monthly basis via the Group Executive Council Communications Report. It intends to develop a Group PR strategy this year.
Press/PR represents just one component of the work of its communications staff.
• TOTAL: Hospital Group and voluntary hospital spend on PR firms in 2015: at least €730,027
The tally of released information equates to €730,027 expenditure on PR firms’ services in 2015. This excludes in-house or national communications resources.
News agenda
Expenditure on PR within public services is often viewed critically. This is amplified when it is a health service stricken by funding shortfalls and where many patients are waiting inordinate periods for treatments that could save, extend or change their lives.
Moreover, the public is generally not privy to the strategic advice supplied to hospitals by PR companies, or to their recommended approaches on publicity pertaining to patient safety events. These companies are in the business of reputation management.
At the same time, there is broad acknowledgement that persistently negative stories affect staff morale and that generating news on positive developments may be an important counterbalance.
In 2015, Beaumont Hospital (which said it did not have any employed staff with a PR remit) spent the largest amount on a PR company, out of all voluntary hospitals that supplied information (€100,945 to Drury Porter Novelli).
In January 2015, concern about “recent negative media reports” and the impact on patients and staff was raised at a meeting of its board, according to meeting minutes.
It was “highlighted that the hospital should focus on publicity for the significant positive developments in the hospital, such as upcoming coverage of neurosurgery and cochlear implantation as mentioned by the Chief Executive”.
Chair Ms Ann Fitzgerald informed the board that she and CEO Mr Liam Duffy “would be meeting with the hospital’s external communications advisors to formulate a plan for 2015, and this would be brought to the board in the near future”.
At a board meeting in March 2015, Mr Gerry Naughton of Drury Porter Novelli put forward “proposals to raise the positive profile of Beaumont Hospital”. In summary, five steps were proposed – change media targeting from general to exclusives; invest more in “mining for positive human interest stories”; work more closely with the RCSI and the Beaumont Hospital Foundation; ensure senior staff are media trained; and “be open to (selective) media briefings”. In the minutes, the board noted social media as a future consideration.
MI contacted the CEO’s office at Beaumont to seek Mr Duffy’s views on the impact of PR services. However, Mr Duffy was due to retire and had not responded by press time. Drury Porter Novelli was asked about the impact, in its view, of the proactive approach to generating positive stories about the work of Beaumont – and about the differences in approach between managing PR for a publicly-funded hospital and a client in the corporate for-profit space
A spokesperson said it was not its practice to comment on clients in this manner.
Dr John Duddy, a Specialist Registrar in Neurosurgery at Beaumont, said staff morale is affected by a constant cycle of negative news that often overlooks the positive work going on. He said more transparency is required on the role of PR companies in the public health service and in-house resources would be the best option. It would not be in the public interest for hospitals to “spin their way out of a negative incident”, he underlined.
Dr Duddy added that social/online media is a relatively inexpensive means of promoting positive service developments and should be more widely used by hospitals.
Concern
Dr Paul Connors, the HSE’s National Director of Communications, acknowledged that the cost of engaging PR firms and the multiplicity of arrangements in the health service is “a concern”. Dr Connors told MI he has spoken to Hospital Group CEOs at their CEOs’ Forum regarding the need for Groups to develop their own communications support. In that context he considers the engagement of companies as an “interim” measure. It takes time to build in-house communications capacity, which includes “a wide gambit” of functions from digital to public affairs, he said.
Dr Connors said the health system is undergoing a “massive change-management programme”. In the past 12-14 months, the HSE Press Office has found it harder to receive information from the wider system undergoing this change, which in turn has slowed responses to journalists, he said.
MI sought comment from people working for PR companies regarding their role in public hospitals. One PR consultant, who did not wish to be named, said a big public hospital could attract several media queries per day, predominantly from daily print and broadcast outlets.
“The reality is that the level of media query is significant. There is constant demand from media for responses,” they said.
Many hospitals are struggling to recruit healthcare professionals and improving a hospital’s image was important in this context, they argued.
Querying MI on the background of this article, CEO of the Public Relations Institute of Ireland (PRII) Mr John Carroll said he understood “the salacious aspect of looking at PR, and making the case that all PR expenditure is wasted expenditure”. He said there was a “misconception of the role of PR practitioners”.
Mr Carroll said hospitals are obliged to communicate with the public. He said journalists want responses, doctors want to practise medicine, and managers want to focus on being managers, and that’s where PR support comes in.
Media relations is part of the role of a communications professional, although not its totality, he added. “However, in the health service this is a particularly demanding aspect,” he said.
“Ensuring that those queries [from media] are responded to professionally, that the information is provided in context and so forth, is a demanding and important task, as inaccurate and inappropriate coverage of an incident or an event can result in a damage to staff morale, as well as to patient and public confidence.”
The role of PR is “not to hide” difficulties but to ensure positive developments are given an airing, he said.
The PRII has no position on whether PR in public hospitals should be an in-house or external resource. Mr Carroll added that the tendering process is a value-for-money mechanism and that he was not in a position to comment on whether there was duplication in the hospital system. “However, if there is, as you suggest, then that surely is true for a wider variety of professional services and not just public relations and communications.”
Another PR consultant, who preferred not to be named, said PR outlay was often viewed as a “frivolous expenditure” that could attract public ire. “Therefore, a headline ‘hospital spends X thousand on spin doctors’ doesn’t actually endear hospital management to using PR, and yet they recognise that sometimes it is a necessary thing to do.”
This PR consultant said there were differences in representing a public hospital and a corporate client. The public was entitled to a level of information not necessarily applicable in the case of a private company.
But some view this controversial coalition of public hospitals and PR companies as nothing short of outrageous. It is anathema to Prof John Crown, Consultant Oncologist at St Vincent’s University Hospital, Dublin.
“The public relations relationship with its client is like an attorney-client relationship – the person who pays the public relations person engages them to make them look good… it is all about burnishing the image of the person who is paying for it,” the former Senator told MI.
“I don’t think hospitals should be spending money on public relations – not when they can’t pay for cancer drugs.”
Prof Crown, speaking to MI before the HSE announced it would reimburse new cancer drug Pembrolizumab, added: “They’re (HSE) telling us they can’t afford cancer drugs and they are paying public relations people to tell us why they can’t afford cancer drugs – that actually happened this week.”
Prof Crown believes more doctors should speak to the media on service issues; he also considers that civil servants should engage directly with the media by taking on such duties in rotation. (Mr Carroll said the PRII has no objection to senior management and medical staff operating as spokespeople, with appropriate training).
Dr James Gray, a Consultant in Emergency Medicine at Tallaght Hospital, Dublin, engages directly with the media on issues affecting the health service. He does not believe that public hospitals should be spending money on PR companies.
He said PR companies such as Drury Porter Novelli - which is contracted by Tallaght – have as their focus “optimisation of institutional reputation and limitation of any negativity”. (The firm provided comments to MI,which in summary, said it supports an open culture).
Dr Gray said he does not seek permission from hospital management to speak to the media on health service issues.
“I have been approached in the past about my media activity but that has ceased as management know I will not be silenced as a patient advocate,” he added.
*In our online version, the total expenditure on PR was updated to include the CHG spend in 2015. Previously it had supplied the figure into June 2016 without disaggregating the 2015 amount.
A Gulf in values on Bahrain?
Medical Independent
9 May 2016
The issue of medical neutrality in Bahrain continues to spark controversy in Ireland.
Catherine Reilly investigates
Screams of pain and fear. Torturers enjoying freedom and impunity. Their laughter crossing “dark cold walls”.
Dr Fatima Haji, a doctor living in Dublin, recently conveyed a stark collage of memories via Twitter.
She was marking the fifth anniversary of a government crackdown on popular protests in Bahrain, a Gulf state governed by an unelected ruling family. The state response brutalised the lives of many healthcare professionals, including her own.
Healthcare workers were interrogated; some were removed from their workplace or houses, arrested and tortured. This, they say, for treating protesters, remonstrating against the government for its assault on medical neutrality and for giving critical media interviews.
“Whoever disappeared at that time disappeared — no phone calls, no contact with the family or lawyers… we didn’t know if they were alive or dead and then the whole other story starts, the torture and the extraction of the ‘confessions’, then the military court, then the civil court… ” recounts Dr Haji to the Medical Independent (MI).
There are numerous Irish aspects to the story, including the ongoing imprisonment of paediatric orthopaedic surgeon Dr Ali Al Ekri, who trained at the RCSI in Dublin, and continuing concern over human rights standards at hospitals used for training by the RCSI Bahrain.
Last week, RCSI Bahrain signed a Memorandum of Understanding with a private hospital in Bahrain, involving collaboration for clinical training.
Dr Al Ekri’s five-year sentence expires in March 2017. Speaking to MI from Bahrain, Dr Al Ekri’s wife — Dr Fareeda Al Dallal — says her husband is “a prisoner of conscience just because he did what he should do as a doctor. He protested against the Minister for Health…because (authorities) prevented the ambulances from reaching the injured protesters.”
“The second thing that he did was he was a witness against the regime and he said what he saw in the media. He was a witness.”
Salmaniya Medical Complex
At the dawn of 2011, Dr Haji’s life was proceeding as normal. She was employed as a rheumatologist in Bahrain’s largest public hospital, Salmaniya Medical Complex (SMC), in the capital Manama. She was planning to undertake a clinical fellowship abroad.
However, by mid-February, the rhythm of life in Bahrain had acquired a thunderous tempo. Largely peaceful protests for reform, fanned by movements in other Arab countries and long-standing discrimination of the majority Shia population, were met with a violent crackdown by the Sunni-dominated government.
Dr Haji says she had “never been political” and does not consider that she was part of the uprising. She says a defamation campaign was launched against healthcare workers.
Her recent tweets radiated a raw sense of pain and outrage.
Yet she draws from a palette of strong emotions and continues to speak out.
“There is a quote in Arabic and I think in English — ‘the thing that doesn’t kill you makes you stronger’,” Dr Haji tells MI. “The first few days of being in custody, I didn’t even know where I was, I was blindfolded and handcuffed all the time, and tortured and electrocuted and harassed on so many occasions … ”
She says she found peace in knowing she had helped patients, regardless of who they were.
The fifth anniversary has stirred feelings. Amnesty International has renewed its call for the release of Dr Al Ekri, who also worked at the SMC. According to Amnesty, he was initially sentenced to 15 years’ imprisonment (later reduced to five years) for the “possession of unlicensed weapons”, “attempting to occupy by force a public building”, “calling for regime change”, “seizure of medical equipment” and “public gathering without authorisation”.
Amnesty believes that Dr Al Ekri was targeted for his “vocal denunciation to the international media of the excessive force used by the armed forces against peaceful protesters during the February-March 2011 protests”.
Dr Haji says that after the SMC was “militarised” by the government, in response to the protests, doctors and nurses were summonsed to an ‘investigation committee’. She was asked about the extra hours she was spending at the hospital; she says she informed the committee this had been sanctioned by the hospital administration, due to under-staffing and the emergency situation. However, she says the committee accused her of empathising with protesters against the King. “They started to have lots of other accusations… ” She was suspended and later taken from her home.
She endured three weeks in detention and, alongside other medics, a military court trial on what she describes as spurious charges. Dr Haji was sentenced to five years before being acquitted at a civilian court in 2012, in the glare of the international spotlight.
BICI report I
n late 2011, the government-commissioned Bahrain Independent Commission of Inquiry (BICI), led by international law expert Prof Cherif Bassiouni, published a report on the protests and the state response. It found that the National Security Agency and the Ministry of Interior “followed a systematic practice of physical and psychological mistreatment, which in many cases amounted to torture, with respect to a large number of detainees in their custody”.
One chapter in the report centred on events at the SMC, but much of it was a complicated series of claim and counter-claim. The report concluded that some medical personnel pursued a political agenda and “moved in and out of their roles as political activists and medical personnel”. It criticised medical staff for not attempting to prevent media filming inside sections of the hospital, which was a contravention of patient confidentiality.
However, it also stated that security services “executed unlawful arrests on SMC premises and attacked and mistreated some individuals, including medical personnel”. It further stated that, on 16 March 2011, the Bahrain Defence Forces “took control of the entire complex and placed some injured persons, whom it sought to keep under its control, on the sixth floor of SMC”.
The government committed to reforms, but activists say little has changed. Mr Brian Dooley at Human Rights First, US, has considerable expertise in monitoring human rights in Bahrain. He describes the situation as “a mess”.
“There’s a lot of PR from the regime about how they’re cleaning up their act but the fundamentals don’t change — torture, arrests of people peacefully criticising the ruling family, long sentences without fair trials,” Mr Dooley tells MI.
Controversies in Bahrain continue to resonate in Ireland. The RCSI’s multi-million euro university campus in Bahrain depends on government healthcare facilities for clinical site training. These include the SMC, King Hamad University Hospital and the Bahrain Defence Forces Hospital.
In December 2014, the Irish Medical Council unconditionally accredited the medical degree programme in RCSI Bahrain after a visit to the university and affiliated clinical training sites. However, some Council members opposed accreditation (see panel).
Mr Dooley has ongoing concerns regarding medical neutrality and fair access to employment at healthcare facilities used for training by RCSI Bahrain.
“People who have been injured protesting are scared to go to government-run facilities in case they get arrested, so they get treated at underground clinics,” Mr Dooley tells MI: “The RSCI’s failure to speak out publicly about the targeting of medics is a disgrace.” He says the College’s approach has shaped the way many Bahrainis view its relationship with the country’s rulers.
Mr Dooley says reports of employment discrimination across government hospital facilities are “common”.
Sectarianism
Sectarianism in employment in Bahrain was one of the issues that deeply perturbed Prof Tom Collins, an educationalist who served as President of RCSI Bahrain from late 2011 until his resignation in March 2013.
Prof Collins recalls a group of RCSI Bahrain nursing graduates who were due to take up employment in the new King Hamad University Hospital. They graduated prior to his arrival in Bahrain.
“As I recall, at least 20 or so of those who expected to get that employment were refused it on, I quote, ‘security grounds’. They were all Shia. Some of them were the first in their families to graduate and I felt I had a responsibility to all graduates to give them what support I could. So I met them. I raised the issue at the highest level in Bahrain, of the fact that they had not been able to secure employment. But ultimately there was very little I could do,” he tells MI.
In 2013, in collaboration with Médecins Sans Frontières (MSF), RCSI Bahrain attempted to organise a conference titled ‘Medical Ethics and Dilemmas in Situations of Political Discord or Violence’. When this venture was blocked by authorities, Prof Collins resigned from his post. He says academic dialogue and exploration, and freedom of expression, run to the core of what universities are about.
While there are “multiple challenges” facing the RCSI in Bahrain, he does not believe these can be balanced from a position of “silence”.
During his time in Bahrain, Prof Collins became increasingly concerned about the overall political climate. He notes that there were some “reformist instincts” within the ruling cadre. “In Bahrain the Crown Prince had a strong reformist orientation and was enthusiastic and supportive of the conference with MSF. But even within the period I was there, I could see his influence was waning, against those more conservative power brokers, in this situation.”
‘Soft power’
The RCSI has frequently maintained that it is employing ‘soft power’ in Bahrain; seeking to exert influence behind-the-scenes.
A College spokesperson tells MI: “We are indeed aware of the Amnesty International campaign for the release of Dr Ali Al Ekri and recently met with Amnesty International and outlined our approach… ”
According to the spokesperson, the RCSI has “fully supported” the BICI’s recommendations and has made “numerous formal representations and written to the King of Bahrain, asking for clemency. Senior Members of the RCSI have frequently met senior government officials in Bahrain. At every opportunity we have voiced our concerns and position on these issues”.
The College says it has “a unique balance of responsibilities and opportunities. We judge that we can be true to our responsibilities and more effective in influencing through private advocacy.
“Our primary responsibility is to contribute to our students’ high-quality education in medical and health sciences in a safe, supportive and non-sectarian environment. To this end we are entirely satisfied that our students’ access to clinical training in the three teaching hospitals is conducted in a safe and non-sectarian environment where the principle of medical neutrality is absolutely respected.
“There is absolutely no discrimination of students and questions are never raised as to religion. The students have free access to all three hospitals. In fact, if we are asked for a sectarian breakdown of our student body we would not be in a position to answer because we don’t ask our students when they enrol what their religion is…
“We believe that the future for Bahrain has to be one of dialogue and reconciliation — we know this well from our own national story. We will continue to contribute through education and continue to advocate for just outcomes.”
Dr Al Dallal awaits her own just outcome. She and Dr Al Ekri have four children together. Their 13-year-old son was born in Ireland, when the family lived here in the early 2000s.
“They are still missing their father; they haven’t seen their father a lot. There is a time to visit him — we are allowed to visit him twice a month.”
Previously, Dr Al Ekri had been hailed a hero by the Bahraini government, after he journeyed to Gaza to provide medical care to Palestinian people. Dr Al Dhallal says her husband had the same intention in Gaza and Manama.
“The same intention to do things, but different situations, different places, different people.”
Waiting
Dr Al Dhallal says the RCSI has not been vocal on her husband’s case. However, she wishes to thank Irish healthcare workers for their solidarity, especially Prof McCormack.
She is also thankful that her husband is in “good health”.
Dr Haji says she did not know Dr Al Ekri well before the events of 2011. She got to know him and his family in the ensuing trial periods. He has the “tough look” of an orthopaedic surgeon but “the heart of a teddy bear”, she says, adding that his outspokenness angered the authorities.
Currently working at the Mater Hospital, Dublin, having come to Ireland in 2014 after her husband took up a fellowship, Dr Haji ultimately plans to return to Bahrain.
Dr Haji says the RCSI needs to make strong public statements on key issues, including on threats to medical neutrality and sectarianism in Bahrain’s healthcare system. She believes there is much more it could do.
In this sense, living in Ireland during the 1916 Rising Centenary commemorations was a strange experience. She notes that, in its 1916 programme, the RCSI underlined the role of alumni and fellows in treating all factions.
“At the beginning I was really outraged with the way they responded. But now, five years from the events, with all that is happening on the anniversary of the 1916 Rising and all the activities they have been announcing and then, how they presented themselves as ‘we have treated equally all the wounds from the British military and the Irish soldiers’ … I am not accusing all of them but some of them definitely are so hypocritical.” She says “the glory is easy to claim after 100 years”.
Sometimes friends remark to Dr Haji that she is doing well here. They say she should just focus on her career. Dr Haji is serious about her career, but feels she must continue to speak out and be a good example to her sons.
“Some people have to do what they have to do, even if the price is so high. But the price of freedom is even higher. The price of truth is higher. We are living in a world where saying the word of truth means you have to pay the price very high… I still believe in saying the word of truth.”
Meeting with Bahraini ambassador was ‘comprehensive’ — Áras
It was an odd coincidence.
In April, on the same day Dr Haji tweeted her painful memories of the Bahraini government crackdown in 2011, President Michael D Higgins received the new ambassador of Bahrain to Ireland, Ambassador Shaikh Fawaz bin Mohamed Al Khalifa, at Áras an Uachtaráin.
The ambassador conveyed the Bahraini leadership’s “commitment to the historic bilateral relations linking the two friendly countries and their people”, according to the Bahraini state media.
A spokesperson for President Higgins told MI that matters discussed in a private meeting with the ambassador could not be disclosed. But they were “comprehensive” and included “general and particular issues”.
“The President has addressed the issue of human rights on many occasions in the past, including at the Royal College of Surgeons earlier this year and at a meeting of Amnesty International last year,” he added.
In February, President Higgins spoke at the RCSI in Dublin on the occasion of the College’s Charter Day and award of an honorory fellowship. President Higgins specifically mentioned the RCSI’s ventures in Malaysia, and referred to human rights generally, but there was no intelligible reference to Bahrain.
In being accorded the highest distinction bestowed by the RCSI, President Higgins joined an exclusive club.
Honorary Fellows include the late Nelson Mandela, the late Mother Theresa, former US President Jimmy Carter and, among others, Bahrain’s King Hamad bin Isa Al Khalifa. The King received this honour in 2006, with the RCSI hailing him as “a man of peace, stability and influence in a difficult and troubled world”.
In 2003, the RCSI awarded an honorary fellowship to Sheikh Khalifa Salman Al Khalifa, who has now been Prime Minister of Bahrain for over 40 years. The BBC described him as a “hardliner” in the wake of the events of 2011.
Orthopaedic Surgeon Prof Damian McCormack, who has spoken out on human rights violations in Bahrain, told MI he was “very disappointed” President Higgins accepted the honorory fellowship.
Council members were concerned on Bahrain
The Medical Council’s accreditation report on RCSI Bahrain was noteworthy for what it did not address, according to a human rights lawyer.
Dr Gearóid Ó Cuinn of Global Legal Action Network (GLAN) said the report does not outline how the Council accounted for the fear and reluctance people would have in criticising standards of medical neutrality and human rights at government hospitals, used by RCSI Bahrain for student training.
One month before the Council’s visit to Bahrain in October 2014, human rights activist Ms Ghada Jamsheer was arrested on charges of defamation after tweeting criticism of King Hamad University Hospital, and its head, while she was a patient.
“The Medical Council arrive less than a month after she is detained, go into the hospitals and say, ‘is everything okay here?’” commented Dr Ó Cuinn.
According to minutes of Medical Council meetings, some members were opposed to accepting the accreditation report on the medical programme at RCSI Bahrain.
A Council meeting in December 2014 heard of the concern of members Mr John Nisbet and Dr Ruairi Hanley with regard to “environmental and political factors” that could impact the safety of students attending RCSI Bahrain.
“Concern was also expressed that there had been insufficient consideration during the accreditation process of ethical and human rights concerns in Bahrain, as articulated in the Ceartas report.”
Ms Anne Carrigy, on behalf of the accreditation team, “confirmed that team members had raised every matter with representatives of RCSI Bahrain, and with students in private session, which was deemed relevant in order to apply the relevant World Federation of Medical Education (WFME) standards with representatives of RCSI Bahrain, and with students.”
Seven members accepted a counter-proposal not to accept the accreditation report, with 10 members against and one abstaining.
A vote was held on the original proposal to accept the report, with 11 in favour, six against and one abstaining.
One of the accreditation report recommendations was that RCSI Bahrain satisfies itself that it has adequate monitoring and control of any potential impacts on programme delivery and achievement of educational outcomes at its campus and at associated clinical sites.
The Council says there is a monitoring phase following accreditation of programmes and schools.
GLAN is calling on the UN Human Rights Council to recommend to Ireland that accreditation of RCSI Bahrain be made conditional on measures that “address human rights violations” associated with hospitals where RCSI Bahrain students train.
It submitted a stakeholder study as part of the UN’s periodic review process of Ireland’s human rights situation. Discussion on Irish submissions take place in Geneva on 11 May.
Dr Ó Cuinn says the standards used by the Medical Council for accreditation — the WFME standards — reference human rights in their preamble and consider medical ethics as a “core competency” of an education programme.
An Academic Fellow at Lancaster University’s Law School, Dr Ó Cuinn was co-author of a recent article in the International Journal of Human Rights on human rights obligations of states engaged in public activity overseas, with RCSI Bahrain as the case study.
Dr Fatima Haji, a doctor living in Dublin, recently conveyed a stark collage of memories via Twitter.
She was marking the fifth anniversary of a government crackdown on popular protests in Bahrain, a Gulf state governed by an unelected ruling family. The state response brutalised the lives of many healthcare professionals, including her own.
Healthcare workers were interrogated; some were removed from their workplace or houses, arrested and tortured. This, they say, for treating protesters, remonstrating against the government for its assault on medical neutrality and for giving critical media interviews.
“Whoever disappeared at that time disappeared — no phone calls, no contact with the family or lawyers… we didn’t know if they were alive or dead and then the whole other story starts, the torture and the extraction of the ‘confessions’, then the military court, then the civil court… ” recounts Dr Haji to the Medical Independent (MI).
There are numerous Irish aspects to the story, including the ongoing imprisonment of paediatric orthopaedic surgeon Dr Ali Al Ekri, who trained at the RCSI in Dublin, and continuing concern over human rights standards at hospitals used for training by the RCSI Bahrain.
Last week, RCSI Bahrain signed a Memorandum of Understanding with a private hospital in Bahrain, involving collaboration for clinical training.
Dr Al Ekri’s five-year sentence expires in March 2017. Speaking to MI from Bahrain, Dr Al Ekri’s wife — Dr Fareeda Al Dallal — says her husband is “a prisoner of conscience just because he did what he should do as a doctor. He protested against the Minister for Health…because (authorities) prevented the ambulances from reaching the injured protesters.”
“The second thing that he did was he was a witness against the regime and he said what he saw in the media. He was a witness.”
Salmaniya Medical Complex
At the dawn of 2011, Dr Haji’s life was proceeding as normal. She was employed as a rheumatologist in Bahrain’s largest public hospital, Salmaniya Medical Complex (SMC), in the capital Manama. She was planning to undertake a clinical fellowship abroad.
However, by mid-February, the rhythm of life in Bahrain had acquired a thunderous tempo. Largely peaceful protests for reform, fanned by movements in other Arab countries and long-standing discrimination of the majority Shia population, were met with a violent crackdown by the Sunni-dominated government.
Dr Haji says she had “never been political” and does not consider that she was part of the uprising. She says a defamation campaign was launched against healthcare workers.
Her recent tweets radiated a raw sense of pain and outrage.
Yet she draws from a palette of strong emotions and continues to speak out.
“There is a quote in Arabic and I think in English — ‘the thing that doesn’t kill you makes you stronger’,” Dr Haji tells MI. “The first few days of being in custody, I didn’t even know where I was, I was blindfolded and handcuffed all the time, and tortured and electrocuted and harassed on so many occasions … ”
She says she found peace in knowing she had helped patients, regardless of who they were.
The fifth anniversary has stirred feelings. Amnesty International has renewed its call for the release of Dr Al Ekri, who also worked at the SMC. According to Amnesty, he was initially sentenced to 15 years’ imprisonment (later reduced to five years) for the “possession of unlicensed weapons”, “attempting to occupy by force a public building”, “calling for regime change”, “seizure of medical equipment” and “public gathering without authorisation”.
Amnesty believes that Dr Al Ekri was targeted for his “vocal denunciation to the international media of the excessive force used by the armed forces against peaceful protesters during the February-March 2011 protests”.
Dr Haji says that after the SMC was “militarised” by the government, in response to the protests, doctors and nurses were summonsed to an ‘investigation committee’. She was asked about the extra hours she was spending at the hospital; she says she informed the committee this had been sanctioned by the hospital administration, due to under-staffing and the emergency situation. However, she says the committee accused her of empathising with protesters against the King. “They started to have lots of other accusations… ” She was suspended and later taken from her home.
She endured three weeks in detention and, alongside other medics, a military court trial on what she describes as spurious charges. Dr Haji was sentenced to five years before being acquitted at a civilian court in 2012, in the glare of the international spotlight.
BICI report I
n late 2011, the government-commissioned Bahrain Independent Commission of Inquiry (BICI), led by international law expert Prof Cherif Bassiouni, published a report on the protests and the state response. It found that the National Security Agency and the Ministry of Interior “followed a systematic practice of physical and psychological mistreatment, which in many cases amounted to torture, with respect to a large number of detainees in their custody”.
One chapter in the report centred on events at the SMC, but much of it was a complicated series of claim and counter-claim. The report concluded that some medical personnel pursued a political agenda and “moved in and out of their roles as political activists and medical personnel”. It criticised medical staff for not attempting to prevent media filming inside sections of the hospital, which was a contravention of patient confidentiality.
However, it also stated that security services “executed unlawful arrests on SMC premises and attacked and mistreated some individuals, including medical personnel”. It further stated that, on 16 March 2011, the Bahrain Defence Forces “took control of the entire complex and placed some injured persons, whom it sought to keep under its control, on the sixth floor of SMC”.
The government committed to reforms, but activists say little has changed. Mr Brian Dooley at Human Rights First, US, has considerable expertise in monitoring human rights in Bahrain. He describes the situation as “a mess”.
“There’s a lot of PR from the regime about how they’re cleaning up their act but the fundamentals don’t change — torture, arrests of people peacefully criticising the ruling family, long sentences without fair trials,” Mr Dooley tells MI.
Controversies in Bahrain continue to resonate in Ireland. The RCSI’s multi-million euro university campus in Bahrain depends on government healthcare facilities for clinical site training. These include the SMC, King Hamad University Hospital and the Bahrain Defence Forces Hospital.
In December 2014, the Irish Medical Council unconditionally accredited the medical degree programme in RCSI Bahrain after a visit to the university and affiliated clinical training sites. However, some Council members opposed accreditation (see panel).
Mr Dooley has ongoing concerns regarding medical neutrality and fair access to employment at healthcare facilities used for training by RCSI Bahrain.
“People who have been injured protesting are scared to go to government-run facilities in case they get arrested, so they get treated at underground clinics,” Mr Dooley tells MI: “The RSCI’s failure to speak out publicly about the targeting of medics is a disgrace.” He says the College’s approach has shaped the way many Bahrainis view its relationship with the country’s rulers.
Mr Dooley says reports of employment discrimination across government hospital facilities are “common”.
Sectarianism
Sectarianism in employment in Bahrain was one of the issues that deeply perturbed Prof Tom Collins, an educationalist who served as President of RCSI Bahrain from late 2011 until his resignation in March 2013.
Prof Collins recalls a group of RCSI Bahrain nursing graduates who were due to take up employment in the new King Hamad University Hospital. They graduated prior to his arrival in Bahrain.
“As I recall, at least 20 or so of those who expected to get that employment were refused it on, I quote, ‘security grounds’. They were all Shia. Some of them were the first in their families to graduate and I felt I had a responsibility to all graduates to give them what support I could. So I met them. I raised the issue at the highest level in Bahrain, of the fact that they had not been able to secure employment. But ultimately there was very little I could do,” he tells MI.
In 2013, in collaboration with Médecins Sans Frontières (MSF), RCSI Bahrain attempted to organise a conference titled ‘Medical Ethics and Dilemmas in Situations of Political Discord or Violence’. When this venture was blocked by authorities, Prof Collins resigned from his post. He says academic dialogue and exploration, and freedom of expression, run to the core of what universities are about.
While there are “multiple challenges” facing the RCSI in Bahrain, he does not believe these can be balanced from a position of “silence”.
During his time in Bahrain, Prof Collins became increasingly concerned about the overall political climate. He notes that there were some “reformist instincts” within the ruling cadre. “In Bahrain the Crown Prince had a strong reformist orientation and was enthusiastic and supportive of the conference with MSF. But even within the period I was there, I could see his influence was waning, against those more conservative power brokers, in this situation.”
‘Soft power’
The RCSI has frequently maintained that it is employing ‘soft power’ in Bahrain; seeking to exert influence behind-the-scenes.
A College spokesperson tells MI: “We are indeed aware of the Amnesty International campaign for the release of Dr Ali Al Ekri and recently met with Amnesty International and outlined our approach… ”
According to the spokesperson, the RCSI has “fully supported” the BICI’s recommendations and has made “numerous formal representations and written to the King of Bahrain, asking for clemency. Senior Members of the RCSI have frequently met senior government officials in Bahrain. At every opportunity we have voiced our concerns and position on these issues”.
The College says it has “a unique balance of responsibilities and opportunities. We judge that we can be true to our responsibilities and more effective in influencing through private advocacy.
“Our primary responsibility is to contribute to our students’ high-quality education in medical and health sciences in a safe, supportive and non-sectarian environment. To this end we are entirely satisfied that our students’ access to clinical training in the three teaching hospitals is conducted in a safe and non-sectarian environment where the principle of medical neutrality is absolutely respected.
“There is absolutely no discrimination of students and questions are never raised as to religion. The students have free access to all three hospitals. In fact, if we are asked for a sectarian breakdown of our student body we would not be in a position to answer because we don’t ask our students when they enrol what their religion is…
“We believe that the future for Bahrain has to be one of dialogue and reconciliation — we know this well from our own national story. We will continue to contribute through education and continue to advocate for just outcomes.”
Dr Al Dallal awaits her own just outcome. She and Dr Al Ekri have four children together. Their 13-year-old son was born in Ireland, when the family lived here in the early 2000s.
“They are still missing their father; they haven’t seen their father a lot. There is a time to visit him — we are allowed to visit him twice a month.”
Previously, Dr Al Ekri had been hailed a hero by the Bahraini government, after he journeyed to Gaza to provide medical care to Palestinian people. Dr Al Dhallal says her husband had the same intention in Gaza and Manama.
“The same intention to do things, but different situations, different places, different people.”
Waiting
Dr Al Dhallal says the RCSI has not been vocal on her husband’s case. However, she wishes to thank Irish healthcare workers for their solidarity, especially Prof McCormack.
She is also thankful that her husband is in “good health”.
Dr Haji says she did not know Dr Al Ekri well before the events of 2011. She got to know him and his family in the ensuing trial periods. He has the “tough look” of an orthopaedic surgeon but “the heart of a teddy bear”, she says, adding that his outspokenness angered the authorities.
Currently working at the Mater Hospital, Dublin, having come to Ireland in 2014 after her husband took up a fellowship, Dr Haji ultimately plans to return to Bahrain.
Dr Haji says the RCSI needs to make strong public statements on key issues, including on threats to medical neutrality and sectarianism in Bahrain’s healthcare system. She believes there is much more it could do.
In this sense, living in Ireland during the 1916 Rising Centenary commemorations was a strange experience. She notes that, in its 1916 programme, the RCSI underlined the role of alumni and fellows in treating all factions.
“At the beginning I was really outraged with the way they responded. But now, five years from the events, with all that is happening on the anniversary of the 1916 Rising and all the activities they have been announcing and then, how they presented themselves as ‘we have treated equally all the wounds from the British military and the Irish soldiers’ … I am not accusing all of them but some of them definitely are so hypocritical.” She says “the glory is easy to claim after 100 years”.
Sometimes friends remark to Dr Haji that she is doing well here. They say she should just focus on her career. Dr Haji is serious about her career, but feels she must continue to speak out and be a good example to her sons.
“Some people have to do what they have to do, even if the price is so high. But the price of freedom is even higher. The price of truth is higher. We are living in a world where saying the word of truth means you have to pay the price very high… I still believe in saying the word of truth.”
Meeting with Bahraini ambassador was ‘comprehensive’ — Áras
It was an odd coincidence.
In April, on the same day Dr Haji tweeted her painful memories of the Bahraini government crackdown in 2011, President Michael D Higgins received the new ambassador of Bahrain to Ireland, Ambassador Shaikh Fawaz bin Mohamed Al Khalifa, at Áras an Uachtaráin.
The ambassador conveyed the Bahraini leadership’s “commitment to the historic bilateral relations linking the two friendly countries and their people”, according to the Bahraini state media.
A spokesperson for President Higgins told MI that matters discussed in a private meeting with the ambassador could not be disclosed. But they were “comprehensive” and included “general and particular issues”.
“The President has addressed the issue of human rights on many occasions in the past, including at the Royal College of Surgeons earlier this year and at a meeting of Amnesty International last year,” he added.
In February, President Higgins spoke at the RCSI in Dublin on the occasion of the College’s Charter Day and award of an honorory fellowship. President Higgins specifically mentioned the RCSI’s ventures in Malaysia, and referred to human rights generally, but there was no intelligible reference to Bahrain.
In being accorded the highest distinction bestowed by the RCSI, President Higgins joined an exclusive club.
Honorary Fellows include the late Nelson Mandela, the late Mother Theresa, former US President Jimmy Carter and, among others, Bahrain’s King Hamad bin Isa Al Khalifa. The King received this honour in 2006, with the RCSI hailing him as “a man of peace, stability and influence in a difficult and troubled world”.
In 2003, the RCSI awarded an honorary fellowship to Sheikh Khalifa Salman Al Khalifa, who has now been Prime Minister of Bahrain for over 40 years. The BBC described him as a “hardliner” in the wake of the events of 2011.
Orthopaedic Surgeon Prof Damian McCormack, who has spoken out on human rights violations in Bahrain, told MI he was “very disappointed” President Higgins accepted the honorory fellowship.
Council members were concerned on Bahrain
The Medical Council’s accreditation report on RCSI Bahrain was noteworthy for what it did not address, according to a human rights lawyer.
Dr Gearóid Ó Cuinn of Global Legal Action Network (GLAN) said the report does not outline how the Council accounted for the fear and reluctance people would have in criticising standards of medical neutrality and human rights at government hospitals, used by RCSI Bahrain for student training.
One month before the Council’s visit to Bahrain in October 2014, human rights activist Ms Ghada Jamsheer was arrested on charges of defamation after tweeting criticism of King Hamad University Hospital, and its head, while she was a patient.
“The Medical Council arrive less than a month after she is detained, go into the hospitals and say, ‘is everything okay here?’” commented Dr Ó Cuinn.
According to minutes of Medical Council meetings, some members were opposed to accepting the accreditation report on the medical programme at RCSI Bahrain.
A Council meeting in December 2014 heard of the concern of members Mr John Nisbet and Dr Ruairi Hanley with regard to “environmental and political factors” that could impact the safety of students attending RCSI Bahrain.
“Concern was also expressed that there had been insufficient consideration during the accreditation process of ethical and human rights concerns in Bahrain, as articulated in the Ceartas report.”
Ms Anne Carrigy, on behalf of the accreditation team, “confirmed that team members had raised every matter with representatives of RCSI Bahrain, and with students in private session, which was deemed relevant in order to apply the relevant World Federation of Medical Education (WFME) standards with representatives of RCSI Bahrain, and with students.”
Seven members accepted a counter-proposal not to accept the accreditation report, with 10 members against and one abstaining.
A vote was held on the original proposal to accept the report, with 11 in favour, six against and one abstaining.
One of the accreditation report recommendations was that RCSI Bahrain satisfies itself that it has adequate monitoring and control of any potential impacts on programme delivery and achievement of educational outcomes at its campus and at associated clinical sites.
The Council says there is a monitoring phase following accreditation of programmes and schools.
GLAN is calling on the UN Human Rights Council to recommend to Ireland that accreditation of RCSI Bahrain be made conditional on measures that “address human rights violations” associated with hospitals where RCSI Bahrain students train.
It submitted a stakeholder study as part of the UN’s periodic review process of Ireland’s human rights situation. Discussion on Irish submissions take place in Geneva on 11 May.
Dr Ó Cuinn says the standards used by the Medical Council for accreditation — the WFME standards — reference human rights in their preamble and consider medical ethics as a “core competency” of an education programme.
An Academic Fellow at Lancaster University’s Law School, Dr Ó Cuinn was co-author of a recent article in the International Journal of Human Rights on human rights obligations of states engaged in public activity overseas, with RCSI Bahrain as the case study.
