The Vasectomy Doctor

by Dr. Andrew Rynne

  I had to get away or I was going to go mad. My marriage was going nowhere and the hospital was going nowhere. The pro-lifers had captured the high moral ground with their Eighth Amendment and it was time to get away for a while. Saudi Arabia was looking for general practitioners to work in their hospitals on short-term contracts of two months and this seemed like an ideal opportunity to do something completely different, to gather my thoughts and to regroup.

  The hospital that I was assigned to was in a city called Khamis Mushait close to the Yemeni border and the Red Sea, in the south-west of the kingdom. The best thing that I can say about Khamis Mushait is that it is situated 3,000 feet above sea level and therefore enjoys a Mediterranean-like climate most of the year round. Thus at least we were spared the stultifying heat and humidity suffered by our colleagues in cities like Jeddah and Riyadh.

  Our group of some ten general practitioners was housed in a compound like a small old-fashioned housing estate. There was about an equal mix of men and women, three of us were from Ireland. The minibus arrived every morning at eight o’clock to take us to work in the GP section of the large King Fahad Military Hospital a couple of miles away. This was an artificial ‘practice’ grafted onto a hospital which reflected the fact that Saudi did not have many indigenous general practices on the ground. I did not think that this was a good idea at all at the time and indeed I suspect that by now the Saudi authorities will have spotted the limitations of this approach to the delivery of community health.

  When Saudi suddenly became extremely oil rich they set about building state of the art infrastructures like hospitals, medical schools and clinics, from which to deliver a healthcare service for the people. Mistakes of course were made and one of them was to graft general practice onto hospitals to be staffed by overseas doctors and then to invite the people to go in and get some health advice. This was a disaster and I know because I worked at the coalface of this system for two months and can honestly say that I never saw one bona fide sick person in all my time there. Not one. Everyone coming in to see these overseas doctors had an agenda that had nothing to do with medicine. And what made it all worse was that doctor and pseudo-patient spoke different languages and came from cultures that were poles apart. This was a total mess and a charade.

  All consultations had to be conducted through an interpreter. This in itself was a massive barrier and frankly unworkable. Take for example lovely eyes sitting here before me now. Her life is a total mess and now to make matters worse she is addicted to the Valium that my previous colleagues kept giving her. This is all wrong; this is bad doctoring and bad medicine. As a doctor I would love to help her to work through her pain and find some resolution or some closure. This would take a lot of time, trust in each other and dialogue. But there is no dialogue, no trust and no continuity of care.

  I ask the interpreter if she would ask the lady behind the boshiya how she feels about her husband having recently taken a second wife. The interpreter, herself a Jordanian Muslim, turns to me and most emphatically says that she cannot ask that kind of question and suggests that I give the lady a repeat prescription for Valium and let’s get on with it. Now my confusion is complete. Is the subject of a woman’s feelings about a second wife really a taboo subject? Or is it only taboo because I am asking another female to put the question to the lady in the thobe. Or is it that the interpreter is in a hurry to get home and would prefer not to be bothered engaging with the beautiful eyes across the desk. I do not know the answers to any of these questions. I am completely out of my depth here. All I do know is that from there on in the interpreter ran the show. I practised medicine in Saudi Arabia in a way that would have had me rightly struck off the register if I were back in Ireland. The patients got their medicines and nobody got any better. In two months’ time another bunch of GPs would arrive and the cycle would be repeated.

  During our time off, and we had a lot of time off, we sat around a swimming pool at our compound or we played tennis or otherwise just chilled out. The only problem with the swimming pool was that there was no water in it. All the water drained away months earlier and they could not find anyone capable of fixing it. That was typical of the place at the time. When things broke down they just stayed that way. Know-how and craftsmanship were thin on the ground. The place was full of chiefs but very few Indians. But the empty pool did not bother me all that much since I do not swim.

  What did bother me though and what bothered most of us was the total lack of alcohol. I suppose the fact that none of us got the DTs on day five off alcohol suggests that none of us were alcoholics in the classic sense but frankly that was not much consolation. But a little help was at hand. After about ten days there I had struck up a warm relationship with a colleague and she and I sussed out a small private speakeasy in town run by Americans working for McDonald Douglas. Here they served sadeki red or white in plastic cups. Sadeki is an illicit alcohol drink made from fermented grape juice and available, to those in the know, all over the Arab world. It’s a bit like reasonably good plonk but that did not matter. It was the fact that we were breaking the law and beating the system that made the whole thing so hilarious. Now we knew what fun people must have had during the prohibition in America in the 1920s.

  Of course we had to be careful. European doctors and Americans were generally left alone but only within reason. Any drunken disorderliness on our behalf would not have been tolerated. The hospital authorities held our passports as security against bad behaviour and it was hard to escape the feeling that one was being constantly watched. But we survived and all in all I have to say that my sojourn in Saudi Arabia was a very interesting one. As doctors we may not have been able to bring much succour to the people but that was only because ‘the system’ got in the way. I returned from that place £4,000 the richer and within weeks of coming home An Bord Pleanála overruled the moral objections and finally we could start to build our little hospital.

  CHAPTER 10

  Clane General Hospital

  Up to and during my term as chairman of the Irish Family Planning Association in the early 1980s there were no facilities in Dublin where a woman could go for a tubal ligation if that was what she wished to do. Someone seeking female sterilisation up to this time had to, in the main, go to the UK. There was a small private hospital down in Cork where a limited number of tubal ligations or TLs were being carried out but the gynaecologist working there, Dr Edgar Ritchie, was anxious to limit the numbers lest the hospital assume the mantle of a ‘sterilisation clinic’. His reservations were very understandable. So whereas by this time we had male sterilisation up and running in Ireland for well over a decade, the female equivalent was almost unavailable. The reason why this was the case was because male sterilisation or vasectomy is a straightforward procedure requiring just a doctor’s surgery setting, a local anaesthetic and one operator, female sterilisation or TL, on the other hand, is a far more complex procedure requiring a hospital setting, a general anaesthetic and a team of doctors and nurses all free of scruples or hang-ups about doing something not approved of by the Holy Roman Catholic Church. And that in fact was the single biggest barrier that we encountered in trying to establish a female sterilisation facility in Ireland – getting a team together that was not cowed by Roman dictate.

  A number of avenues were explored. An existing nursing home would have been an obvious choice. We did not need x-ray or laboratory facilities nor did we need huge sophistication in terms of operating theatre technology. By adding on basic operating or surgery facilities to an existing nursing home and designating about six beds to that unit you would have what we needed. With this in mind I approached the proprietors of a number of Dublin nursing homes and one in Kildare. While they all gave my proposition due and often positive consideration, when they worked out the logistics of the whole thing they politely declined. It soon became apparent to me that if we were going to establish a centre for female sterilisation in Ireland it was not going to happen via the ‘existing nurs
ing homes’ idea.

  That left me with only two alternatives. Either I should build a new facility somewhere or perhaps I could buy some existing facility like a guesthouse and convert it into what was needed. At this stage my horizons were expanding. Building a small hospital to do TLs alone clearly was not a viable proposition since, as time went on and more people were offering the same service, we could not reasonable expect to survive on this alone. Knowing this it became clear that what I should do was to build a small general hospital that offered female sterilisation along with all the other medical, obstetrical and surgical disciplines appropriate to such a setting. And thus was born the concept of what is today, twenty years later, Clane General Hospital, with some fifty visiting consultants, a staff of over one hundred good people and an annual turnover in excess of five million euro and rising.

  Looking at it today with its new extensions and expanded diagnostic facilities, people often come up to me and say something nice like: ‘Wasn’t it very far-sighted of you to start off this hospital and aren’t you the great fellow altogether?’ I just smile and thank the person for saying such kind things. But the fact of the matter is that there was nothing particularly far-sighted about any of it. It was more to do with muddling along, lurching from crisis to crisis and hoping for the best. It was in fact, and we used to say it to each other at the time, a big leap into the darkness. And in any case, for the first four or five years of our existence we were too busy trying to just survive and had very little time to be gazing into the future or being far-sighted. And it was an absolute nightmare that brought me as close to utter ruination as I ever want to go and did nothing at all to save my floundering marriage. I made lots of mistakes of course. But then to be fair about it I didn’t have any models to guide me.

  Mistake number one for example: I never drew up a business plan. Nobody ever told me that I might need one. But had I done, it might have gone some way towards avoiding the stonewall of cash-flow problems that we hit six months after opening the place and struggled with for another two years. And besides that a good and honest business plan would have forced me to see what the minimum number of consultants was that would need to be committed to the place before we could press the ‘go’ button.

  Establishing a private hospital is completely different to say establishing a four-star hotel. People choose to go to a hotel and to stay there for as long or for as short a time as they like. They do this of their own volition. If they like the place they may come back and stay again the following year. If they really like the place they may tell their friends about it. None of this applies to a hospital. People by and large do not choose which hospital they go to. Their own GP and the consultant they are referred to generally make this choice for them. Neither do you decide how long you would like to stay in a hospital but rather this is decided for you by whatever is the matter with you or what sort of operation you have had. By and large hospitals do not do a lot of ‘repeat business’. You stay there once, you get fixed up and you hope to never see the place again. Neither does word of mouth do much for a hospital although it is of course important to have a good professional reputation and to hold on to it.

  The key to starting up a private hospital is to first of all identify a group of well-established and popular consultants who you think might be committed to the new venture. Ideally these consultants should hold a public appointment and should be prepared to become tied into the venture financially. These consultants will already have established a rapport with a large group of GPs who will continue to refer patients to them. These consultants, GPs and their patients then become the natural media in which to grow a thriving hospital.

  When I started Clane Hospital I did not have nearly enough committed and established consultants, I simply did not have enough of this natural medium or the bedrock on which to build a hospital. My failure to attract such consultants may have had a lot to do with my being a GP, as distinct from a consultant. And of course my reputation of being something of a radical did not help either. Medicine is traditionally a deeply conservative profession and many doctors then and even today tend to give mavericks a wide berth or indeed resent their very existence.

  But even before this I had made mistakes or was badly advised. As already mentioned, in our memorandum and articles of association we stated that we intended to do female sterilisation at Clane General Hospital. This was a bad mistake. There was absolutely no need or any legal requirement for us to have specified TL as one of the surgical procedures that were to be carried out at Clane Hospital. What mentioning this in our articles did was to give ammunition to a third party objector to An Bord Pleanála who appealed Kildare county council’s permission as soon as it was granted. This nearly put us out of business before we started.

  During the time I was in Saudi and while we were awaiting An Bord Pleanála’s decision on the ‘constitutional objection’, just up the road from us in Celbridge a colleague, Dr Gerry Waters, announced to an eager press that he was about to open a centre where female sterilisation would be available. It was to be a simple dedicated unit with overnight facilities that he was to call the Whitethorn Clinic. On a regular basis a London consultant would be flown in to carry out tubal ligations in this clinic. This was not good news for us. We had been relying on these very operations to prime our planned hospital and here it now looked as though Gerry had stolen the march on us. Of course looking back on all of this now none of it really mattered all that much as things turned out, it was just that at the time they seemed so terribly important. In any case our company had been formed, investors had come in and the land purchased and at this stage we had little choice but to forge ahead.

  When An Bord Pleanála eventually confirmed planning permission on 8 January 1985 we wasted little time in starting what we liked to think of as ‘phase one’ of Clane General Hospital. At this particular time there was a serious lull in the building trade so it was relatively easy to get builders and to ensure that they stuck to their task. Thus it was that we had the first part of the hospital, with its small out-patients department, administrative offices, fourteen beds, x-ray department, physiotherapy department, operating theatre, anaesthetic and recovery rooms, all finished and kitted out within eight months of starting the project. On 24 August of that same year, with about twenty local GPs, media and other well-wishers in attendance, Fine Gael TD Monica Barnes officially opened the place for us. That was a good day.

  Things limped along all right for the rest of that year. We had a fair backlog of tubal ligations to work through, a cosmetic surgeon started to do some work and our co-director and investor, Mr Robin Mooney, was bringing in a trickle of surgical cases. I was administrator, chairman of the board of directors and had moved my general practice into offices annexed to the hospital. But by the following spring it was becoming clear that we were facing a serious cash-flow problem. Later that year the shareholders had to make additional investments on several occasions in order to keep ourselves afloat and on one occasion I had to sell my car to pay the nurses’ wages. As is often the case in situations like these there was a lot of blaming and most of it was coming in my direction. For example my having a general practice located in the hospital was perceived as a prime reason why GPs were slow to refer patients to Clane and why more consultants were not joining us. It was difficult to ascertain to what extent, if any, this theory was correct. It may well have had some validity but equally there undoubtedly was something of making me the fall guy as well.

  That year also an old medical school friend of mine, Dr Billy Byrne, came up with the suggestion that he and I set up a company to carry out clinical trials on behalf of the international pharmaceutical industry. We called the company International Medical Research (IMR) and entered into an agreement with the hospital to use their beds and ancillary facilities in the event of our winning contracts for such clinical trials.

  That second year also further disaster struck when we had an anaesthetic death. A middle-aged lady u
ndergoing a facelift never came round from the anaesthetic and died three days later. This kind of thing tragically can happen in any hospital but we were particularly vulnerable to the adverse publicity that came in its wake. This was by way of front-page coverage in the Sunday Independent – one of Ireland’s most popular Sunday newspapers. They used a large photograph of me to accompany the ‘story’ even though I was neither surgeon nor anaesthetist. I had to take the full brunt of blame in the public eye. I remember the night before this news broke neither Ann nor I slept a wink because we knew what was coming. That Sunday afternoon we were at a bit of a get-together where I met a colleague of mine, Dr Ralph Counahan, who went out of his way to commiserate with us and to shore us up a bit in what must have been one of our most miserable hours. He may never have known just how important those few words were to me at that precise time. Poor Ralph died himself a few years later.

  The clinical trials end of things in fact went quite well and IMR won a few simple ‘bio-availability’ studies that brought some business to the hospital. We also did a private placing of twenty-five per cent of IMR shares, raising a very respectable quarter of a million pounds through Davy Stockbrokers. One would imagine that this might have calmed nerves all around but in fact it did the exact opposite. The modest success of IMR brought out the begrudgery factor in some of my co-directors in the hospital who now began to look on IMR, not as a potential saviour, but rather as a threat. There were ‘meetings’ in the car park, in the corridors and down in Manzor’s pub in Clane but I was not at any of them. Earlier I had been relieved of my position as hospital administrator – a good move on behalf of my fellow directors because I was not particularly good at the job that, by this time, consisted mostly of batting off creditors. But soon I was to be voted off the chair of the board, something that I took to be pure vindictiveness. A little later I was forced by the board of the hospital to relocate my general practice out of the hospital altogether. These were turbulent days.