Migraine International: Ireland
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The wild and windy Antrim coast between Derry and Belfast (Game of Thrones fans will appreciate the sites that served as “Dragonstone Cliffs” and “Slavers’ Bay” in the series)
Although it’s been over 30 years, I still can recall clearly my initial experience with Irish healthcare.
Having spent a wee bit too long in a Donegal pub with some new companions, I was driving on a narrow and winding country road back to Dublin. As I rounded a curve I saw just ahead a big tanker truck on its side, wheels still revolving from its failed navigation of the same curve. The driver was hanging halfway out his window, covered with blood and apparently unconscious.
Wary of the fuel leaking copiously from the truck and the imminent risk of conflagration, I reached up and pulled the driver out of his cab, taking care to mind his potentially fractured, neck, and laid him out on some grass well away from the tanker. He needed little more from me than what amounted to first-aid: immobilize the neck, compress his more actively bleeding sites, and ensure the airway is open and his breathing intact.
A fellow traveler stopped her car to offer assistance and used her cell phone to call the Irish equivalent of 911. Within 15 minutes there appeared on the road what seemed for all the world to be a “Woodie”, a wood-paneled station wagon of the vintage beloved by Southern California surfers, circa 1965. It was an ambulance, and when it backed up to where I sat with the trucker, its saloon-like back doors swung open. Out jumped a middle-aged man wearing a tweed jacket and vest and carrying a leather bag. Looking precisely like a protagonist from “All Creatures Great and Small”, he politely introduced himself as the physician, thanked me for my efforts and assured me that he and his mates would take over from here. I watched the tail-lights of the ambulance vanish as the trucker was transported back to Donegal and its Letterkenny Hospital. I resumed my journey back to Dublin.
There is a postscript. About 3 weeks later and with me home once again in San Diego, my phone began to ring insistently at 3 AM. It was the trucker and my companions from the pub in Donegal, clearly many pints into it and eager for me to know that I would have unlimited beer at their expense when I returned to visit…which I should do “as soon as ye feckin’ be able, lad.”
Portions of the “The Banshees of the Inisherin” were filmed here on Inishmore, the largest of the Aran Islands that lie just off Galway. Riding my bike on a sunny warm day I kept expecting Colin Farrell to step out from the doorway of one of the beautiful stone cottages built low to escape the wind.
As it turned out, however, I would not return to Ireland until years later, when I did so with the Migraineur team. We flew into Dublin, drove northwestward up to Derry, eastward on the Antrim Coast to Belfast, south back to Dublin, due west to Galway, southeast to Kilkenny and then again to Dublin and eventually home. I didn’t make it back to the pub in Donegal, but we did enjoy ourselves in the pubs of Derry, Belfast, and – most memorably – Galway. While our primary objective was to gather information about Irish healthcare generally and migraine specifically, Ireland is far too intriguing to permit an all work/no play itinerary. Hopefully the photographs and videos that accompany this article will help convey the astounding charm of this land and its people.
While “The Troubles” that consumed Northern Ireland and the Republic of Ireland have declined substantially since I first began spending time on the island decades ago, and while Northern Ireland shares an open border with the Republic on the south and west, the two remain distinct from one another. The Republic is an independent nation and primarily Catholic, while Northern Ireland is a member of the United Kingdom and is split more or less evenly between Catholics and Protestants. While many continue to hope for a unified Ireland, past violence casts a long shadow.
Health and Social Care (HSC) is the publicly funded healthcare system in Northern Ireland. Although HSC was created to be separate from the United Kingdom’s National Health Service, it is nonetheless considered a part of the overall national health system in the UK. On almost every measure, however, Northern Ireland’s HSC ranks below everywhere else in the UK. Waiting times are long and continue to rise – more than half of patients wait more than a year simply to have an outpatient appointment.
As with so much involving the two regions, Northern Ireland and the Republic share many of the same problems in the area of healthcare but are not necessarily traveling the same path.
Our managing editor combines business with pleasure in a cozy Kilkenny pub.
To some extent the Republic of Ireland continues to have a dual healthcare system that consists of both private and public healthcare options. In May 2021 the Irish government set out to create a universally accessible healthcare system (Slaintecare) by removing private healthcare from public hospitals and abolishing the country’s two-tier health system, replacing it with a universal healthcare model similar to the UK’s National Health Service. Healthcare in Ireland is primarily supported by government taxation (67%), with much smaller contributions from private payments and private insurance. Since this Slaintecare program was implemented, wait times – previously up to one year for elective surgery, for example – have declined.
There are 86 hospitals in the Republic, yielding an average of 3 hospital beds per 1000 inhabitants. In the US there are approximately 7,335 active hospitals, and beds per 1,000 citizens is slightly lower at ~2.38.
The United States expends about 17% of its gross domestic product (GDP) on healthcare, compared to less than half that amount for the Republic of Ireland. The US spends $8,745 per capita on healthcare, whereas, once again, Ireland spends less than half that amount. Physician reimbursement for primary care is relatively quite low in Ireland, and the primary care infrastructure in Ireland is rated as “poor” by western European standards. Total expenditure on healthcare as a share of GDP was only 6.1% in 2022, well below the European Union average of 9.9% and far below the 17% of GDP expended by the US.
Despite this, people in the Republic of Ireland lead longer and healthier lives than most other Europeans. The life expectancy in Ireland in 2022 was 82.7 years, and Ireland ranked 2nd in the 2022 World Index of Healthcare Innovation with an overall score exceeded only by Switzerland’s.
What about migraine? As many as 750,000 individuals in Ireland suffer from migraine, yielding a prevalence rate of about 16% in the general population. Neurologists typically serve as the vanguard for clinical care and research involving migraine and the other primary headache disorders, and in Ireland that’s a problem: one survey indicated that there are currently just 24 neurologists in Ireland for 4.5 million people (1 for every ~187,000 vs 6 times as many - 1 for every ~20,000 - in the U.S.). This number has not been skyrocketing up over recent years: in 2004 it was 14, unchanged from 1984. The average wait time for a “routine” neurological appointment is one year.
Why is this? Can you not make a decent living as a neurologist in Ireland? Well, the mean salary for a neurologist in Ireland (~$221,000) compares favorably with that of US neurologists (~$285,000). So what’s the problem, then? Ask a neurologist (if you can locate one) and they will cite too many patients with neurologic disorders/too few neurologists to see those patients/too little time available to spend with a patient and all the other frustrations produced by a supply:demand imbalance that are so familiar to headache medicine providers in the US. In the end, the Irish national healthcare system seems either disinclined or unable to redress this imbalance, and decades of underinvestment have resulted in Ireland having the lowest ratio of consultant neurologists to general population in the developed world. Put simply, Ireland has well less than half the neurologists the country needs.
In Protestant Belfast – a reminder that “The Troubles” are not altogether in the past
Despite this major problem with access to medical care – or perhaps in response to it – a strong national support system for migraine has developed and is epitomized by the Migraine Association of Ireland (info@migraine.ie). Founded in 1994, Dublin-based Migraine Ireland is a vigorously effective charity organization that provides information, support and advocacy for those with migraine and their families. We at Migraineur are most pleased to have recently received the Association’s enthusiastic endorsement.
A bit of a paradox, eh? Lower healthcare expenditures and limitations on access...but healthier and longer-lived people. How can this be?
Go to Ireland, and perhaps there you will find the answer. Maybe on a cold wet night in a cozy pub as you listen to the trad and nurse a pint. Maybe as you stand in the wind on the Giants Causeway, gazing seaward and feeling snug in your Aran wool sweater. The Emerald Isle offers the beauty its name suggests, and its towns and cities are replete with charming, friendly, and supportive people who clearly enjoy good company, good conversation and a good pint.
Sláinte!
