Apparently it is claimed that EBM is relatively new. Initially, that’s a surprise. It dates from, it appears, about 1996. While still supporting its practitioners I doubt this claim. It claims too much. It seeks to appropriate the word evidence to apply only to some evidence and not to other evidence. Did the medical profession not act on evidence before 1996?

I think it did.

The practice of bloodletting lasted for at least 2,000 years with no proven benefit to the modern mind. This did not mean it could not be justified. The justification lay in the acceptance of the theory of the four humours.

According to the theory, a human person was, in effect, constituted of a mixture of the four humours. Bloodletting was calculated to affect the balance of these humours. The effect of these humours, black bile, yellow bile, phlegm and blood extended to the explanation of character.

Those with too much blood were sanguine. Those with too much phlegm were phlegmatic. Those with too much yellow bile were choleric, and those with too much black bile were melancholic. To be sanguine is to be courageous, hopeful and amorous. To be phlegmatic is to be calm and unemotional. To be melancholic is to be depressed, sleepless and irritable. To be choleric is to be easily angered and bad tempered.

It is relatively easy to find living examples of these types and, having done so, to think that that discovery is supportive evidence of the theory of the four humours.

The alternative theory, that of EBM, is to follow the scientific method.

Based on observations of a phenomenon, a scientist may generate a model. This is an attempt to describe or depict the phenomenon in terms of a logical physical or mathematical representation. As empirical evidence is gathered, a scientist can suggest a hypothesis to explain the phenomenon. This description can be used to make predictions that are testable by experiment or observation using the scientific method. When a hypothesis proves unsatisfactory, it is either modified or discarded.�

The significant word is “hypothesis�. The quote suggests that the hypothesis follows the gathering of evidence. This is not likely. The hypothesis, or its predecessor (another hypothesis) must precede the gathering of evidence. This is true even when the evidence presents itself to us almost complete, say, when a body is discovered with a knife sticking out of its back. We have already formed the view that such circumstances are more consistent with murder or manslaughter than with suicide or accident.

The “scientific method� is not new. Eratosthenes applied it to the measurement of the circumference of the Earth in 240 BC. He learned of a well at Syene in southern Egypt, where the sun, on the summer solstice, shone directly down into the well. At Alexandria in northern Egypt, on the solstice, the sun was not overhead; it was at an angle of seven degrees 12 minutes. He estimated the distance from Alexandria to Syene and concluded that that distance represented one fiftieth of the circumference of the Earth, because the angle of the sun in Alexandria on the solstice was one fiftieth of a circle. Of course, he also concluded that the Earth was circular in shape.

The quality of the hypothesis is critical. So, too, is the ability to collect evidence.

Generally the Minister for Health and Children expounds a hypothesis to explain health care infections. These are infections contracted almost exclusively in places such as hospitals and nursing homes. The Minister’s theory focuses on the supposed natural history of the pathogens involved. It resolutely assumes that the first and principal defence of humanity from pathogens is antibiotic use and that that defence has been breached. We know this because, in the context of addressing health care infections, she castigates the medical profession for over-prescribing antibiotics in the past. Sometimes this idea is elided into the idea that it is consumption of antibiotics that is the problem and by implication that the patients are responsible.

She does endorse other ideas but, in doing so, implies that the general public, like the medical profession, are implicated in the chain of causation through visiting patients in hospitals.

What is revealing is her own admission that you can only manage what you measure.
It was only in March 2008 that she made Clostridium difficile a notifiable disease.

This was the only method of determining the incidence of this dangerous, often fatal, disease.

This proposition was the subject of a post HERE in 2007.

EBM is of little use as an idea if it is not preceded by the appropriate hypothesis, uncontaminated by an agenda to dissipate and diffuse responsibility and also preceded by the effective search for evidence.

Are we to think governments disbelieve knowledge revealed by statistics? Well, we should not.

Here in Ireland we have a deep resistance in our government to the disclosure of information. When will we follow the lead of the UK government? The Irish public pays for the HSE and is, in principle, entitled to know something as important as the level of death in our various hospitals. Indeed, there are many other statistical items of information that the public ought to know, like the incidence of nosocomial (health care-institution related) infections or disease associated with our different hospitals.

What is staggering is that the reason the public needs to know such things is to ensure that the HSE management effectively deals with the problems that would be revealed generally. I say generally, because it must be a certainty that the knowledge is already known to the HSE and the Department of Health and Children. It is, in short, already revealed; revealed to some, but not to the public. This is what must be changed.

At the end of the street there is a memorial in Victorian style to Constable Patrick Sheehan who died, in 1905, trying to rescue a workman from a gas filled sewer.

The gas must be still there, affecting the Minister for Health.

The Health Service Executive is, currently, dysfunctional and a failure. It has failed on a number of fronts but consistently it has failed on the issue of hospital hygiene. The extreme cases of Ennis General Hospital and now St. Columcille’s Hospital where multiple deaths through nosocomial infections have taken place are representative of the general situation.

The Minister’s response to the situation is bizarre, and reported HERE:

She pointed out that the health service has a national plan to tackle health acquired infections which would see them reduced by 20% in the coming years, and MRSA in particular by 30%.

This would involve a reduction in the use of antibiotics, she said, of 20%.

The reference to antibiotics is a reference to her theory that health care infections are caused by the evolution of microbes. She attributes the evolution to excessive use of antibiotics.

She is not deterred in her assertions by any contrary evidence. Like the fact that Irish hospitals have a low standard of hygiene and that poor hospital hygiene is the cause of the infections. Or the fact that Clostridium difficile has not perceptibly evolved. Clostridium difficile is the infection that caused the deaths in Ennis and St. Columcille’s.

One can only feel, if the gas is not the explanation for her views, that she is motivated by the fact that no person or institution is answerable for excessive use of antibiotics and no legal liability would attach to the HSE if her view prevails.

I have tried to defend the correct use of the word “refute� before (several times).
It is too good a word to allow its destruction unopposed.

I have also criticised the Minister for Health and the Health Service Executive over the failure to address the problem that is Clostridium difficile infections and lack of hygiene in Irish hospitals, HERE and HERE and HERE.

That abuse of language, misrepresentation and Clostridium difficile deaths should all appear in one report, indeed in one single sentence, is vindication.

Here is the sentence:

…refuted the suggestion that a marginal reduction in the amount spent had any connection with the issue of C difficile�,

from THIS REPORT.

It has overtones of the concept of a new year’s resolution. That concept has universal approbation (grouches excepted), brooking no dissent on the desirability of the idea of such resolutions. It also invokes a notion of “the norm� that is somewhat (mistakenly, I say) exclusionary. I have in mind the near certainty that Josef Stalin, or indeed, George W. Bush, never did or do make new year resolutions or ordered the creation of a centre of excellence.

I suggest the reason for this has nothing to do with their characters; it has to do with the fact that neither of them is (or was, in the case of Uncle Joe) a businessman. (Bush tried his hand at business but he was not a businessman).

The phrase is a stroke of dubious, comparative advertising genius and essentially, only a business consultant’s faddish phrase. After all, in what field do we establish a “Centre of Mediocrity�? Or a “Centre of the Shoddy�?

It collaterally depreciates possibly perfectly serviceable institutions. Or, given the current use in Ireland, it brilliantly distracts attention from institutions which are far from serviceable like, reputedly, Our Lady of Lourdes hospital in Drogheda, as seen HERE and HERE.

Who ever aspired to have a hospital that was not excellent?

The real drawback of the “centre of excellence� phrase is its avoidance of consideration of what we have, in favour of what we, by implication, have not.

There is abundant evidence that hygiene in hospitals is poor. See HERE and HERE.

Here is a quote relating to Our Lady of Lourdes hospital in Drogheda.

On the ‘Rate my Hospital’ website, patients or their relatives are asked to rate hospitals on a scale of one to five under a wide range of headings, including car parking, cleanliness, quality of care, catering and many other areas.

The Lourdes Hospital in Drogheda scored an average of 2.39 (48%) under hygiene among the 369 people who completed surveys on services at the hospital while Mallow scored an average of 4.20 (84%) among the 49 people who completed surveys on it.

Note the reference to St Columcille’s Hospital in Loughlinstown, Co. Dublin. This hospital and its suspect hygiene has obliquely featured in a previous post HERE.

In relative terms, fixing hygiene problems is cheap. Very little technology or new infrastructure would be needed. The Dublin County Coroner believes the appointment of a microbiologist in St Columcille’s Hospital in Loughlinstown, Co. Dublin would avoid the situation where he, the coroner, encounters the consequences of a hygiene deficit in the hospital, but it is not obvious that such an appointment is absolutely necessary. After all, we would hardly expect the microbiologist to go about actually cleaning the hospital.

The “centre of excellence� phrase has one merit; it draws attention to the centre. The centre is the Government. The Government is accountable for what is wrong with the Health Service. (The Irish Constitution, Article 28, 4, 1 and 2).

4. 1° The Government shall be responsible to Dáil Éireann.
2° The Government shall meet and act as a collective authority, and shall be collectively responsible for the Departments of State administered by the members of the Government.

This is the legal position.

Last November he was lamenting the situation in St. Colmcille’s hospital with respect to the deaths of patients there from Clostridium difficile infections.

Now, as shown by an Irish Times report, he is still dealing with the problem and is reduced to writing to that very same hospital urging the appointment of a microbiologist.

We must wonder what the chances of that happening are.

This post is an unashamed plug for the book, published [2007] by Hodder Headline Ireland.

The author is an anonymous junior hospital doctor, concealing his (I say her) identity as Doctor X. Currently I have read only the chapter entitled “Dirt and Bugs�, but on the strength of that alone the Minister for Health will in future be unable to “spin� the shocking levels of nosocomial infections in Irish hospitals.

There is a depressing conclusion also; most intelligent lay persons would have no difficulty envisaging the state of affairs revealed by Doctor X in “Dirt and Bugs� (without the benefit of his/her revelations). When the Health Service Executive issue hospital “hygiene audit� results, they, as professionals, must already know what Doctor X knows and therefore they know that the hygiene audits are misleading as to the true state of affairs in hospitals.

The reasons are very clear; it was budgeted to cost €9 million but has cost €176.8 million to date.

It had been known for some time that it was a black hole for public money.

By way of spin the HSE says the “investment� in computers will remain. (Bad luck, Mr. Dell ).

Is this, as it appears, a typical case of cost overrun? (What does that mean?)

Did the HSE keep changing the specification?

Did the contract for the purchase and supply of the system provide for the allocation of liability in the event of what has happened, happening?

If it did not, why did it not?

Who drafted the terms of the contract?

Who approved the terms of the contract?

Do those individuals, if they are not part of the supplier or the HSE, have adequate professional indemnity insurance?

NOTE: nothing in this post is intended to suggest that any person or firm connected with the Ppars project has acted wrongfully and any such seeming implication is abjured.