188 / 298
GAZETTE
SEPTEMBER 1981
Law institutions. Despite that, it is important at this point
to indicate that the answer to the problem is not to be
found in reducing the role and operation of the private
sector, for voluntary effort and local control over
management of the service are essential ingredients of a
good service. If anything, the answer lies in an upgrading
of the public sector health service by the restoration to it
of local control.
The explanation for the origin of our two-tiered health
service and the apparently high rate of mental illness in
this country both lie in the period of our colonial history.
Since the dark ages, the nature of mental illness has
always evoked fear and mystery. The requirements of a
colonial administration inspired the building of enormous
mental hospital institutions throughout the country. It is
an interesting fact that the social stigma of mental illness
is particularly strong in Ireland, just as the number of
people we have locked away in our mental hospitals since
those times is particularly high. I suspect that the
explanation of these facts lies as much in particular
aspects of the Irish character and personality which have
been moulded and fashioned by the later centuries of
colonial domination as in any innate propensities of the
Celtic gene. Oppression, poverty, dispossession and
depopulation by death and emigration resulted in an
increase in such reactions as escape through alcohol,
melancholic depression and schizophrenia — the
psychosis of isolation and withdrawal. These, and other
coping styles, such as learned helplessness and
dependency evolved in response to this period of
domination, were understandable in their day but are
maladaptive in present times in an independent nation
with a growing economy.
As a consequence, through the 19th century, a colonial
administration responded to the social pathology and
problems it had itself created by erecting the greatest per
capita number of mental hospitals anywhere in the world
to deal with an artificially produced "high" rate of mental
illness. The Poor Law system which it had introduced to
deal with widespread poverty eventually fused with the
administration and image of the mental hospital system
dealing, as they both did, with related aspects of the same
colonially induced social pathology in Ireland. Because
of the basic fear of mental illness and the Poor Law
image, with its connotations of poverty and personal
failure which have subsequently become attached to it,
the sense of social stigma and self-protective withdrawal
from contact with the mentally ill is particularly strong in
this country.
Thus there can be no doubt that society as a whole has
acquiesced in the continuation of these Poor Law
attitudes to the mentally ill. It is necessary to create and
maintain an increased level of public awareness and an
informed social conscience if we are ever to be successful
in dismantling the barriers of ignorance, prejudice and
fear which unnecessarily typify society's attitude to the
mentally ill.
It is a regrettable fact that because they, too, are
members of society at large and share society's ignorance
and fear of mental illness, our legislators and Health
Department policy makers have likewise acquiesced in
the perpetuation of Poor Law attitudes to the mentally ill.
As such, they constitute a key group who have to be
persuaded that their policy of institutional containment of
the mentally disabled is an inefficient, costly and
damaging policy. Until the psychiatric profession and
other concerned groups succeed in persuading central
government that this is so, the lot of the mentally ill looks
bleak.
The cumulative effect of the lack of informed
awareness of the lot of the mentally disabled at
Department of Health level is clearly evident in the
administrative structures which they have established
and, in turn, in the distribution and utilisation of resources
through these administrative structures. The Health
Boards established 10 years ago were a noble concept
and intended as a vehicle for local control over local
health services. Unfortunately, they constitute a failed
experiment, as the Department of Health has effectively
centralised policy-making through total control of the
allocation of resources in accordance with the
Department's perception of policy and priorities.
As a consequence, there has been an imbalanced
distribution of resources, ' reflecting the selective
developments of the health service according to
Departmental policy, with little regard for the
requirements indicated locally by the Health Boards.
Regardless of White Papers or other expressions of intent,
policy is where the money is spent. Analysis of 10-year
trends of expenditure in the health service, both Revenue
and Capital, demonstrates clearly that there is a policy to
develop the general hospital sector, on which expenditure
is growing exponentially. Certainly general hospitals are
necessary and required. But one has to ask upon what
moral, upon what social, and upon what professional
values are they apparently being built, to the exclusion of
any development in the care of the mentally disabled.
Indeed, corrected for inflation, it is quite apparent that the
lot of the mentally disabled is growing considerably
worse, rather than better.
The administrative structures within the Department of
Health by which needs are identified and through which
policy is formulated, are in urgent need of review. They
do not reflect the needs of the weaker sectors of the
community such as the mentally ill, the mentally
handicapped and the elderly. Responsibility for this must
ultimately rest with successive Ministers for health. It is a
regrettable fact that there are few votes to be obtained
behind the walls of mental institutions. The patients of the
psychiatric and geriatric services, lacking a political voice
or pressure group active on their behalf, constitute a
disenfranchised and forgettable minority, who can be
electorally ignored.
Instead of using the available resources for the
development of a balanced health service, based on an
informed and equitable social policy, our politicians and
successive governments have been content to lead safely
from behind, by responding to the sources of pressure
which, naturally, translate into votes. As a result and
particularly for those sectors of the health service which
are not politically rewarding to politicians, too much
hidden policy-making power has fallen on the shoulders of
a civil service which was never structured for it and which
is not publically accountable for it.
Turning to the role of professional staff in psychiatric
service, it has become increasingly clear that the doctors
and nurses who run the psychiatric service operate within
a Civil Service structure. In this, by becoming officer-
employees in a hierarchical administrative system, rather
than by remaining separate contractors of their service,
188