Book review: Tony Holohan’s slow rise to oversee the health of a nation in crisis

Then, boom! 2020 and 2021: The covid-19 pandemic. Peak Tony Holohan, two years in which he was rarely out of the headlines. What many of us didn’t know for some time, despite opaque statements about compassionate leave, was that the man charged with guiding us through the worst public health crisis for more than a century was facing an immense personal challenge of his own. His beloved wife, Emer, also a doctor, and mother to their two children, was dying from multiple myeloma.

The disease, a bone marrow cancer, is incurable and was first diagnosed in 2012.

It was therefore an accompaniment throughout the crucial years of Holohan’s remit as the nation’s chief strategist and advisor on health-related matters.

His book, We Need To Talk, reviews 14 years in office which encompassed the dioxin scare where Ireland’s pig herd was contaminated with poisons; a rash of neonatal deaths at the Midland Regional Hospital in Portlaoise; a SARS outbreak; swine flu which led to the establishment of the National Public Health Emergency Team (Nphet) which played a prominent role in the covid response; the campaign to amend the 8th Referendum (he was a strong advocate of reform), and the CervicalCheck crisis of 2018.

On that chastening experience he is clear. “Up to 2018 nothing came close to its impact,” says Holohan who devotes two separate chapters to an accounting of it. He was misrepresented, he says, as trying to block the Scally inquiry when the opposite was true. He references a conference where the “press were hostile; no longer impartial; no longer analytical ... very few voices of reason”.

It is in this episode that we can discern tensions with eager-to-please politicians which came to characterise some of the more febrile exchanges during the height of the pandemic, in particular his demand to introduce a full level-5 lockdown — a word Holohan refuses to use because of its totalitarian overtones — just 72 hours after Nphet said level-2 restrictions were adequate. The government adopted level-3, only to move later to level-5 for six weeks.

Holohan was right, just as he was to urge cancellation that spring of the Six Nations encounter in Dublin between Ireland and Italy, which was at that moment Europe’s hot spot for virus transmission. But that is only becoming manifest with the perspective of time.

In the CervicalCheck uproar Holohan and doctors were accused of lacking a duty of candour by failing to inform patients of the results of a retrospective audit on the results of smear tests. In his book the former CMO says he was not aware that the results were not being passed on as an act of policy by colposcopists and gynaecologists.

But when that emerged, he had to deal with minister of health, Simon Harris. Harris it was who agreed that women should have repeat out-of-cycle smears, a decision which engulfed and paralysed the testing regime.

A pattern of declining to tell people in power what they wanted to hear, rather than what they should hear, or of sometimes not telling them at all, was a characteristic of the Holohan style. At best it served him well.

It is difficult to recall either he, or his senior medical team, having to stand shoulder to shoulder with party politicians during covid in the manner that his UK counterparts such as Chris Witty and Patrick Vallance were dragooned alongside Boris Johnson or Matt Hancock as supporting acts in press conferences.

At its worst it resulted in difficult governmental moments for Holohan, and senior colleagues, never more in evidence than in an unseemly, and ultimately self-defeating row over his appointment (it eventually proved to be a publicly-funded secondment on existing terms and conditions) to a prestigious role at Trinity College, Dublin.

It was, says the book, his idea, but neither he nor his boss, the abrasive Robert Watt, found it necessary to brief the health minister, or taoiseach Micheál Martin, a long-time ally, on the financial implications, and they found themselves blindsided when the details emerged.

Failure, or disinclination, to follow the old adage faugh-a-ballagh, and clear the way in the corridors of power, resulted in Ireland losing expertise and wisdom from a post it will probably need in the future. We will see whether entreaties will be sent to the tent of Achilles when that happens.

Tony Holohan had to work seven days a week while his wife became weaker and sicker. An early diagnosis of her illness had been missed by the service which he championed and defended while being acutely aware of its deficiencies. When she died in February 2021 there was a socially-distanced, limited number, funeral in line with the regulations which covered the country.

“The length of time her diagnosis took, the false reassurances we received along the way, and the stage her cancer had reached by the time she was finally diagnosed, all caused very great distress to her, to the children and to me,” he said.

“There may be comfort for others to learn that these things happen indiscriminately. Having medical knowledge, even a certain position within the medical community, does not insure you against error or harm.”

His conclusion is that many patients who suffer in such ways are left in limbo. Unless the case is extremely serious the Medical Council is unlikely to take action and the health service provider will not do anything either because clinical judgement is declared to be outside their province.

With his memoir Tony Holohan has been the first senior official to stake his claim on the future account of the management of the pandemic.

There is much he has left unsaid, and the record will be added to when the lamentably over-delayed inquiry into how Ireland responded finally stutters into action. By then many of the medical people at the top of the health service at the time will no longer be in post. The most responsible ministers might be out of office.

Back in 2016 when he was discussing the Civil Liability Amendment Bill, Holohan downplayed concerns that any process of open disclosure would not work within the medical profession unless it is mandatory.

However, he accepted that it could cause ‘finger pointing’, adding “if that’s the culture, it speaks to the journey and how far we have to go”. It’s a conclusion that will be put to the test in any hearings about what happened.

For the moment this narrative in his book is the one we have. And that makes it worth reading.

He is a man who had to deal with the exponential growth of a potentially fatal virus in a country with no knowledge, no capacity, and no vaccine. When his advice was not followed more people died.

History will show that, in terms of public health, he did a pretty good job at a time of immense personal strain. And carried most of the public with him.

• We Need To Talk by Dr Tony Holohan
• Eriu, hb €19.99
• ebook, €12.65