The Phoenix Flame

The Phoenix Flame – A Study of Fenianism and John Devoy. By Desmond Ryan. Arthur Barker, London, 1937.

This review was written on August 5th 2004

I did not have a very high opinion of Ryan’s writing and I found his early chapters dealing with the origins and growth of the Fenians to be rather confusing and poorly structured, as indeed were the first chapter or two dealing with John Devoy. However, I found the later chapters dealing with Devoy and his huge and long lasting influence on the progress of Irish nationalism to be better written and more absorbing. They gave me a better appreciation of the worth of Desmond Ryan’s work. His book is as much a short biographical note on John Devoy as it is an account of Fenianism, but perhaps this is a logical consequence in view of Devoy’s seminal contribution to Ireland’s political evolution during Fenianism and later, and the long years of Devoy’s life.

John Devoy

I had never read much about the Fenians nor about the New Irelanders who preceded them. I was therefore interested in this work. It is divided into two sections, the first seven chapters dealing with the origins and history of the Fenians and the last with the life and influence of John Devoy. It was an organic nationalistic movement which was the logical successor to Daniel O’Connell and the subsequent less pacifist movement supported by the New Irelanders. Fenianism started after O’Connell had failed to gain Repeal (of the Irish parliament) by constitutional means. That and the failure of the Irish Ireland movement of the 1840s, led to disappointment and disillusionment, particularly among the more ardent nationalists. The emphasis was now on military revolution, a policy which was to end with a return to the more pacific policies in the late 19th century of the Irish Parliamentary Party lead by Butt and later by Parnell, and of Davitt’s Land League. The spirit of Fenianism survived only through the continuous existence of the IRB, dormant until its reorganisation early in the second decade of the twentieth century. My uncle-in-law and godfather, Denis McCullough of Belfast and a few of his colleagues had an important role in its revival.

The Fenians had a huge influence, not only in Ireland but also in Britain and in the British Army. It had critical support among the Irish Americans and the Fenian leaders who had escaped or been deported to the United States and who lead the highly influential Clan na nGaedheal there. Support from America was in terms of money and of ex-American Civil War veterans who came to Ireland to organise and to assist in the proposed revolution. Such American support would have been vital to the success of a rebellion but a serious split in Clan na nGaedheal, added to the problems at home, had a disastrous effect on the prospects of success. The Fenians in Ireland were lead by James Stephens who was an outstanding organiser but he was hopelessly incompetent as a revolutionary because of his caution and indecision, his proneness to self-deception, his poor judgement, his lack of diplomacy and his unwillingness to accept advice from his many supporters. While the Fenian movement was basically a movement of violence and committed to revolutionary methods, the Fenian leaders were totally against unnecessary killings and terrorism, but poor organisation and the independent activities of extremists lead to such events as the murder of policeman Brett by the Fenians in Manchester and the subsequent dynamiting of the walls of Clerkenwell prison which led to the deaths of seven innocent people and of many wounded. These and the subsequent Phoenix Park murders were condemned by the Fenian leadership and were carried out without their authority.

James Stephens

The movement had its complement of spies and, because of the information supplied by them to the British authorities in Ireland and in Britain, and the indecision of Stephens and his lieutenants to plan and launch a nationwide rebellion, the movement was to lose all its efficacy and to lose the sympathy which it might have received from the people of Ireland and from those in Britain who had moderate views about the justice of Irish nationalism. Nevertheless the Fenian movement was highly effective in furthering the whole cause of Irish nationalism if only because, instead of attempting military victory, the Fenians did achieve some bungling heroism. While Stephens was resisting a decision to initiate a widespread rebellion, the British authorities were gradually arresting, imprisoning and transporting leaders and activists, thanks to information they were receiving from spies within the organisation. The imprisoning and deportation of so many hundreds of Fenians, as John Devoy said with heads erect and defiance on their lips, made a huge contribution to the ultimate goal of Irish independence and, like the influence of the 1916 signatories, the Fenians found victory in defeat. In Desmond Ryan’s word, Fenianism in chains above all proved more powerful than Fenianism in the field.

The Fenians were badly treated in British jails but their generally courageous response to maltreatment and their vigorous reaction to the unnecessary hardships and cruelties imposed by the prison authorities led to considerable public sympathy and to the success of the movement, despite its military failures. The movement was made up of a wide variety of people with varying views on the question of military intervention but, apart from the occasional extremist who acted independently of the leadership, there was a general horror of terrorism or the killing of innocent people. The Irish American veterans were among the more impatient to be involved in direct action.  Even their reluctance to kill the enemy must have played a part in their indecision to revolt, a reminder of my father’s statement to me about his own reluctance during the War of Independence to even cause the unnecessary killing of enemy soldiers. The entire Fenian movement was dogged by divisions, disagreements and personal antagonisms which added to the sense of anarchy within it.

Fenianism, through the influence of the better known leaders, was, after the failed rebellion of 1867, to lend considerable support to Butt and Parnell and the Irish Parliamentary Party, and to John Mitchel’s moderate policies and to Michael Davitt’s successful Land League. John Devoy and some others of Clan na nGaedheal in the United States were also supporters in bringing the more extreme elements of Fenianism behind the policies of Davitt and Parnell. Butt had been a constitutional nationalist who had defended the Fenians in court. He preceded Parnell in supporting and organising the more constitutional policies of the Irish Parliamentary Party in Westminster.

Desmond Ryan states Thanks to Devoy the old Phoenix Flame burned still in the new movement, and thanks to him the rank and file of the Fenians stood behind the Land League until the Land War was won. And to the end Devoy backed Parnell until his fall, and he backed Davitt and the Land League. Later still he backed the Anglo-Irish Treaty and, although now at an advanced aged, he did his best to influence the anti-treatyites to accept the agreement with Britain. Devoy was fully supportive of military revolution but was opposed to any form of terrorism or anarchy and unnecessary loss of life, and he was mature enough as a patriot and a nationalist to know when more constitutional methods were likely to succeed in achieving self-determination. After all, there were other equally important changes taking place in Ireland as well as the political movements of the time – the changing policies of Westminster to kill the Irish discontent by kindness, the widening of the electorate, the gradual taking over of local government by the plain people of Ireland and the vitally important advances in the education of the Catholic population. The religious orders who played such a seminal part in educating the Catholic people of Ireland during the nineteenth and early twenty centuries can surely claim to have done as much to progress the cause of Irish independence as the politicians and the soldiers. Nor should one too easily forget the huge apolitical progress of the Irish cultural revival which was being led and supported by all sections of the community, Protestant as well as Catholic.  

It was Devoy’s mature approach to the solution of Ireland’s woes which made him such an important and revered historical figure to such of his successors as my father and my father’s colleagues who supported the Treaty, despite their initial willingness to take part in the military resistance to British intransigence. To understand Fenianism and to learn the true greatness of Devoy, it is necessary to read his narrative Recollections of an Irish Rebel, published posthumously by Charles P. Young, New York, in 1929. Writing of him in the introduction to his autobiography, Judge Danial F. Cahalan said For more than sixty years, in storm and sunshine, in sickness and in health, he dreamed and toiled and worked for the cause of Ireland.

It was reading this book that I first realised that the 1916 Rebellion, heroic as it may have been, was a disaster when combined with de Valera’s failure as our national  leader to support the Anglo-Irish Treaty and to precipitate the country into the ‘compound  disaster’ (my father’s words) of a civil war.

As an aside to this book, I should say that my mother, Min Ryan, was sent by Cumann na mBan to America in late May or early June 1916 to inform Devoy of the circumstances of the Rising. The Rising was kept completely secret by the British from the outside world during the Great War and little was known about it by Devoy and the American people as late as six weeks later until my mother arrived with her account. Devoy mentions her arrival in volume II of his autobiographical Devoy’s Post Bag.

The American way...

A History of the American People by Paul Johnson. Weidenfeld &  Nicolson, London. 1997. pp 814 of text; 111 of references, maps and index. 

This review was written on February 23rd 2005

The American War of Independence finished with the Paris Treaty of 1783 and America’s link with the British Crown. Like the freedom we achieved in Ireland in 1922, there were many citizens of the colony who were loyal to Britain and its king, and who were bitterly disappointed by the success of the war. Between patriots, loyalists, Indians and slaves, the revolutionary war was to some extent a civil war as much as a war of liberation. Many of those loyal to Britain crossed the border to Canada, thus changing the balance there where previously the French dominated the local scene. Through this demographic change Britain gained Canada as compensation for the loss of the American States. A few others returned to England but most remained in the States where they were subjected to some discrimination during the early years of independence. Whatever resistance to independence from Britain existed in the colony, it was inevitable that, in such a distant and potentially powerful and wealthy colony, its population would not remain subservient to any other nation.

This book is a very comprehensive account of the United States since the first immigrants arrived at the end of the 16^th century and survived to be the harbingers of the powerful nation we have to-day.  I found the book of particular relevance because of the huge impact the United States has had on the world during the last two hundred years, leading to the gradual Americanisation of the planet.  The Americans have created a secular and materialistic society committed to consumerism, waste and self-gratification and yet, paradoxically, with a strong contrasting tradition of church going. Church going and moral rectitude there seems consistent with personal ambition and wealth, and with business success.  Government was designed to allow ordinary people equality and the opportunity to leave them free from interference and oppression. Revivalism and fundamentalism were the passions that stirred the American frontiersman but did not diminish their ardour in seeking wealth and power and in decimating the indigenous population. Kellog, who set up the great food industry, was an ardent Seventh Day Adventist, illustrating the close compatibility between business, money, wealth and church going. It was an important principle that private interest had priority over public welfare. This may explain why the wealthiest country has such a relatively poor welfare and social security system.

It was axiomatic that American culture was egalitarian and democratic and that the people were anti-elitist. There was a strong prejudice against legislation and meddling with the people’s natural initiative and opportunities to advance and enrich themselves. ‘Open the door to opportunity, talent and virtue, and they will do themselves justice.’

In no country is the American influence more evident than in Ireland. It has contributed to many of our social habits, to our culture in entertainment and in the commercial world, and it has introduced into our country many aspects of organised crime, violence and commercial racketeering. It has also made us more and more dependent on America as we become a component of the American commercial empire and as we witness the increasing imbalance between the commercial and military power in the United States and the rest of the world.

In 2005, with Bush in command for his second term and following the American invasion of Iraq, we can only speculate what America is likely to do next in the world. As Lord Acton said ‘Power corrupts and absolute power corrupts absolutely’, and there is no reason to believe that the extraordinary power in the hands of the  American will not lead to corrupt and disastrous consequences which may end in catastrophe for the human race. Traditionally the Americans have lead the world in establishing personal freedom within the democratic system but may they not respond to Bush’s neo-conservatism in the same way as the great majority of the German people responded to Nazism and continued to support and adulate Hitler up to the very end of the World War?

The book is comprehensive and covers many aspects of the social, economic and political history of America. Much emphasis is laid on the personal freedom of individuals which was the fundamental tradition of the States from the early years. For those immigrants who escaped from the feudal, aristocratic and monarchic systems of Europe, it is not surprising that the American dream of personal freedom acted as such a strong magnet from the earliest times; freedom from religious prejudice and oppression, from poverty and the devastation of recurring famines and deadly pandemics.

Much as personal freedom and the democratic system were preferable to the subjugation of the masses of Europe, they were not achieved without serious problems. Personal responsibility was not assured in equal measure in the United States and particularly so in the early years. There was a gradual and increasing migration across the continent with the passage of time but the rule of law seldom accompanies a pioneering people. The tardy development of legal restraints led to early violence, lawlessness and corruption, little known among the plain people of Europe, and this tradition of violence, corruption and racketeering at all levels of society remains with us to this day. Like many other American attributes, violence against the person, property and society is becoming part of the Irish scene and that of other European countries. In what was known as the Wild West there were constant conflicts between vigilantes and horse and cattle thieves, whites against Indians, miners versus farmers, and farmers and landowners versus railroads, although the situation did improve in the west as legal structures were set up in the new states.

Corruption is an inherent form of behaviour among us all. It becomes more widespread in a society striving for more and more possessions, whatever their needs, and it can only be controlled in a democracy by a strong spiritual and cultural commitment to virtue or by the effective rule of law. In practice the rule of law in a democratic society, obsessed by the urge to acquire more possessions, seems relatively ineffective in controlling the opportunities for corruption. Does democracy with its assurance of personal freedom but lacking the certainty of personal responsibility hold within itself the seeds of its own destruction?

Every branch of the administration and particularly the civil service was infiltrated by the spoils system. The presidency was seriously discredited at times and this is inevitable where money and commercial power play such a large part in electing the president. Andrew Jackson was beaten in the 1824 election by the corruption of Clay and Adams. This was the time when the two-party system was founded. It is also part of the culture of the Americans that successful businessmen and financiers became the icons of a materialistic society. Most of the really rich, such as Carnegie, Frick and Morgan, made their money on railways, oil, steel and mining, in a vast country with unlimited natural resources and relatively few people to exploit and enjoy these. Personal freedom and corruption brought huge opportunities for people to amass great fortunes. Does freedom eventually lead to sin and to chaos unless society is governed by a culture of caring and virtue?

In 1993 there were 559 members of Congress, that is, members of the Senate and the House of Representatives combined. Of these, 239 were practising lawyers. One hundred and fifty five were businessmen of whom about 70 were qualified lawyers. There were 77 in education, 33 in medicine and 97 in the public services. Parliament was heavily dominated by the legal profession. One reason for the imbalance in congressional personnel was the huge cost of becoming elected, computed at $5.000 per week for the House and $12,000 for the Senate. It was virtually impossible to become a member of Congress without being wealthy. In the 1990s the President and his wife, 42% of the House and 61% of the Senate had law degrees. It appears that the number of lawyers in government continues to grow. It surely must be ironic that at the time of independence difficult questions of legislation were referred to the lawyers because they were deemed to be independent of personal ambition!

A worrying aspect of American governance is the increasing power of the courts.  This applies in particular to the Supreme Court. The adoption by the courts of legislative measures which by right should be a matter for the President and Congress is a trend which is apparent in Ireland too where parliament may be reluctant to adopt measures which may be unpopular with the electorate.  The author provides several examples of such intervention by the Supreme Court in the United States, including its role in establishing desegregation, a decision which should have been the responsibility of the President and Congress. Another worry, at least in Ireland, is the widespread lack of accountability resulting from the easy access to the law courts.

The author provides important biographical notes about the outstanding leaders of the revolution and the subsequent architects of the new republic. These accounts confirm the qualities of courage, energy, idealism and eccentricity which mark those who inspire us and provide the dynamics of history.  Washington, Franklin, Jefferson, Adams are among those whose full biographies could be read with profit.

Trinity Episcopal Church, Unfinished Capitol in background

A feature of American society is the intensely materialistic aspirations of the people combined with the widespread commitment to religion. With the exception of the Catholic Church, which has a strong following in the States, most other Christian denominations are committed to a fundamentalism based almost solely on Bible reading. The Episcopalian Church, the direct extension of the Anglican Church, shows a steady decline in numbers of churchgoers. It is likely that one of the strongest appeals that Bush had to the electorate at the time of his re-election was his constant reference to God and to his reaching out to the Bible belt in the Southern States. He claims God is on his side, a belief he shares with Paisley, the Pope, the Muslims and all zealous political and religious movements. Perhaps there are many different gods and they may be in constant conflict with each other, like their adherents on Earth? I, as a Stoic, may be an exception thanks to my exclusive secular belief.

There is an important chapter about the American Civil War and its genesis. It appeared to be an inevitable consequence of the division between the Northern anti-slavery States and the Southern slavery States. Slavery originated in Barbados and spread rapidly to the Southern States and Islands when cotton became an important industry. The slavery division between the Northern and Southern States originated as early as the end of the 18^th century at the time of the Revolution and it festered for another 80 years up to the Civil War in 1850. The war lasted for about four years with after-effects which continued for another fifteen years. While it seemed to be inevitable in view of the bitter division about slavery, it was in fact a major failure on the part of the Federal government in Washington to control the extremists on both sides of the divide. Owing to this central failure to solve differences amicably, the Southern slave States seceded unilaterally without discussing the proposal with their electorates, thus precipitating the war. Like all civil wars, it was conducted with great bitterness and there was little respect for the rule of law. It led to much destruction where the fighting took place and left scars on the American psyche which was to endure for a few generations.

Although the end of slavery was inevitable, nevertheless one could not but have sympathy for the slave states because of the stable system which had evolved there. On many of the estates the slaves became loyal and happy subjects and enjoyed the security of a stable community. There were of course, as always happens in human affairs, many examples of abuse and cruelty but it was sad to realise that many of the slaves were much worse off when they were freed. Many left the Southern States and became rudderless, underprivileged and a hated minority in all parts of the Union, including the Northern states where the seeds of their freedom were set.

It is only in recent times that the bitter racial divide which existed in America after the civil war has begun to narrow but even to-day the blacks remain underprivileged in political, social and economic terms. A paper in the Lancet published in 2004 shows that infant mortality, adult mortality, school drop-outs and health care in general showed a substantial disparity between blacks and whites with a twofold difference between blacks and whites in terms of lives lost before the age of 75 years.  Asians and Hispanics also enjoy better conditions than the blacks and are much closer to the whites in terms of prosperity, health and education. The United States is still a deeply divided nation, most especially on ethnic grounds.

Many of the immigrants from Ireland, England, Scotland and other European countries were subjected to religious persecution in their native lands and this applied to Catholics and the disestablished churches – the Quakers, Huguenots, and the many low churches which broke from the Anglican persuasion. Religion was always a feature of the American culture where atheism and agnosticism was generally frowned upon. From the early days of immigration religion was the binding force that secured the communities on the East coast. The popularity of religion, while always strong in the United States compared to Europe, tended to fluctuate from time to time. There was a surge in church going among all denominations during Eisenhower’s presidency. In 1910 43% of citizens were attached to church. This had risen to 49% in 1939 and by 1950 it was 55%. After Eisenhower’s presidency it had reached 69%, back to 62% by 1970. The substantial increase during the 20^th century might be attributed to the huge evangelical movement during the 1930s and later, with such well known evangelists as Monsignor Sheehan and Billy Graham and many other figures travelling the continent and spreading the Bible and the gospel of Christ at their revivalist meetings.   It is no surprise that the churches which have the most numerous adherents to-day are the Catholics, and the low churches which have forsaken much of the ritual of the Anglicans to dwell mostly on the ‘truths’ of the Bible. The Episcopalian Church, the direct American extension of the Anglican Church, is in continued decline as it gives away to the Catholics and a bewildering variety of traditional and latter-day Bible adherents.

It was not uncommon to find that the religious could also be among the corrupt. Some amassed great wealth and some became great benefactors in their later years, perhaps realising that they could not take their worldly goods with them. As was said, plutocracy often leads to democracy. Thus the public was often the beneficiary of a crooked man’s generosity.

As regards violence, in 1992 one of every four American citizens was the victim of crime. On this date there was a greater proportion of criminals among children than any other age group. According to Johnson, reported violent crime had increased by 560% from 1960 to 1990, and there was a greater preponderance of criminals among blacks. He drew a direct correlation between the rise of crime and the decline of religion, although the evidence of secular churchgoing changes seemed inconsistent with this view.

In his chapters on social and economic affairs, Johnson’s description of the rise and fall of prohibition should be an object lesson to all legislators and is a classical example of the so-called Karl Popper’s law of intended effect for, apart from not reducing alcohol consumption and alcoholism, it lead to widespread organised crime. It was a do-gooder’s conception and the not unexpected result of their poor understanding of human nature. The prohibition laws were rescinded in 1933 but the organised crime continued in many other areas to blot America’s social and political life and history. Prohibition was an experiment in social engineering which did permanent damage to American society. We can draw a parallel to our own current laws criminalizing drugs in Ireland. We are living in an increasing drug culture, contributed primarily by the pharmaceutical industry and the medical profession but spilling over into the criminal supply of addictive drugs to the public. The criminalising of drugs has been an abysmal failure, both in terms of controlling the scourge and in leading to widespread crime. It is another classic case of the Karl Popper law and, like the scourge of prohibition; it can only be controlled by decriminalising the personal use of drugs while at the same time employing legislative and commercial measures to control the sources of supply.

There are interesting allusions to the drinking habits of the Americans. The history of the origin and growth of the Cola soft drink industry is a parable of the commercial history of the American nation. The past American craze for dry martini sparks the author’s reminder of Barbara Parker’s quote

I like to have a dry martini;

Two at the very most;

After three I’m under the table;

After four the host.

There are also chapters on the evolution of American music, education, literature and the visual arts. The chapter on demography is essential reading if one is to understand the dynamics of the American phenomenon.

The chapter on the history of California is fascinating. It describes the early immigration from the East about 1850, mainly as a result of finding the rich deposits of gold; a huge gold rush followed. It describes the foundation of San Francisco (and its disastrous earthquake) and its reputation in the early years as America’s premier sin city, later to be cleaned up by William Randolph Hearst. Johnson describes the meteoric rise and growth of Los Angeles, a city which owes its size and its huge contribution to American culture in the areas of music, films, the arts and architecture to the many Eastern Europeans immigrants, including the Russians Jews, who found their permanent home on this part of the West Coast of America. Frank Lloyd Wright made a seminal contribution to American architecture and his career was intimately related to Los Angeles where he built some of his extraordinary houses which made such an impact on national and international architecture.

Paul Johnson

Johnson as a historian is rather biased in his interpretation of the recent American political scene and is well qualified to join the neo-conservatives. He had strong views of his own about the various latter day presidents. He was lost in his admiration of Truman as he was about Eisenhower. He had a special admiration for Eisenhower. Eisenhower could do no wrong and was a man of extraordinary judgment. His few critics had little foundation for their views. And perhaps he was right in his judgment of Eisenhower who made the prophetic comment in his valedictory address in 1961

In the councils of government, we must guard against the acquisition of influence, whether sought or unsought, by the military/industrial complex.

His military leadership during the World War certainly qualified him to share insightful views about the military. Eisenhower was critical of militarism, of generals being involved in politics and of the excessive growth of military power. He disapproved of the arms lobby encouraging government to expand the military arsenal.  

The author was critical enough of FDR but admitted that he had good qualities as a president. He is informative about all the presidents from Wilson to Clinton. Wilson he described as having made a disastrous contribution to foreign policy after the Great War despite a successful domestic career. He was the president who was seriously ill during the last two years of his presidency but his wife and doctor managed to conceal this from his closest colleagues and the public.

Johnson is neo-conservative in his views of the latter day presidents, approving strongly of the republican incumbents Nixon and Reagan, and being disparaging and contemptuous of the Kennedy and LBJ regimes. He is dismissive of Clinton, describing him as a second rater. He refers to his ‘failures and moral inadequacies’. The author would undoubtedly have been enthusiastic about Bush’s foreign policy.

He is harshly critical of Jack Kennedy and the extended Kennedy family. He makes so many improbable accusations about them, their lying ways, their corruption, their contact with well known criminals and their extraordinary sexual appetites, that one must have serious doubts about Johnson as an objective and credible historian.  If he is correct in averring that Jack Kennedy’s election to the White House was based on money and corruption, and his father’s malpractices, criminality, dishonesty and lies, can much of these factors not have been a feature of other presidential candidates? He states that most of the intellectuals and liberals who supported Kennedy were guilty of self-deception and were involved in one of the biggest frauds in American history. He doubts whether Kennedy was the real winner, stating that the elections in Texas and Illinois were rigged in his favour. Cortisone treatment was employed to give Kennedy a more handsome and elegant appearance. In Kennedy’s TV confrontation he had with Nixon, the author charges the TV company with using extraordinary means of embarrassing Nixon during the interview. His account of Kennedy’s sexual activities beggars description. He had sex every day, he could have it with anybody and he had sex in the early morning before his inauguration! His seemingly unbalanced opinion of Kennedy can only damage his own reputation.

Johnson is equally critical and contemptuous of Linden Johnson who took over from Kennedy. He refers to the many scandals that Johnson was involved in and to his corruption and unpleasant character. He too had a voracious sexual appetite, no more discriminating than Kennedy’s, and was an inveterate bottom pincher in swimming pools! A philanderer and at least one homosexual episode!

On the financial side, LBJ was the first president to introduce budget deficits, thanks to his introduction of progressive and radical social services and his concern about mounting environmental problems. Under his presidency he had nine million acres of land put aside as a wilderness and by the time of his retirement this had increased to one hundred million. With the accession of Bush this land is apparently now under threat as part of his alleged antagonism to the environmental lobby. Since LBJ’s time the successive American governments have apparently thrown all discretion to the winds in matters of budget deficits. LBJ also continued to support the Vietnam War and considerably increased the American military strength in Vietnam. The War started in 1961 in Kennedy’s time and did not finish until 1975. However, American intervention in Vietnam had started as early as 1954 but was initially a more clandestine operation. The amount of ordnance employed in the War included three times the explosives employed by US bombers in the World War. The Vietnam War and other foreign interventions by the Americans are a reminder of how vulnerable we and the rest of the world are to the American industrial/military influence under Bush.

In view of the author’s definite bias in favour of the Republicans and the conservative lobby in America, it comes as no surprise that he is an admirer of Thatcher and describes her successor John Major as ‘featureless’. Clinton is lacklustre and the author makes excuses to justify such disastrous American policy decisions as the Iran arms scandal and the intervention in Nicaragua during Reagan’s administration. They were excused by him ‘in the American interest even if they were guilty of technically breaking the law’!

He describes the interesting episode of the McCarthy intervention into American affairs in the 1950s. It was a dramatic and emotional response to the Cold War and to the passionate anti-communism of Senator Joseph McCarthy who managed to highjack the administration into adopting draconian measures against many citizens, innocent and otherwise, who were suspected to have contacts with or leanings towards Moscow. McCarthyism terminated as abruptly as it emerged, to the longstanding embarrassment of the American government and people. It was a sudden break from sanity and was likened to the Salem witch hunt of the 18^th Century.

Of particular interest to medics and those who might have spent several days lying on a hospital trolly...

 

Unhealthy State - Anatomy of a Sick Society. by Maev-Ann Wren. New Island, Dublin. 2003. pp 445.

A detailed review written on July 29th, 2005.

This rather long-winded text was based on an earlier review I wrote after receiving a copy of Unhealthy State in 2003. I had thought of sending a copy to the author and to the Minister for Health but before doing so I realised that, in trying to solve the endemic problems of our health services, I was ignoring many of the fundamental factors which bedevilled a solution of these, and that we in Ireland shared many of these factors with the international community. It was in an attempt to delve deeper into the basis of our health crisis, a crisis which we share with most Western countries, that I have written this longer commentary

The author’s examination of the health delivery service is detailed, comprehensive and highly critical. It appeared at the same time as several commission reports which had been set up to examine different aspects of the service. The earliest of these recent reports was the Deloitte and Touche report ordered by the Department of Health to examine the value for money of the service. The Hanly (on medical staffing) and Prospectus (to assess functions and structures of the service) reports appeared in 2003 and were commissioned by the same department. The Brennan report (management and control of spending) was commissioned by the Department of Finance. Unhealthy State is based on extensive research into all aspects of private and public health and will undoubtedly provoke a reaction which will bring about at least some change. Ms Wren is particularly critical of the lack of equity in the service with poor access to primary care for the less privileged members of the community.  And many of the existing problems within the service she attributes to under funding of health by successive governments.  She is also critical of the specialists in the hospital services because of their method of payment, their high average income in the public service and the high income of some who are in private practice. She is critical of the current mix of public and private medicine and of the fees charged by general practitioners.

She underlines the fact that the Irish health service has evolved over the years in a piecemeal and haphazard fashion because of poor long-term central policy and strategy, and failure to face up to abuses which she attributes to the medical profession, local politicians and other dissident groups.   She is particularly critical of the current Fianna Fail administrations. The recent reports which have been issued on health affairs, widely quoted in her pages, and her detailed analysis, have lead to widespread comment in the popular and medical press. The media comments have been critical of the government and the medical profession, while the medical press has been invariably defensive of the profession.

Close to 50% of the Republic’s population is covered by health insurance, of whom more than 80% are with the VHI. The head of the VHI, Vincent Sheridan, is currently pressing the government to privatise the company because he believes that there are compelling financial and economic reasons why the health insurance industry should be more competitive and in a position to make decisions free from government interference. I spoke to Mr. Sheridan about his proposals but his reasoning was a little beyond my understanding. I gave him a copy of our IMA 1974 report on compulsory health insurance as a possible health delivery system for Ireland but he had no strong views about this proposal one way or another.

Sheridan reminded me that, in speaking to Tom O’Higgins shortly before his death; O’Higgins told him that the VHI scheme which he launched as Minister of Health in 1956 was modelled on the Australian system of health insurance, a fact which I was unaware of. We spoke about such problems as conflict of interest, lack of audit and unusually high incomes from private practice which clearly impinge on both the private and public services, but, even if the insurance authorities are aware of such anomalies, they obviously do not feel that they have any function in interfering with professional matters. I also referred to the lack of evidence based practice but again this is entirely a matter for the profession itself to attend to. A real problem must be that it is the hospital doctors who determine the resources which are needed but doctors have little interest in or knowledge of  cost efficacy, and so far it has been very much a consultant, and possibly doctor, driven service.

What are the basic elements of an ideal health delivery service which would exist within the many current political, financial, professional, social, and cultural restraints?  That such a system has not been devised in Western countries is clearly apparent, almost certainly because of the rapid advances in medical care and technology since the mid-twentieth century, because of an increasingly assertive, demanding, litigious and educated public, the gradual erosion of the extended family, and to some extent at least, the partial erosion of the vocational aspects of the profession by an increasing commitment to accumulating wealth, a trend which the profession shares with the rest of the community.

The ideal system must include immediate access to primary and specialist care for the entire community; efficient central direction and efficient administration at local level; well trained health professionals; emphasis on cost efficiency as well as high professional standards through audit and peer review; and financial investment commensurate with other demands on the public and private purses. It might well be asked if it is possible to provide a service which would satisfy everybody, bearing in mind the increasing cost of medical technology and the prospect of a more demanding and ageing society, where the old are subjected to expensive ‘salvage’ medicine, Ivan Illich’s prolonging of death, which will raise increasingly serious ethical as well as financial questions. The VHI and BUPA premiums have increased at an average of 10% over the last five years. With the escalating costs of medical care it would be wise to assume that these increases, at three times the rise in the cost of living index, are likely to continue.  Certainly any pretensions of achieving a more equitable and efficient service will require government to move from a low tax to an high tax economy, and may lead to the need to contribute 20% or more of GDP to health care by 2010. The estimate of 12% by 2022 by the United Kingdom Treasury is likely to be very wide of the mark. It will also require a new sense of idealism on the part of the electorate if we are to achieve a more just and stable society.

In commenting on Ms Wren’s book, I would like to deal with the following subjects raised by her - the question of equity, the public/private mix, the role of the medical profession, the role of the nursing profession, the role of government and health promotion.

The Question of Equity.

Inequalities in access to optimum services are perhaps the most glaring shortcoming in the current health service. It exists at both primary general practitioner as well as at hospital level. To achieve equity would require drastic changes and more assertive authority by government. Equity at a primary level could be more closely achieved by increasing the number of medical cards to a higher threshold of income and by including other non-eligible people who may be disadvantaged for one reason or another. Or might the middle 20% or so of those who experience hardship when attending GPs and who have difficulties in paying for medications not be partially assisted by a state scheme?

There are serious inequities in the hospital services where public patients are subjected to unacceptably long waiting lists for specialist consultations and treatment in hospital, and are subjected to other disadvantages, including less certain contact with consultants, more dependence on doctors in training in their management and treatment, and the cancelling of appointments and services, including operations, because of shortage of beds, shortage of staff and other shortcomings. Shortage of beds is considered to be the major factor in creating the long waiting list as is shortage of staff. It is possible that staff shortages might be solved by providing more money and by increasing the payment of health staff, but perhaps more efficient use of beds might be more effective and less costly. A large number of beds are currently occupied by patients in our hospitals who cannot be discharged because of the deficiencies in suitable domestic and institutional accommodation for the old, the permanently disabled and those in unsuitable domestic circumstances. Perhaps we should give priority to the provision of much better facilities in this area, and such a priority would anticipate the inevitable increase in the proportion of older people during future decades. Bed usage is also reduced by failure to extend the elective hospital services beyond the restrictions imposed by the concept of limiting hours of work to the eight hour, five day week.

The increasing use of day care or overnight care should be strongly encouraged as well. I suspect that a policy simply devoted to increasing the number of beds without tackling the problem of inappropriate in-patients, the reduction of the average stay of patients, discouraging the admission of patients simply for tests, and extending the hours of elective work, would have little effect on waiting lists. Higher staff levels, particularly of nurses and consultants, and a careful analysis of the nature of the waiting lists are mandatory. For instance, I believe the waiting list for heart surgery is long because many of those who are awaiting by-pass surgery are best to continue treatment by medical means, particularly in the light of major recent advances in medical treatment in patients with angina and those who have recovered from a heart attack. Uncertainties in this area can be attributed to the lack of proper trials which would provide evidence based guidance about appropriate treatment. Heart surgery may seem more attractive to the patient and the doctor because it provides more compelling abreaction than the less dramatic medical treatment based on patience, counselling and patient co-operation. The contemporary cardiologist is deeply committed to invasive investigations and treatment but the disadvantages of invasive treatments, such as coronary surgery and angioplasty, and the efficacy of a conservative approach are not sufficiently realised.

There are also problems within the private system of medical practice. There is compelling evidence that private patients, at least outside those admitted to public hospitals, are subjected to many more investigations, including the more elaborate ones, and more intensive and prolonged treatment than public patients, a belief which is consistent with the necessity for private hospitals to adequately use the expensive diagnostic facilities which they provide. The contention that private patients are subjected to over-diagnosis and over-treatment is supported by Ms. Wren’s evidence that private patients are three times more likely to have a coronary angiogram than public patients. Whether this means under investigation of public patients or over investigation of private patients is a moot point. I would consider the latter to be more likely. There is a compelling reason for more audit and accountability by doctors and medical institutions, both in the private and public arenas. In the context of the increasing cost and complexity of medical practice, it is unlikely that we can achieve much needed improvements in our health services without effective audit of all aspects of the system.

There are obvious problems of conflict of interest for doctors, particularly in the private system. They are in the areas of ownership of profit making private hospitals and clinics, and of invitations to doctors to invest in new pharmaceutical companies. There are also elements of conflict of interest in certain areas where specialists benefit financially by ordering tests which they perform themselves. There was an old ordinance in the rules of the Royal College of Physicians that no fellow of the college could have a financial interest in a chemist’s shop. I do not know if this rule has lapsed nor do I know if the various royal colleges have a current view on such problems of conflict of interest. One would expect that the Medical Council would have strong views on this subject but, despite writing twice to the ethical committee of the Council enquiring about their attitude to this recent development in the profession, I simply had my attention drawn to the rules and regulations of the Council, and the question of having shares in a profit making private hospital was studiously avoided.

Like many other countries, Ireland has seen a dramatic increase in consumerism and in the materialistic and acquisitive aspirations of all levels of the population, a trend which parallels an increasingly secular and corrupt society, and which contains the basis of the current threat to the planet and to future generations. There is no reason to believe that we are thus a happier, more stable or rational society than we were in past days of relative austerity and of greater limits on individual irresponsibility.  It has been shown that the acquisition of goods we want but do not need does not contribute to a more contented society and that too much choice can have a detrimental effect on our happiness and sense of satisfaction.

Can the current worldwide trends of consumerism and waste, and the ubiquitous spread of corruption be reversed in an increasingly secular world where democracy is considered the political norm and where power is increasingly placed in the hands of the individual who not infrequently does not share with power a corresponding sense of responsibility? It is hard to believe that we have it within our power to go back to a lifestyle which is consistent with maintaining a balance between Man and Nature and which brings a new spirituality into that relationship. However the difficulties of changing the public attitudes, at least as doctors and as members of a caring profession, should set an example to the rest of the world

The private and public mix.

There appears to be no inherent objection to the retention of private medical practice as long as inequalities are eliminated from our health service. However, assuming a satisfactory service to public patients, it is unlikely that a significant proportion of the population would pay for private medicine, apart from contributing for private accommodation. The current personal contact maintained between doctor and patient (and certainly desired by both) in the private system is an important component of professional practice and this professional need might be best maintained by a universal and compulsory insurance system of service if we were to satisfy the matter of equity. This would be close to the Canadian and the French systems. It is difficult to believe that the current situation of public/private mix in the public hospitals could be developed further without the virtual elimination of private profit or non-private hospitals, although such hospitals seem to survive even under the most socialised systems.

The medical profession.

Ms Wren, Brennan and Hanly refer to the hospital consultants’ common contract. They maintain that its design and generosity is unique in Western countries. Any fair minded person, including some of the consultants, will agree that a review is required to identify changes which need to be made in the contract to bring the method of employment of consultants more into line with normal circumstances. This need not include the exclusion of private practice among consultants who desire to continue in the area. The profession needs to grasp the nettle of the common contract which we can hardly expect to continue in its current form. Increasing the number of consultants and reducing the number of residents seems an obvious step, while consultants who practise in private hospitals off site should not expect the same income for their more limited commitment to the pubic service. Also, the cost of clinical research should not be a charge on the public service, whatever about the cost of teaching.

It would also appear reasonable to cap the private income of all consultants who are in the public service, particularly those who initiate, perform and profit by the more elaborate investigations. According to Ms Wren, consultants can earn more than E500,000 annually. I would estimate that they are the relatively few who perform invasive investigations. Capping would, I believe, benefit the consultants, relieving the frenetic and over-worked conditions which many of those who attend private hospitals outside the public hospital campus seem to be prone to.

The number of private patients in the public hospitals frequently exceeds the 20% allowed under the common contract.   Such patients must be an important source of income, particularly for the consultants in the larger urban areas. It would be desirable to claim a proportion of the private fees derived from this group of private patients for research, and for professional and academic purposes for the health professionals. I suspect that the income from private patients in public hospitals may not be equally shared by the consultant staff. This point should be clarified. It would seem reasonable that such fees should be equally divided between all members of staff.

It is unlikely that real order can be brought into the health services here without some radical changes within the medical profession and this would need to come from within the profession itself. Doctors have traditionally received the support of the Irish people when they are involved in controversy with politicians or other critics. The sympathy of the people is probably a product of the widespread dedication of the profession to charitable work in the past but the charitable role of the doctor is now less evident and it is likely that our profession will not retain the affection and the sympathy of our patients in the future when we are struggling with our adversaries. Consultants in our larger hospitals are not organised in a hierarchical way so that there is less accountability and virtually no audit or attention to cost control. Many years ago I proposed to our newly appointed professors of medicine and surgery at St. Vincent’s Hospital that we should adopt a hierarchical system along the lines of the Cogwheel Report. Each department would have a rotating head who ex-officio would be a member of the medical committee. The chairman of the committee would be elected by the consultants and would be appointed for a limited tenure, say, for five to seven years, rather along the mastership system in our maternity hospitals. He would be required to work closely with the administration and would receive sessional payments for his services. He would be ex-officio a member of the board of the hospital and would be responsible to the board for the standards maintained by his colleagues. Through the medical committee he would have certain executive powers to deal with medical staff problems.

The nursing profession.

The changing financial and academic status of the nurses in recent years has added significantly to the financial and organisational problems of the hospitals. The move from the hospital to the university campus during the years of nurse training has deprived the hospital of valuable nursing input and has deprived the nurse at a sensitive time in his or her career of the vocational stimulus which is essential in a caring profession and which is derived from direct hands-on patient care. Equally important has been the adverse effect on the ethos of our hospitals because of the loss of our on-site training schools, and the inevitable reduction of the strong links which existed between the nursing staff and its alma mater. In my time at St. Vincent’s Hospital our nursing school, first established in 1892, was highly regarded both nationally and internationally, and was an integral part of the hospital’s proud history. It vanished overnight two years ago, as did the founders of the hospital, the Sisters of Charity, and with them went the spirit and the pride which was the source of our loyalty to a great institution. In Ireland we are facing an increasing shortage of nurses, a shortage which is being filled by foreign nurses who are being induced to come here although their country’s situation may be at least as bad as ours. Is the fall in recruits for nursing among the young in Ireland caused by economic, social or cultural factors or is it related to a decline in the attributes of caring and compassion which is nowadays evident in many walks of life and which appeared to motivate people more in former times?

I believe the major cause of the current decline in the numbers of  Irish nurses in our hospitals can be attributed to the loss of our hospital schools and the training of young nurses for their first three or four years on the university campus. While the number of applicants for nursing remains at a satisfactory level, there is now a huge drop-out among undergraduates and postgraduates, a phenomenon which was not a problem in the days of the hospital school. It would be worth enquiring if the same shortage pertained in other western countries at the time they adopted the university training system. I cannot believe that the candidate for nursing who spends the first three or four years on the campus of University College, Dublin, or any other Irish university, is likely to retain the full flush of enthusiasm and compassion for the sick which are often behind the choice of nursing in the first place.  Poor financial rewards and irregular hours are often cited as problems in attracting people to the nursing profession, but I would question these assumptions. In earlier years, these considerations appeared to have little influence on a profession which was traditionally dedicated to patient care, and nowadays the conditions of nursing have been greatly improved. Unfortunately, increasing material expectations will always create financial difficulties for those on a fixed salary and with an effective organisation which can hold society to ransom.

The role of government.

On page 84 Ms Wren states ‘the political system is one of the barriers to reform, if not the major one’. The government and politicians’ roles are dealt with in great detail by the author. It is clear that, from the end of world war one, successive Irish governments have failed to establish a coherent and rational policy in relation to the health services. The failure of government is perhaps understandable, bearing in mind the failure to predict the rapid advances in medical care and technology, the rampant cost of such advances, and the increasing expectations of a better educated and litigious public. Nevertheless, most other western countries have shown better vision in adapting to the social and health changes over the past 50 years. It is reasonable to claim that the Irish system has evolved in a piecemeal manner with little coordinated central planning and with government’s failure to impose its policies because of dissenting  and minority groups, mainly local politicians, the medical profession and medical industry.

One might attribute government failures to conceive and impose well planned policies on our particular brand of the party system where there is an increasing trend by government to put party and electoral considerations before its responsibilities to the community. Ms. Wren refers repeatedly to the government’s supine response to the minority groups who successfully resist efforts to bring about necessary changes in the health delivery service. She reminds us how ineffective has been the Department of Health over the years since it was established in 1946. Both Lloyd George and Winston Churchill, in their separate musings about democracy, universal suffrage and the parliamentary system, had reservations about the party system. Lloyd George wrote about the evils of the party system and looked with disfavour on party control. We can certainly share the same view about the current situation in Ireland. Every aspect of public life, every branch of administration, including health, education, transport and local government, to mention a few, has suffered because of the failure of our democratically elected leaders to put the public good before their determination to remain in power. Surely the Platonic concept of democratic leadership, based on detachment from personal gain and on personal integrity, which we enjoyed in Ireland in the 1920s and 1930s, is a thing of the past and can only be retrieved by radical changes in public ethics and in the electoral system which prevails in Ireland.

Desirable changes might be achieved by the elimination of the rigid whip system in parliament (except perhaps for a limited number of finance bills); by single seat constituencies with the transferable vote to allow our TDs to devote their time, energies and skills to central affairs, and not be constantly looking over their shoulders to constituency affairs and electoral rivals from the same party who may  be beavering away locally; by reducing the number of TDs and paying them better (and at least as well as high court judges and hospital consultants); and by confirming recent dual mandate legislation which prevents TDs from membership of local councils and committees where political privilege might be abused.

Where central government has been most at fault is its failure to provide for the increasing need of the old, the lonely and the disabled. It is estimated that up to 20% of the patients who are lodged in the main hospitals in Dublin are there because they are awaiting discharge to more suitable institutions or to their homes where no assistance may be available to care for them. And not a few are in hospital awaiting transport or the support of relatives. It must be clear if we had more efficient means of discharging patients, it would make a significant difference to our exceptionally long waiting lists, the main reason for the inequalities in our health delivery system.

Winston Churchill, writing before 1932, was less than enthusiastic about the political system in the United Kingdom at the time, believing that it no longer attracted the ablest people in government. If we are to attract the ablest and most trustworthy ministers in Ireland, we should adopt a more satisfactory party and electoral system.

Health promotion

At various points, Wren refers to the neglect of health promotion and the need for more emphasis on health education. It is hardly necessary to note the very poor constituency preventive medicine has within the profession and among our politicians. The anodyne of health promotion is received by the great majority of my colleagues and our politicians with the glazed look, and, anyhow, if we were to become an active health promoting population, it is unlikely to reduce the cost of the health service because of the huge cost of caring for the aged sick and infirm. But undoubtedly there are huge opportunities for improving the health of the middle aged and younger old population.

Ms. Wren is wrong in assuming that life expectancy depends on a nation’s wealth and a good health service. On page 240 she writes

Only when all citizens can access adequately resourced primary care and when hospitals treat the most ill first can Irish life expectancy and health be expected to  improve significantly relative to other EU states.

She disagrees with the Fianna Fail TD and Minister of State at the Department of Health in 1999, Frank Fahy, who was concerned about healthy life styles within the service, while she appears to approve of the Chief Medical Officer in the Department of Health, Dr Jim Kiely, when he said that health ‘was related ----- to the problem of inequitable access to health services based on need’. Good medical facilities may play a small part in improving life expectancy but the life style of the population is much more important as is apparent when we correlate the proportion of GDP devoted to health in various western countries with life expectancy. There is no such correlation, positive or negative. Countries such as Greece, with one of the lowest investment in terms of proportion of GDP devoted to health, has a better life expectancy than the wealthy United States which has the highest. The countries in southern Europe have at least as good a life expectancy as the heavier spending and wealthier northern European countries. And the health of a nation is not entirely divorced from the wider consideration of an increasingly secular, violent, corrupt and less compassionate society in a culture of excess.

It is interesting if somewhat irrelevant to my subject that the same lack of correlation exists in western countries in relation to education. The wealthiest countries are not necessarily the best educated, at least at primary and secondary levels, almost certainly because their heavier spending on education goes to high technology investment and not to the more important encouragement of the teacher/pupil relationship. The education authorities need to know more about the tradition of teaching which existed in this country by dedicated religious and lay teachers in the past, with nothing, neither computers nor inside loos, but close contact between teacher and pupil, a system which lead to the emerging of a disadvantaged Catholic population ready and able to undertake self-government. We need fewer computers and less grandiose buildings but a more dedicated and hands-on teaching profession as well as more caring parents.

Addendum:

In July 2005 I came across the May and June 1959 copies of the Fine Gael monthly journal of current affairs The National Observer where I recalled two articles I had written about the problems and possible solutions of the health services in Ireland at the time. In view of the recent establishment of the Health Services Executive by Mary Harney, it is interesting to note my views of 46 years ago

I am sure the first important step is that health administration should be removed from the milieu of party politics. This can only be achieved by transferring the main responsibility for affairs of health from the Department of Health to an authority constituted along the same lines as our semi-State or semi-autonomous bodies, such as the electricity, turf and transport concerns. --------. I believe this change would enormously simplify administration in the future whilst providing a continuity of policy in health legislation which is badly needed and which would be appreciated by all people interested in social welfare.

This Council (that is, the independent health body - RM) should be established with strong and comprehensive executive powers over all health services in the country requiring the assistance of public money. It should also bear the responsibility for the direction of new health policy. It should be answerable to the Government on matters of finance -----.

My contention was that the health service in 1959 was weighed down with anomalies and inefficiencies, that it lacked a coordinated focus, that its shortcomings were aggravated by political Influences at central and local levels, that the Department and local health authorities shared much of the blame, and that the views of the medical profession were ignored in relation to policy and performance. My one hopeful comment referred to the success of the Voluntary Health Insurance which had been established three years earlier. At a later date, in 1974, I was to chair the IMA working party which recommended the adoption of a one tier nation-wide compulsory health insurance system, copies of which are available.