Joanna Tuffy (Dublin Mid West, Labour)
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The next item on the agenda is accreditation of the Bahrain facility of the Royal College of Surgeons in Ireland. A report on the accreditation of the Bahrain facility of the Royal College of Surgeons in Ireland was prepared by Ceartas, Irish Lawyers for Human Rights, in May of this year. That body wrote to the committee requesting an opportunity to raise the issue with us and, accordingly, there will be a presentation on the matter today. Following this we will have discussions about the junior cycle.

From Ceartas, I welcome Dr. Gearóid Ó Cuinn and Mr. Gerry Liston. By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I advise witnesses that the opening statements they have submitted to the committee will be published on the committee's website after this meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

Dr. Gearóid Ó Cuinn:

I thank the committee for the opportunity to make this presentation. Today I will speak on the issue of the Royal College of Surgeons in Ireland facility in Bahrain, with regard to which Ceartas has committed to taking legal action on international human rights issues from Ireland. As the RCSI facility in Bahrain awards Irish medical degrees as a result of section 88 of the Medical Practitioners Act, there is an obligation on the Irish Medical Council to monitor and accredit RCSI Bahrain and its programmes of education. For the purposes of accreditation, the Irish Medical Council has adopted the World Federation for Medical Education standards, also known as the WFME standards, which I will refer to throughout the presentation. These standards provide a mechanism for quality improvement in medical education and recognise the practical dimensions of medicine and the requirement for hands-on experience in clinical tuition. Therefore, they demand that the locations of clinical tuition must be safe, appropriate and able to deliver training in the core competencies of medicine, including medical ethics.

These are the same standards applied to medical education programmes in Ireland. Many of the human rights abuses documented in Bahrain over the past two years have involved medical personnel and facilities, public and private, utilised by RCSI Bahrain. As the committee may already know, Dr. Ali Al-Ekri, an RCSI fellow, is one of the medics who continues to serve a prison sentence for what the Physicians for Human Rights termed "treating protesters and giving interviews". From the perspective of Ceartas, there was an overlap between the human rights violations in hospitals and the WFME standards used by the Irish Medical Council.

I will sum up three major areas of concern that we have identified, much of which is already detailed in our distributed report. The first is access and provision of health care. During the Arab Spring protests in 2011, numerous medical personnel were tortured and imprisoned, and today injured protesters and those affected by indiscriminate use of force by the Bahrain authorities fear using hospitals and clinics used by RCSI in the training of students. We have documented consistent allegations of abuse in this regard, including accounts from reputable sources of patients being picked up from RCSI-utilised hospitals and subsequently tortured.

The second is a restriction on freedom of expression and matters related to health care. Medical personnel have consistently reported on a fear of speaking out and I direct the committee to the annexes of our report, showing communiqués instructing doctors to pass information on suspected activists to security forces. In some cases, patients are vetted before they are treated and doctors who complain of human rights abuses are targeted. I would be happy to supplement accounts in our report with more ongoing examples that have occurred recently. In sum, the continuing detention of Dr. Al-Ekri and the targeting of doctors and violations of medical neutrality have all had a chilling effect on the medical system that interfaces with the political system.

Third, turning to discrimination, the heads of hospitals and clinics have been replaced with doctors from the Sunni sect. We have also documented how 30 RCSI students were denied work placements simply for being Shia. The examples are too numerous to mention but they have been documented at length in our report. For more information on discrimination in access to appropriate health care, I direct the committee to the report of the Bahrain Centre for Human Rights on the politicisation of sickle-cell disease, which makes for grim reading; sickle-cell disease mostly affects the Shia population.

As I mentioned already, the WFME standards adopted by the Irish Medical Council require that the facilities used in clinical tuition should be safe, appropriate and able to deliver on core competencies, including medical ethics. We submit that the facilities used by RCSI Bahrain are not an environment living up to Irish standards, and these allegations are of such a consistent and serious nature that they overshadow any claims of medical excellence.

We also wish to highlight the fact that RCSI Bahrain is not immune from the political order that is prevalent in Bahrain at present. Members might already know that the conference on medical ethics which it tried to organise in association with Médicins san Frontières was blocked. This resulted in the resignation of Professor Tom Collins, the head of RCSI Bahrain, who also confirmed the militarisation of the health care system and the hapless position of RCSI Bahrain in its ability to influence the situation there. RCSI Bahrain's strategic plan for the next few years fails to mention the unrest that has swept Bahrain and how it has disrupted the health care system, but it has mentioned things such as the economic downturn. RCSI Bahrain's open days are now sponsored by the Bahrain Defence Force.

With regard to the future, what we consider to be of particular importance to the committee is the fact that until RCSI's education programme is evaluated by the Medical Council, the use of Bahraini hospitals is deemed to be approved by section 88 of the Medical Practitioners Act 2007. This undermines the integrity of Irish standards and Irish medical degrees. The Medical Council taking a stance in line with international standards should not be done in an à la cartefashion. The Medical Council should proactively embrace these standards and apply them as it would in Ireland. This is explicitly required under the Medical Practitioners Act.

In terms of recommendations for action, we respectfully suggest that the committee recommends to the Minister for Education and Skills that RCSI Bahrain falls short of Irish accreditation standards and that this situation prompts appropriate action in accordance with the Medical Practitioners Act 2007. Likewise, the committee should bring to the Minister's attention the adequacy of other streams of Irish accreditation, including the National University of Ireland and Quality and Qualifications Ireland. We urge the committee to invite the Medical Council to explain how it intends to approach the accreditation of RCSI Bahrain and the human rights concerns affecting the sites of clinical tuition used by RCSI Bahrain.

Averil Power (Fianna Fail)
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This is a very serious issue and the committee should be concerned about it. It not only affects the reputation of the RCSI in Bahrain and here, but also the reputation of Irish education. Education is something we are trying to market to other countries and its reputation should not be in doubt. The witness has made the main points. I was in Bahrain with an Irish delegation of doctors, human rights activists and others two years ago and heard the testimonies the witness mentioned. Students told us that in previous years all members of the graduating class would automatically get a placement in a state hospital so they could complete their professional training. However, after the protests that took place during the Arab spring in Bahrain, a distinction is now being made on sectarian grounds between the students. It should be a matter of extreme concern to us that an Irish institution would be involved in that type of practice.

There is also the resignation of Professor Tom Collins. He is an incredibly well respected academic in Ireland as a result of his work on the National Council for Curriculum and Assessment, NCCA, the Curriculum Advisory Council and other bodies. Having visited Bahrain, he resigned from that position and said he was not satisfied to continue in it given the human rights context. We should take that very seriously. It is appropriate for the committee to express its concerns on this issue and ask that they be examined. It is alarming that matters are just getting worse daily in Bahrain. There are also wider issues surrounding medical neutrality and so forth. Amnesty International, the European commissioner for human rights and various groups have expressed concerns that Irish trained medical personnel such as Dr. Ali Al-Ekri and others who trained in Dublin as part of the RCSI training were arrested in Bahrain simply for treating injured protestors and for expressing concern and anger on television at the fact that people had been shot in the back of the head and so forth. They were rounded up and arrested for that reason and they are still in prison.

I thank Dr. Gearóid Ó Cuinn for making this presentation. It is appropriate for this committee to express concern about an Irish institution being under such a dark cloud with regard to the human rights and particularly the safety of its students. Every institution has a responsibility to protect the safety of all its students, regardless of their ethnicity, religion or anything else.

Trevor Ó Clochartaigh (Sinn Fein)
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Go raibh mile maith ag Dr. Ó Cuinn for a very important presentation. I, too, am concerned about the length of time it is taking to get action on the issue. I echo what was said by Senator Power and support her call. Just because something is happening a long way from Ireland does not mean we should wash our hands of it; far from it. The basic civil rights of the doctors in question must be supported and we must do everything we can to do that. I support the call that this committee do that in the ways that have been suggested.

Dr. Gearóid Ó Cuinn:

We welcome the support. We agree that certain things should be of concern. Apart from what I have presented to the committee, we are also very concerned about the lack of transparency. Organisations such as Médicins sans Frontières, Physicians for Human Rights and, critically, the UN Special Rapporteur on torture cannot get into Bahrain, so how do we know what is happening within the facilities and whose word do we take on this? One of the problems we have discovered as well is that documenting the abuses is getting more difficult. We recently participated in a campaign called End Impunity which finished two days ago. Some of the members we worked with have subsequently been arrested. Others have gone into exile, including Yousif Saif who is the head of documentation for the Bahrain Center for Human Rights. We believe the violations will soon become invisible, but that does not mean they are not ongoing. There must be an effort by the Medical Council to systematically find out what is happening.

Lastly, with regard to what we have seen from RCSI senior staff who have commented in the Irish media, I have given members of the committee copies of some news items. News item No. 2 refers to extremely anecdotal evidence of their awareness of what is happening in the facilities. They quote what they have heard from some of their medical students, but we have heard nothing. What we have documented is that people are afraid to speak out, especially students who have invested so heavily in their medical careers. Something programmatic must be done to ensure that Irish standards are really being maintained in this essentially hostile environment.

Joanna Tuffy (Dublin Mid West, Labour)
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Does Mr. Liston wish to add to that?

Mr. Gerry Liston:

It is important to stress the legislative context here. At present, the situation in Bahrain is being approved by the operation of Irish law. As Dr. Ó Cuinn stressed, until the Medical Council goes out and conducts a process of accreditation in Bahrain, section 88(6) of the Medical Practitioners Act 2007 deems the situation to be approved. That adds to the urgency. Irish law is approving the situation in Bahrain at present and that heightens the urgency. The Medical Council must go there and conduct its process of accreditation.

Marie Louise O'Donnell (Independent)
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What the witnesses say is damning and worrying. What is the position of the RCSI in reaction to all of this?

Dr. Gearóid Ó Cuinn:

We can only see from what it has said publicly. We have pointed out that its strategic plan does not even mention the impact the unrest has had on the health sector. It is not clear. We have also learned from Médicins san Frontières that it attempted to screen a film, "Access to the Danger Zone", narrated by Daniel Day-Lewis. This was pulled in mysterious circumstances after an e-mail had been sent to staff and students. After Professor Tom Collins resigned, there has been a silence on the issue. It cannot even have a conversation on medical ethics. What does it say about the position of doctors who are in hospitals and people who are being trained on medical ethics? These students graduate with National University of Ireland, NUI, degrees. Is it appropriate that they are graduating with this level of fear and mistrust, where they cannot even bring up medical ethics in a conversation?

Its position is not clear. After Professor Collins resigned, a delegation went to Bahrain, but it appears it did so to apologise. Nothing was released in favour of Professor Collins's position or on the issue of medical ethics as an area of acute concern for Bahrain.

Joanna Tuffy (Dublin Mid West, Labour)
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What do the witnesses want the committee to do to follow up on this?

Dr. Gearóid Ó Cuinn:

To emphasise what I said at the end of my presentation, I ask the committee to recommend to the Minister for Education and Skills that RCSI currently falls short of Irish accreditation standards and that action is required in accordance with the Medical Practitioners Act.

In other words, the standards set in Ireland need to be applied in Bahrain. If one hands out Irish degrees, they need to live up to those standards, to which the Bahrainis have consented. It is not the RCSI telling Bahrain what to do because the Bahrainis have already consented to the standards.

The committee could invite the Medical Council to attend and explain how it will approach the key issues of human rights violations in the facilities. Will they be factored into their analysis as they should be in accordance with the World Federation for Medical Education standards that have been adopted by the Medical Council for Irish degrees? Standard 8.5 on page 11 of our report relates to basic medical education. It states: "The medical school must have a constructive interaction with the health and health related sectors of society and government." It also refers to appropriate supervision and a safe environment. On page 14 of our report we have listed all of the WFME standards that require free and open communication for feedback, complaints and reviews. With a restrictive environment where people cannot speak out, how can this process hope to live up to Irish standards? It would be appreciated if the committee could look at key questions of how the facilities live up to Irish standards.

Trevor Ó Clochartaigh (Sinn Fein)
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Is it a question of money? Is there a contract between the RCSI and the Bahraini authorities that is worth a lot of money to the college? Is the RCSI turning a blind eye to the human rights of the doctors that we are talking about due to the financial implications? How much is the education and training contract worth to the college?

Dr. Gearóid Ó Cuinn:

Those are very good questions but I do not want to comment on the specific amount of money. Clearly, there is tension between the issues of medical ethics and neutrality and the RCSI investments. It beggars the question: what is a non-profit organisation like the RCSI doing in an oil rich monarchical sectarian state? The answer is unclear. It is not as if the region lacks health infrastructure.

The RCSI is subject to the Freedom of Information Act. It would be interesting to see how the RCSI conducts itself if such requests were made. Would it cite economic sensitivity or would it, in the spirit of transparency, openly give such information on contracts with the Bahrainis?

Joanna Tuffy (Dublin Mid West, Labour)
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Does the committee wish to write to the Minister along the lines suggested by Dr. Ó Cuinn? We could forward a similarly worded letter to the Medical Council. Do members wish to make any suggestions?

Marie Louise O'Donnell (Independent)
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Did Dr. Ó Cuinn also suggest that the Medical Council visit Bahrain? Was that one of his suggestions?

Dr. Gearóid Ó Cuinn:

Yes. Also, under Irish law the council is obliged to conduct a site visit to Bahrain anyway.

Marie Louise O'Donnell (Independent)
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Yes.

Dr. Gearóid Ó Cuinn:

That is important. If a special rapporteur on torture cannot get into the country, perhaps the Medical Council getting in could be of some importance.

Marie Louise O'Donnell (Independent)
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It is definitely something the committee could request.

Joanna Tuffy (Dublin Mid West, Labour)
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Do members agree with the suggestion?

Averil Power (Fianna Fail)
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I propose a two-pronged approach. It is a good suggestion to invite the Medical Council and others to discuss the matter.

Joanna Tuffy (Dublin Mid West, Labour)
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Okay.

Averil Power (Fianna Fail)
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I know, however, that given the committee's agenda, it will take some time to arrange such a meeting.

Joanna Tuffy (Dublin Mid West, Labour)
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It will be in the New Year.

Averil Power (Fianna Fail)
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In the interim we could write to the Minister for Education and Skills, as suggested by the group, to express the committee's concern that the college may not be acting in accordance with its accreditation and to seek an urgent investigation. At least we will have sought an investigation straight away while waiting for groups to meet the committee given that the situation has been going on for just over two and half years.

Joanna Tuffy (Dublin Mid West, Labour)
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Is there a suggestion that we should also write to the college?

Averil Power (Fianna Fail)
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Yes. Does Dr. Ó Cuinn want us to write to NUI as well? Does he suggest that we just write to the Minister?

Dr. Gearóid Ó Cuinn:

Yes, the NUI. Judging from Bahraini documents, they are expecting some mysterious accreditation process by NUI. It is unclear what standards will be used, whether it will address the issues that are happening on the ground or whether it will focus narrowly on the school and the classroom. The two things are interlinked. There is also Quality Qualifications Ireland that accredits quality assurance but does not visit.

Marie Moloney (Labour)
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I second the proposal to write to the Minister. The delegation should bring this issue to the Oireachtas Joint Committee on Health and Children because this is a health issue as well as an education issue.

Last year, I met a lovely doctor from Bahrain. Her name escapes me but she could not return home simply because she had given medical attention to a protester and feared for her life. Her children live in Bahrain but she could not return to see them. She lived in Ireland for quite some time before she could return home safely. It would do no harm if the delegation brought the matter to the health committee regarding the health issues over there at present. I second the proposal to write to the Minister for Education and Skills.

Joanna Tuffy (Dublin Mid West, Labour)
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We will write to the Minister for Education and Skills, the Medical Council and invite the Medical Council to attend in the New Year. Did Dr. Ó Cuinn also suggest that we write to the NUI? Does the NUI not come under the remit of the Minister?

Dr. Gearóid Ó Cuinn:

That is a good question. Everything does tend to come under the remit of the Medical Practitioners Act, but it is an education issue. It would be interesting to find out how the RCSI evaluates the facilities and what mechanisms it has in place.

Joanna Tuffy (Dublin Mid West, Labour)
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We can write to the RCSI.

Marie Louise O'Donnell (Independent)
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It is important that we do so because the RCSI is at the centre of the matter.

Joanna Tuffy (Dublin Mid West, Labour)
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Yes, and it would be good to do so out of courtesy. Is that agreed? Agreed. I thank Dr. Ó Cuinn for his attendance.

Dr. Gearóid Ó Cuinn:

Thank you.