I share the deep preoccupation of the Medical Association of Malta regarding the proposed new appointment of a non-medical practitioner as Director ofPublic Health.

To some, public health, especially with its local heavy emphasis on infectious diseases, might appear a quaint, outdated specialty. However, public health concerns are now higher than at any time since World War II, and for very good reason.

The most burning issue facing all of medicine at the moment is the realisation that we are very rapidly entering the post-antibiotic era.

We are frequently seeing organisms resistant to multiple antibiotics which cause life-threatening infections; and they do not cause rare infections, but urinary infections and wound infections and the other bread and butter infections that hospital doctors see every day.

Three years ago, we thought it would take 20 years to arrive at the current level of spread of carbapenem-resistant organisms (CROs). These organisms are so serious that in the UK, once diagnosed, hospitals require the individual to be isolated at every hospital admission thereafter, and isolation is needed to a much tighter level than say with MRSA.

Malta was one of the early European countries to report the presence of CRO, and it is surrounded by countries where CRO is the highest in Europe - Italy and France, for example. Even worse, colistin resistance is now starting to spread - it has just been reported in the US - and if it spreads as fast as CRO, one enters the doomsday scenario very quickly indeed.

And as the Chief Medical Officer of England has emphasised, the post-antibiotic era will force us to fundamentally rethink all of medicine.

Joint replacements, cardiac surgery, immunosuppressive treatments for cancer and other conditions will suddenly become much more dangerous when common infections are impossible to treat, and even hospitalisation and institutionalisation may need to be thought through again very carefully.

The post-antibiotic era will force us to fundamentally rethink all of medicine

We will be living in a very different, much more complex medical world which is challenging the brightest brains in medicine at the moment.

Will the new Director of Public Health be able to plan for all these eventualities? Will they be nimble in their responses to such infections, borne of long involvement and deep knowledge of such issues, or will they have to learn on the job?

Malta has an international responsibility in this respect to protect other countries as they protect us too. We live in a globalised world.

We are also seeing the very real threat of spread of the Zika virus which would make pregnancy a very scary ordeal for entire families. A few years ago we had the SARS epidemic, and the WHO expect something similar to happen again soon.

We got off lightly that time, but some countries did not; at one point so many cardiologists in Hong Kong were seriously ill with the SARS virus that one of them had to be wheeled out of his hospital bed to do a cardiological investigation on a patient in intensive care.

Will the new director be able to handle a deadly viral epidemic which affects large numbers of health care staff, as SARS did?

Finally, there are many other non-infectious as well as infectious public health issues which confront Malta with enormous consequences. A rapidly ageing population. The large obesity epidemic and the Type 2 diabetes it brings with it. Alcohol abuse, which has reached very high levels quickly.

We have a large immigrant population with their own patterns of disease who have to be catered for humanely while keeping the public safe. And ofcourse there is always the unexpected and unknown.

Fifty years ago it was Legionella, then HIV and AIDS, then SARS... Will thenew director be competent to deal with these issues?

It takes a massively experienced medical practitioner with very steady nerves to take on this agenda. It is notenough for the minister to say theproposed appointee has a publichealth background.

He has to explain why she is uniquely qualified in this situation to take this post. What qualities does she bring that put her in a better position to meet these challenges than any other alternative?

Just as important, the director has to be able to take medical practitioners with him/her when announcing new initiatives aimed to head off such eventualities, or even aimed at improving the health of the population. Will the new director enjoy the trust and respect of local medical practitioners that is crucial to run health policy?

With the situation we are facing today, we simply must have the most competent person available to do this job. Does the minister really feel this is the case? And equally, does the appointee herself feel she is really up to it?

This post is not an honour, or a sinecure; it is about the nation’s health.

Victor Pace is a consultant at St Christopher’s Hospice in London. One of his main interests is the impact of emergent infections on palliative care delivery.