Dara Gantly

Dara Gantly examines whether the Department of Health’s new Statement of Strategy holds many surprises for the profession.

Fresh from a not-too-successful day at the races in Newmarket, Dr Ruairi Hanley believes introducing mandatory vaccinations would be a surefire bet for the nation’s health.

Regular readers will be aware that, owing to the joyous arrival of our daughter, I did not make it to the Cheltenham festival this year. I decided to compensate myself by arranging an expedition to Newmarket for the Guineas meeting, which took place over the May bank holiday weekend.

As is traditional whenever I attend such events, the experience was financially unsuccessful. My policy of refusing to back short-price favourites proved particularly inept, with the spectacular victory of Camelot in the 2000 Guineas.

Despite not having backed the horse in question, it was hard not to be moved to cheers by the sight of a magnificent Irish-trained winner, brought home in style by young Joseph O’Brien for his father Aidan. The boys from Ballydoyle proved themselves to be once again a world-class act and a credit to their nation.

Naturally, with their customary grace in such matters, some English journalists apparently decided to deliberately amend the nationality of both the jockey and trainer of the Guineas champion. I thus read with incredulity as one publication declared this to be a “British” classic victory.

This irritating little example of ‘Irish sovereignty denial’ calls to mind a famous, possibly apocryphal, anecdote that was attributed to a legendary Irish actor with a reputation for hell raising. Back in the 1960s, this gentleman received an honour for an outstanding performance in a feature film. An English newspaper immediately ran the headline “British Actor Wins Prestigious Award”.

A few weeks later, the same thespian was involved in some form of public order incident in a bar. The same newspaper duly carried this story under the heading: “Irish Actor in Drunken Brawl”.

Many of us assume that all journalists across the Irish Sea have moved on from the 1960s and now accept the concept of our sovereign Republic. Alas, it seems some remain slow learners.

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Donnybrook in Newmarket
Speaking of brawls, while in Newmarket, I had the misfortune to witness a somewhat unsavoury incident. Outside my hotel, two intoxicated race goers (easily identified by their formal dress and badges) began a violent fist fight in broad daylight on the main street.

What stood out about this particular piece of drunken thuggery was the fact that both of the combatants were young women wearing expensive party frocks, designer handbags and high heels.

The local police were required in some numbers to bring an end to hostilities, while various yobs in shiny suits stood around guffawing and swilling lager from cans.

This is not the first time I have witnessed violent incidents at English sporting events. In contrast, I can say with certainty that after almost two decades of going to race meetings and festivals in Ireland, I have never once seen women hitting each other.

It is ironic to consider that, given all the negative publicity surrounding this country and its attitude to alcohol, we still seem to celebrate sporting occasions without beating each other to a pulp.

Perhaps those who comment on such matters should make more effort to acknowledge our good behaviour as well as our bad.

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Ireland should lead the world on mandatory vaccination

Vaccination rates
On the flight home from Britain, I attempted to pass the time by reading one of my favourite magazines, The Economist. The latest edition included a fascinating article on declining vaccination rates in the United States.

The authors explained that in California, there were growing pockets of children who were not immunised against serious infectious diseases because their parents simply refused to give consent. Some of these people are hard-line “conservatives” who regard mandatory vaccination as an intrusion on their civil liberties. Others are described as “liberal, organic food and yoga” types who are convinced that the injections are somehow dangerous. I have long suspected it is this second group that also dominates the lingering anti-vaccination mindset here in Ireland.

The difficulty lies with how to address this problem. The Economist rightly recommends that health officials should attempt to “educate more parents with good science rather than Internet drivel”.

Unfortunately, this is easier said than done. In some corners of cyberspace the discredited theories of those who tried to link MMR to autism continue to be peddled. Those who reject these baseless allegations are portrayed as the willing pawns of an evil pharmaceutical-medical establishment.

While it is easy to dismiss such online gibberings, it never ceases to amaze me how many of my fellow citizens place their confidence in Internet forums instead of in a qualified doctor who has treated their family for decades. Furthermore, I find the ongoing national obsession with frequently unproven and unscientific alternative medicine to be truly disturbing.

I am afraid that, for Ireland, more direct action is needed than mere educational measures. The time has come for immunisation to become mandatory in this State with financial penalties, such as removal of child benefit payments, for those who refuse to comply.

While some might argue this approach could be counterproductive, I believe the time for talk has ended. There reaches a point where even endless amounts of rational argument can no longer win over a small minority of truly irrational people.

Just as we did with the smoking ban, Ireland should lead the world on mandatory vaccination.  One day, our children will thank us.

Dear Editor,
I contacted you last year (‘HSE tackles waiting lists by stealth’, Irish Medical Times, July 1, 2011, see http://bit.ly/Jpq2Az) when two of my patients were referred back to me by two different hospital administrations, having already spent several months on the waiting list to see a consultant, the justification being that “the patient is not in our catchment area”.

It is my impression from discussions with colleagues that this is starting to happen again.

I believe that this practice is totally unacceptable for a number of reasons:
•    To the best of my knowledge, no hospital has ever informed GPs exactly what their catchment area is;
•    If catchment areas are to become the norm, general practice should be consulted first;
•    It is often desirable to refer away from your local hospital for a number of reasons, such as access to particular specialist or sub-specialist expertise; and indeed, whatever happened to patient choice?
•    It is totally unacceptable for such declarations to be made several months after a referral is made, as the patient will move to the bottom of a new list. Does this mean that the letter has only been read several months later?
•    At present, I work in an area that the HSE designate as Dublin North East. There are well-established links between hospitals in Dublin and the North East. I believe that I should be allowed to refer to all hospitals in that area.

I would call upon the HSE or the Minister for Health to clarify the situation, and not to undertake any further medical apartheid of waiting lists.

Dr Conor O’Shea,
Wheaton Hall Medical Practice,
Drogheda, Co Louth

Dr Muiris Houston

Dr Muiris Houston says the results of the most comprehensive study of youth mental health ever undertaken in Ireland points to the need for us all to become an influencing ‘Good Adult’.

I’ve heard many positive reports about Jigsaw, the community mental health service for young people. Among other places, it’s active in Galway city, and young people and students around these parts speak of it highly.

Jigsaw is an initiative set up by Headstrong, the organisation founded by clinical psychologist Tony Bates. Since it started, it has done immense work in the area of young peoples’ psychological health.

Now, in collaboration with UCD School of Psychology, Headstrong has carried out one of the most comprehensive studies of mental health ever undertaken in Ireland.

Acutely aware
Capturing the views of nearly 15,000 young people, aged 12 to 25 years and from a variety of backgrounds, it shows that young people are acutely aware of their mental health. Some 6,085 students from 72 post-primary schools participated in the survey. A further 8,221 young people from a variety of different backgrounds (aged 17 to 25 years) took part.

The My World Survey (MWS), published this week, gives us valuable insights into issues such as self-esteem and optimism, important risk factors when it comes to self-harm and suicide.

“It is evident from the findings that mental health difficulties emerge in early adolescence and peak in the late teens and early 20s, making this period in young people’s lives a highly vulnerable one. This peak in mental health difficulties, in general, is coupled with a decrease in protective factors such as self-esteem, optimism and positive coping strategies,” Tony Bates says in a commentary on the research.

Suicide prevention
A key finding is that suicidal thoughts, self-harm and suicide attempts are higher for those who don’t talk about their feelings. Forty-one per cent of all males in the study and 44 per cent of females have had thoughts about suicide.

Sixteen per cent of males and 24 per cent of females have self-harmed and 6 per cent of males overall and 8 per cent of females have attempted suicide. And those who experienced suicidal thoughts reported that they did not talk about their problems.  Those who reported fewer problems were more likely to seek help and talk about them.

Left to right: Darren Scully, Headstrong Youth Advisory Panel; Minister Kathleen Lynch; Tanya Wrightson; and Tim Smith of the HYAP at the announcement last October of six new Jigsaw sites to improve Youth Mental Health services

Substance misuse
What about drink and drugs? This is the first national study to track drinking behaviour and then link it to mental health.  Some 45 per cent of young people, from 12 to 25, have drinking habits that are problematic, harmful or even show dependency.  This increases to a worrying 61 per cent for young adults between 17 and 25.  And this excessive drinking is having serious effects on young people’s mental health, their levels of depression and stress.

We now know young people increase their drink consumption from age 13-14; they move outside the normal range of alcohol consumption at age 18-19 and remain above it until age 25. And for the first time we know, from evidence, that drink is impacting not just on young people’s physical health, but on their mental health too.

But over one-third of young people do not talk or seek informal help when they have problems. Those who know that they have emotional difficulties but who do not seek necessary formal help have the highest levels of distress and the lowest well-being.

Which brings us to what I consider one of the key aspects of the research: the concept that one ‘Good Adult’ is central to the mental health of young people.

Good Adult
The availability of a parent, sports coach or teacher that the young person trusts has a major influence on the young person’s self belief, their confidence, their coping skills and their optimism about the future. The presence of this figure in a young person’s life is a moderating, insulating force, one that helps to develop the resilience and self-esteem they need to live this stage in their lives to the full.

The ‘Good Adult’ is a critical factor that enables young people to resolve the challenges they face. Tony Bates sums it up well when he says: “We are all potential ‘Good Adults’ in the lives of young people we know in our families, our communities, schools and youth services. Many of us may not appreciate the power we have in influencing a young person’s self-belief and how they learn from us the fundamental skills they need to live. The MWS findings highlight how all young people, especially those who are not coping with their lives, need our support, now more than ever.”

The data from MWS offers us, for the first time, an understanding of where young people are ‘at’ psychologically. We now have an evidence base to plan for the nation’s future mental health needs.

Let’s go and do it.

Ed Madden, BL, looks at a recent English High Court case in which a judge explained why he made an order declaring that a woman lacked capacity to consent to sexual relations.

A 29-year-old woman  known as ‘H’ has mild learning difficulties and atypical autism, with a full scale IQ of 64. In December 2011, Mr Justice Hedley in the High Court in London made an order declaring her incapacity in a number of respects and made best-interests declarations as to her future care.

In particular, the judge made an order declaring that H lacked capacity to consent to sexual relations. He also made a consequential order to protect her best interests, which was very restrictive and amounted to the deprivation of her liberty. In early 2012, the judge gave his reasons for making these orders and first outlined the background to the case.

After she was born, H lived with her parents and a younger brother. She attended a special school from the age of 5 until she was 17, when she transferred to a community college. She remained in the college until she was 19. By that time, her parents had separated and she was living at home with her father and brother. Sadly, her father died in 2007. Following his death, H led what the judge referred to as “a rather itinerant lifestyle”.

Attempts were made by hospital staff to ascertain what she understood about sexual relations

Dr Xenitidis, a consultant psychiatrist, was jointly instructed to provide an expert opinion on H’s capacity. He told the Court that the woman’s history demonstrated a very early and a very deep degree of sexualisation. In 2003, a man was convicted of attempted rape following a sexual offence against her. Other men had engaged in sexual behaviour with her to which she consented, but which could be seen as “unconventional and exploitative”. Matters came to a head in 2009 when she sought refuge in the home of a man called ‘R’.

R was not a man with an “enviable background”. Nonetheless, he acted quickly and responsibly to see that H’s interests were safeguarded. He drew the attention of the relevant authorities to her sexual activities and to her vulnerability. This resulted in a domiciliary visit by a psychiatrist.

Sexual activity
During an interview with the psychiatrist, H gave an extensive, if confused, history of a willingness to have sex with anyone who asked her, including strangers. She indicated that she was engaging in sex with multiple partners at the same time, including a group of much older men. On the day of the interview she was admitted to a psychiatric hospital — initially as an ‘informal patient’.

Some three months after her admission, she was compulsorily detained under Section 3 of the Mental Health Act 1983. She remained in hospital until she was discharged in August 2011.
While in hospital, her behaviour often displayed highly sexualised and bizarre features. Attempts were made by hospital staff to ascertain what she understood about sexual relations and to give her some education in issues of self-protection.

Since the court case in December 2011, H lives in accommodation provided by a private agency under contract with the local authority. Three other residents live in the same building. She is supervised on a 1:1 basis at all times, whether in or out of the property. Those who enter the property are carefully regulated. The purpose of the restrictions is to prevent H from engaging in sexual relations (which she would otherwise willingly do).

Best interests
The judge said that these were considerable incursions into personal autonomy and freedom. They depended on a ‘best-interests’ judgment as to H’s needs and had their legal foundation in a finding of incapacity to consent to sexual relations under the Mental Capacity Act 2005. It was strange, but nevertheless true, that the freedom to make unwise decisions was one that the court was required to guard and only to restrict if and when the best interests of H “positively so require”.

In the present case, the Court had come to the conclusion that H lacked capacity to consent to sexual relations on two specific bases: first, that she did not understand the health implications of sexual relations — a matter made more serious by her history of multiple partners “indiscriminately accommodated”; and secondly, that she was not capable of effectively deploying the information which she did have into the decision-making process. These matters were evidenced by the history of the case and by the expert psychiatric assessment of Dr Xenitidis.

Capacity to marry
Having concluded that H lacked capacity to consent to sexual relations, the judge dealt with the issue of capacity to marry. Marriage raised more complex issues than consent to sexual relations. However, for so long as marriage requires sexual intercourse for its consummation, it follows that the person who lacks capacity to consent to sexual relations must also lack the capacity to marry. The judge, however, declined to make a formal declaration regarding such capacity. He also declined to make a formal declaration regarding the issue of contraception.

H’s case will be subject to a major review by the High Court in November 2012, both as to capacity and best interests. In the intervening period, further learning will take place on H’s part, both in the area of sexual and personal safety and in the area of life skills generally.

Reference: [2012] EWHC 49 (COP)

Dear Editor,

I was recently diagnosed with cancer of the prostate, which as we all now know is very common in men of my age — 60 — PR examination essential. Not wanting the rumour mills to start turning, I put the diagnosis out there among the patients.

Several days later an elderly man sat in front of me and told me he was very upset about some bad news he had heard about me from Mrs Gossip, a usually trustworthy spreader of sad news.

Stoically I informed him that, yes, I had cancer and that I was to be operated on in several days by Prof Robot and that I would be out sick for two months.

He smiled and shook my hand and said, “Thanks be to God that’s all it is. I was told you were retiring!”

Upset? No, quite the opposite. We all need lifts and tonics like this in our own times of crisis.

A.H.

(Name and address with Editor)

Dear Editor,

I would like to commend Dr Austin O’Carroll for speaking out about the unacceptably long waiting lists for drug users, particularly in rural areas of the country (Irish Medical Times, May 4, 2012, http://bit.ly/IY5Cli).

Heroin use is on the increase and spread beyond Dublin and has been growing steadily over the past 10 years. The response of successive Governments has been pretty similar. There tends to be an acknowledgement of the problem but a rudderless lack of strategy in how to deal with it.

I have written many times in the media about how this problem can be solved and have met a number of Ministers with responsibility for drug strategy. Every one of them seems to be preoccupied with heroin users becoming methadone abstinent, while failing to appreciate the strong research evidence for long-term methadone maintenance treatment.

Unless more GPs become involved in this work and restrictions are eased for those GPs already treating drug users, then it is inevitable that there will be more deaths. GPs are not being equipped to treat heroin users at source. Furthermore, concerns have been consistently raised about the quality of the clinical guidelines in place. This issue is unresolved and this is affecting the quality of treatment delivery. These guidelines are the cornerstone for audit assessment and, as it stands, successful audit is the only way GPs can gain the necessary experience to treat heroin users waiting for treatment.

The Government needs to see the wood for the trees. The drug problem in this country is worsening and lack of timely access to treatment is costing lives.

Dr Garrett McGovern,

Medical Addiction Specialist,

Dundrum,

Dublin 14.

Dear Editor,

On reading your publication of May 4, 2012, I noted the article on page 4 (‘MC awards legal services contract’, Irish Medical Times, http://bit.ly/IAfowV) referring to the renewal of a legal services contract by the Medical Council.

There was also a front-page article (‘Grace period before ‘escalation’ on late fees’, http://bit.ly/IsHNjq) and an Editorial comment (http://bit.ly/Iy4o2Z)on a new late payment fee planned for those doctors who don’t pay their annual retention fee on time. It would appear the commentary displayed some empathy for the Council.

Did the Council seek legal advice on their lease of Kingram House at a cost of €820,000 per year — either for five or 20 years (depending on whether or not it had exercised its option last year to purchase the shareholding)?

From its latest available Annual Report (2010), this accounted at the time for nearly 10 per cent of the Council’s income (€8,692,204 in 2010), all paid for by doctors.

As you stated in your Editorial ‘Far from a Kingram’s ransom’, the Council has predicted a deficit for 2012 of €1.121 million. Given these record financial loses, will the Council continue to give its staff annual bonuses?  More than €60,000 was paid to staff by way of a bonus payment in 2010, among its 49 employees.

Has our Medical Council adopted the same corporate ethos as our banking fraternity?

Dr Ross Ardill,

Custom House Square Medical Centre,

Dublin 1.

Dara Gantly

Dara Gantly marks the opening salvo in what may well develop into the first real industrial relations test for Minister for Health Dr James Reilly.

The circulation by the Department of Health of a discussion paper on the proposed new Consultant Level 1 post to the Forum of Irish Postgraduate Medical Training Bodies for comment was never going to go by without some reaction from the IMO, irrespective of whether the union was included in the initial discussions. Given the massive implications for its members, to imagine otherwise would be naïve.

So what has been the reaction? The IMO has written to Dr James Reilly seeking the job description, salary scale and progression arrangements associated with the proposed new grade. It also wants the Department of Health to forward data on the current consultant and SpR NCHD posts, their location and specialty, together with the quantity of unfilled vacancies. All legitimate questions, one would agree, from a union representing those members who will be affected by the proposed new post.

The IMO is concerned over the “lack of clarity” on how the proposed post would operate in practice, and indeed would like to know such basics as how many consultant Level 1 posts the Department envisages creating. Again, a legitimate query that should really be answered, especially given the ongoing haemorrhaging of our NCHD workforce to health services abroad. If we are to stem the tide, isn’t it important we spell out the ‘attractiveness’ of these new posts as soon as possible — that is, if they do prove attractive.

As part of the consultation process, it is reported that the medical training bodies are surveying more than 1,000 NCHDs online to gauge their support for the mooted new consultant grade. But will they be attracted by a Type A consultant post, working exclusively in public hospitals on a lower salary, if this is proposed? What about allowing for doctors to work outside the country, with all the expertise they can bring back to the health service? Will doctors be able to have tenure, while also being able to go abroad to complete a Fellowship?

The IMO’s Director of Industrial Relations Steve Tweed believes the most notable aspect of the proposal is the lack of clarity on how the proposed post would operate in practice. “Certainly, from an industrial relations perspective, there are many unanswered questions which require further detail before an informed debate could take place on the merits, or otherwise, of the proposal,” he has informed Minister Reilly, while expressing ‘disappointment’ at not being included in the discussions at this early stage.

But why not include them? To paraphrase a paraphrase I used not too long ago in this publication, when one wants to speak to NCHDs about a new grade, who does one speak to, if not the IMO? If the impasse over the GP contract has taught us anything, surely it’s that this lack of engagement is impeding progress on the many reforms envisaged by the new Government.

Does the Minister agree with the contents of the report on the new grade carried out by Dr Ambrose McLoughlin? Well, Dr McLoughlin has since been appointed the new Secretary General of the Department of Health, which would suggest he is the right man in the Minister’s eyes for this and many other tasks ahead. But again, it’s all about the detail and that old devil again — although doctors won’t want to be left with a choice between that devil and the deep blue sea!

Will the new grade of consultant be employed on a shift basis? Will the post be family friendly? Indeed, will it be a runner for those doctors already abroad and looking to return to Ireland?

You may recall the Minister earlier this year wanted to rewrite the lyrics to Ireland’s Call. Standing ‘shoulder-to-shoulder’ with members of the Seanad in February, Dr Reilly said he hoped soon to send out a call to doctors working abroad to come back to this country. “Senators are familiar with the rugby song, Ireland’s Call. I will issue my own ‘Ireland’s Call’ to bring our medical professionals back,” he pledged. But will this fall on deaf medical ears?

Next year will mark the 10th anniversary of the Report of the National Task Force on Medical Staffing. Better known as the Hanly Report, it recommended a ‘consultant-provided service’ where consultants would work in teams, with revised working patterns, alongside a significantly-reduced number of NCHDs.

In order to achieve a fully-operational, consultant-provided service by 2013, the Task Force estimated that some 3,600 consultants would be needed, representing an increase of some 1,870 posts (+108 per cent) over the figure for 2003. Is this still Government policy? Are the 3,600 posts now to be made up of consultant Level 1 post holders?

Of course, I don’t expect answers to all of the above questions. But you should.

The media needs to show balance and fairness on the drink driving issue

Dr Ruairi Hanley wonders if our attitude to politicians who are caught driving under the influence of alcohol

Dr Ruairi Hanley

can be diluted by the media’s political allegiance.

I shall begin this week by asking a simple question: which current Cabinet Minister has a conviction for drink driving?

I suspect the majority of readers would probably struggle to provide the correct answer. I will enlighten them shortly. However, before I do so, let me pose another question: how many of you remember the antics of Dr Jim McDaid? Back in 2005, the former Fianna Fáil TD was caught driving the wrong way up a dual carriageway while substantially over the legal alcohol limit.

I think it is fair to say this particular episode received significant media coverage. Jim’s adventures on the M7 are undoubtedly forever lodged in the memory of anyone who even glanced at a newspaper at that time.

Now, let us return to the Cabinet Member who also has a drink driving conviction, one that, unlike Jim McDaid’s, seems to have been largely forgotten. The offence in question took place in 1991 and the individual found guilty was then the deputy leader of a political party, having previously served as a cabinet minister. He went on to lead that party, before being appointed Minister for Finance in December 1994. In 2011, he returned to Cabinet as Minister for Education.

Yes indeed, it is Minister Ruairi Quinn, who I believe holds the dubious honour of being the most senior politician in the history of the State to have been previously caught driving under the influence.

The full details of this case are as follows. (For the record, these have been obtained from the Irish Times archive of January 22, 1992.)

Deputy Quinn was driving erratically at 2.49am on March 10, 1991, in the Clontarf area. He was intercepted by Garda Michael McConalogue, who said that the vehicle driven by the TD had “broken the continuous white line a number of times. Cars coming towards him had to slow down and veer to the left”.

Ban and fine

When the Garda stopped Mr Quinn, he walked in an “unsteady manner” to the rear of his car. A strong smell of alcohol was noted from him, while his eyes were described as “glazed”. At Clontarf Garda Station, Deputy Quinn provided a urine sample, which showed him to have an impressive “202mg of alcohol for 100ml of urine”. The man now responsible for the education of the children of Ireland was banned from driving for a year and fined £250. However, he was congratulated by the judge for having shown courtesy to the gardaí.

Now that we have established what happened, I must ask why this entire incident appears to have disappeared from our national recollection. Readers might think I am being harsh here. I invite them to consult the Wikipedia entry for ‘Ruairi Quinn’, from which the drink driving conviction is noticeably absent.

Next, I suggest that they review the biography of Jim McDaid on the same website, where his escapade on the dual carriageway is well documented. Wikipedia even clarifies that Jim managed to have a blood alcohol level of 267mg.

This apparent inconsistency is not confined to the Internet. On April 29, the Sunday Independent magazine ran a glossy four-page spread on the Minister. We were told all about his religious views, medical history and indeed his political career dating back to the 1960s. Under the heading ‘Radical Chic’, readers were informed that Ruairi Quinn’s office is “impeccably tasteful”.  But of the events in Clontarf back in 1991, there was no mention.

At this point, I would like to state that I am not for a moment suggesting that Ruairi Quinn has attempted to conceal his record. He bears no responsibility whatsoever for what journalists or online biographers choose to write about him. Indeed, in 1992 he did not contest the charges in court and behaved respectfully towards the gardaí doing their duty.

However, I must ask if I am the only person who is vaguely disturbed by the fact that our Minister for Education is a convicted drink-driver? I also must ask why, when he was appointed to this office in 2011, not one prominent journalist in the State raised this issue? I cannot but wonder if a similar degree of apparent media reticence would have greeted the reappointment of Jim McDaid to Cabinet?

Medical Council

Furthermore, as a member of the medical profession, I understand that if I received a drink driving conviction, I would face possible sanction and disciplinary action from the Medical Council. My right to practise and professional reputation would thus be placed in jeopardy. Yet, in stark contrast, it appears that prominent politicians can go on to enjoy massively successful careers after such events.

Second chance

My view on this matter is simple. Everyone makes mistakes in life and everyone is entitled to a second chance. There is no doubt that Ruairi Quinn has achieved much that is good for our society in his career to date and that the incident was out of character. I recognise he is far from the only TD who has been found guilty of this crime.

Nonetheless, when it comes to drink-driving, I think it is only fair that our media be required to show consistency, balance and fairness, regardless of political allegiance.

In this case, it appears many journalists have chosen not to do so. Only they can explain why.

Quis custodiet ipsos custodes?