Wednesday, 14 February 1945
Seanad Éireann Debate
Parliamentary Secretary to the Minister for Local Government and Public Health (Dr. Ward): In submitting this Bill to the House I avail myself of the occasion to give Senators some information on the general position throughout the country regarding tuberculosis.
For some time, largely by reason of the changing attitude of the medical profession to tuberculosis, and to a lesser extent due to epidemiological changes in the disease, it has been clear to me that a change in our methods of tuberculosis control, involving radical alteration in the local authority services, was necessary. For example, reports received from county medical officers of health in response to my inquiry, showed that a great. proportion of the cases referred to the tuberculosis service of the local authority were in an advanced stage of the disease when they sought assistance. Such experience is common elsewhere and has brought about a natural reaction on the part of the medical profession, and it is now universally agreed that the first essential in any campaign against the disease is a successful search for, and detection of cases in an early and curable stage.
It is unnecessary to point out that to secure early detection we shall require co-ordination of effort between not only the various branches of the profession, tuberculosis experts, general practitioners, public health officers and surgeons, but also the general public, all of whom would need to co-operate in a national endeavour to deal with the disease in a manner that would be calculated to achieve success.
The development of this aspect of the tuberculosis services maintained by local authorities is at present being actively pursued. As can be understood, great difficulties confront us, difficulties occasioned by the times in which we live, by the necessity to preserve the rights of the individual and yet safeguard the community, difficulties both expected and unexpected. But of all these difficulties the greatest is the lack of bed accommodation in sanatoria not only for the cases of which we are already aware, but for those which exist below the surface, and which without sign or indication, even to the unfortunate victim, progress towards a fatal stage and infect many others before detection.
It is futile to develop a full case-finding service until accommodation  is available for the cases found. It is idle to hope that finding cases will be of much advantage unless the accommodation in our institutions is of a nature sufficiently attractive to the cases found to ensure that they will cheerfully avail of it, and it is clear that provision for the reasonable maintenance of the dependants of a breadwinner who contracts the disease must find a place in our completed plans. It is probably unnecessary for me to elaborate arguments in favour of the provision of increased sanatorium accommodation. Apart from the expected demands resulting from case-finding campaigns, Senators are aware that for some time past there has been an acute shortage of beds for tuberculous persons. In each county there are lengthy waiting lists, and prolonged delays have occurred between the date of diagnosis of the disease and the date of admission of the patient to a sanatorium.
The number of deaths from tuberculosis in the year 1904 was 8,798, whereas for the year 1938 the figure was 3,216, the lowest ever recorded in the country. For over 30 years it had shown a continuous and pleasing fall. Since 1938, however, there has been a rather sharp upward trend in mortality, and in the year 1942 the number had increased to 4,347. In 1943 a decrease to 4,306 took place. During that year, 24,580 persons received treatment under tuberculosis schemes administered by local authorities, and of that number approximately 8,000 received institutional treatment.
Reports received from medical superintendent officers of health and county medical officers of health indicate that many factors may have contributed to the rise in the death-rate. Housing conditions, malnutrition, return from outside the State of workers broken down in health, physical strain of training in the Defence Forces, increase in dancing facilities, movement from rural to urban areas, have all been cited as causes. It is possible that all or any of these factors may have had some influence, but it is not possible to dogmatise as to the actual cause or causes. I have fully examined  the position and I am satisfied that some new factor affecting all sections of the community has exercised an influence. There is evidence to suggest that during the emergency we have been suffering from calcium deficiency and that a deficiency in blood calcium may have rendered us particularly vulnerable. This aspect of the problem is under investigation, as are also other aspects, such as housing conditions and malnutrition.
Considerable public interest has been taken in the spread of the disease in recent years. The Tuberculosis Subcommittee appointed by the Royal Irish Academy of Medicine made a special report in 1942. The Hospitals Commission has dealt exhaustively with the question and has recommended the establishment of regional sanatoria in Dublin, Cork, and in the West. The commission considered that the provision of out-door pavilions in the grounds of existing hospitals would not provide a solution and urged the earliest possible realisation of the projected sanatoria.
The Anti-tuberculosis Section of the Irish Red Cross Society has rendered valuable assistance, and in December, 1943, it presented to me a report on the outlines of a long-term tuberculosis policy. They adopted two principles:—
(2) That the patients should not be classified as early, moderate, and advanced with a view to treatment in separate self-contained institutions, but that all types of pulmonary tuberculosis should be treated in the same institution with separate accommodation for sputum positive and sputum negative cases.
The elements of a satisfactory tuberculosis scheme are:— effective and modern methods of diagnosis which will enable the disease to be detected in the early stages, not only in the  case of persons who contract it but also in unsuspected persons who may be sources of infection; segregation of pulmonary sputum positive cases with a view to the limitation of the spread of the disease; provision of the most efficient and up-to-date sanatorium treatment; medical observation, advice, nutritional and other assistance as required, for persons most liable to contract the disease by reason of their exposure to infection; organisation of assistance measures so that those who require institutional treatment will not be prevented by economic causes from taking advantage of treatment; and, lastly, a campaign of education in the true facts of the disease so that the prejudices which prevent our services operating successfully will be overcome.
It is apparent to me that of all these factors the last is of supreme importance. All these essential features will be contained in the services of the local authorities following their reorganisation. But they all are pivoted on or are entirely dependent on the sanatorium — without the sanatorium it is almost useless to find cases. Welfare work is only fully successful when organised in relation to the sanatorium. Education and propaganda fall down unless there is a record of good results and cures — tangible evidence of the value of treatment-to show to people.
The isolation of known open cases is, undoubtedly, the objective of greatest urgency. The prevalence of tuberculosis infection can only be reduced by this means. Isolation is the measure which, applied to the smaller number of persons, gives the maximum of protection to the community. From the knowledge of the disease available not only from sources outside the State but from the experience of our own medical observers we know that if is in the household associates, and those living in close proximity, that the search for the new or unknown cases should begin. Such a search will reveal—of a certainty—many persons hitherto unsuspected who had fallen victims to the disease. The desirable degree of isolation is not possible unless there are institutions in which persons  can be accommodated. It is impossible to segregate satisfactorily in their own homes persons who are in an infectious stage. Failure to isolate such persons or to provide them with the means of removal from their families and from the general community is responsible for the spread of the disease.
It has always been found that during wars the number of deaths due to tuberculosis increases. As I explained earlier, it is not always possible to determine the cause of this increase, but this feature has a relationship to the sanatoria project, because a rise in the death rate always is accompanied by an increase in the number infected.
The principal weapon in the fight against tuberculosis is the approved tuberculosis scheme operated by each local authority. The medical superintendent officer of health and county medical officer of health of each county as the case may be is the authority co-ordinating the various elements of the scheme in each area. Under his direction there are assistant medical officers of health with special experience of tuberculosis work, or whole time tuberculosis officers. I propose in the course of my re-organisation to equip, re-group, and by means of intensive training bring the local authority services up to the highest standard.
The tuberculosis dispensary is an important element in the scheme, and the successful reorganisation of this service will, I believe, reflect itself in the results of our efforts. Such centres exist and are necessary for the operation of the tuberculosis specialist services in each area. It is my intention to develop and equip them, to the greatest possible extent, so that they will be in future the principal diagnostic centres. They will be equipped so that each centre will provide facilities for the fullest and most comprehensive investigation of the disease. It is unnecessary to go into details of the development in mass-radiography, tuberculin testing, post-graduate education of personnel, recruitment of staff, equipment and all the multifarious activities contained in the project on which I have engaged, but as soon as supply conditions permit I propose to  lose no time in providing the essential equipment that cannot at the moment be made available, and in the meantime the things that can be done to improve the service will be done.
The number of beds required has been carefully considered. It has been decided that we need at least 4,300. There are available at present approximately 2,200, so that 2,100 additional beds will be needed.
Under present conditions it would be impossible to provide these additional beds without radically changing established procedure. It has, therefore, been decided to set up a special organisation within my Department to provide and equip sanatoria on a regional basis. While the Bill proposes to confer the necessary power on the Minister for Local Government and Public Health the powers of local bodies in this respect are not being interfered with, and their responsibility for the provision of measures to combat tuberculosis are not being in any way lessened. It is intended that the administration of schemes for the treatment of tuberculosis shall continue to be the responsibility of the local authorities. In fact, the main object of this Bill is to provide these bodies with the institutions which are required to enable them, in partnership with the State, to intensify their efforts in the eradication of the disease.
In this connection the provision of accommodation for the advanced case has presented many difficulties. The disease is generally very infectious at this stage and consequently institutional care is imperative. Where treatment is afforded in small local institutions it is difficult if the institution is utilised solely for advanced cases to prevent the institution becoming associated with such cases only, eventually meaning that early cases, or cases which consider themselves early, refuse to enter. On the other hand it is not always possible to provide in such local sanatoria satisfactory segregated accommodation for persons in different stages of the disease. In the new institutions, which it is proposed to establish, separate units can be provided  within each institution for cases in all stages of the disease.
I propose to establish three new regional institutions: (1) An institution containing 1,000 beds to serve the needs of Dublin City and County; (2) an institution containing 680 beds to be located in Cork to serve the Counties of Cork, Limerick, Waterford, Clare, Kerry and Tipperary (N.R.) and (S.R.) together with county boroughs of Cork, Limerick and Waterford; (3) an institution containing 400 beds to be located in Galway and to serve Counties of Galway, Mayo, Roscommon, Sligo, Donegal and Leitrim.
The eastern region consisting of Counties Carlow, Cavan, Kildare. Kilkenny, Laoighis, Longford, Louth, Meath, Monaghan, Offaly, Westmeath, Wexford and Wicklow will be served by the institutions at Peamount and Newcastle and Our Lady of Lourdes Hospital, Dun Laoghaire.
Under present conditions the provision of regional sanatoria of the size contemplated presents many difficulties. The successful completion of such a large building project requires a complete team of advisers, professional and technical, whose work can be co-ordinated under one organisation. The work must be directed and co-ordinated from the earliest stage of planning to the actual completion and equipping of the buildings. The successful provision of modern hospital buildings requiring highly technical equipment depends not only upon the architects but also upon the various branches of engineering, such as civil, structural and mechanical. Architects and engineers must work in close harmony as a team and, moreover, they must have available to them throughout the whole course of the work, but particularly in the early planning stages, administrative and medical advisers for consultation in connection with the patients' accommodation, staffing, services, and equipment. The local authorities would not themselves have that complete team at their disposal. Moreover, their proposals would require examination at the various stages of planning as the work  progressed, while difficulties would likely arise during the construction period calling for decisions on the spot as to alterations in the plans, or the substitution of materials for others not readily available.
It is clear, therefore, that with the best will in the world the local authorities would be badly handicapped, and even with the closest possible liaison with my Department they would be unable to obtain the same co-ordination and speed that would be achieved by a single organisation working together in the same building under one direction. It is proposed, therefore, that the establishment of the sanatoria shall be carried out under the direction of the chief engineering adviser of the Department and his staff, who will have the Department's administrative and medical advisers available for consultation.
In this manner the work will achieve that necessary co-ordination and direction which is essential. The institutions will be of a simple character but will, at the same time, provide all the essentials for the modern treatment and comfort of the patients. Owing to the difficulty of obtaining materials there will be many departures from standard practice. The building will be designed to have all the normal amenities but some of these amenities may have to be provided later as the necessary materials become available.
The cost of establishing the sanatoria is provisionally estimated at £1,500,000 and will be provided from the Hospitals Trust Fund. The sanatoria will be transferred to, and will vest in, the local authority when they have been established. The local authorities concerned may be called upon to repay to the Hospitals Trust Board such amount as is considered reasonable, but the amount shall not exceed one-third of the total cost.
Section 5 of the Bill empowers the Minister to direct the Hospitals Trust Board to make payments out of the Hospitals Trust Fund for the purpose of defraying the expenses of the establishment and equipment of a sanatorium, and Section 6 authorises the transfer to a county or county borough  council or councils of a sanatorium when established and equipped. The local authority or authorities to which the sanatorium is transferred will be responsible for the upkeep and management of the sanatorium.
Part III of the Bill sets out the procedure to be followed where land is to be acquired compulsorily. The various steps to be taken, firstly, by preliminary order and, secondly, by vesting order are defined in Sections 9 and 10. The remaining sections are concerned with procedure in relation to registration, compensation and deducing of title.
In bringing this Bill to the Seanad I am confident it will have the approbation of the House. By this step we are making an advance at a time when the results to be obtained will be greater than might be achieved at any other time.
I wish the Seanad to regard the provision of additional bed accommodation not only as the most urgent immediate requirement upon which our further progress will depend—but also as a part of the general plan I have outlined, and which I hope to bring to maturity.
Given the full co-operation of all good citizens, and the financial resources necessary, I believe the 1942 death rate could be reduced by 50 per cent. within ten years. Such a possible achievement is worth working for, and if we can convince all concerned that it is worth paying for, one of the obstacles between us and real progress will have disappeared.
Mr. Hayes: This Bill, I think, had a great welcome in the other House. As a matter of fact, I do not know if there was any dissenting voice at all in the other House, and it certainly is a step forward towards tackling the problem of tuberculosis in this country. The main purpose of the Bill, as the Parliamentary Secretary has pointed out, is the establishment of new sanatoria, and that is only one of the steps to be taken before this disease can be properly tackled. The Bill makes certain definite provisions in regard to the use of the Hospitals Trust Fund towards the relief of  rates, and I rather gather, from what the Parliamentary Secretary said in the other House, that that is a very popular step. I am not prepared to say whether it is a proper thing to be done, but the fact is that it is there, and let us hope that it is a good thing. In that connection, however, I think that something should be done for the voluntary hospitals because I think that that was the principal object in the minds of the original promoters of the scheme.
I should like to point out also that this Bill provides an example of centralisation — of more and more centralised control. Not only that, but the Parliamentary Secretary was able to give us some very sound arguments in favour of centralised control. Now, while I realise the soundness of some arguments in favour of centralised control, I cannot help feeling that much of our legislation, aiming at centralisation, is leading more and more towards dictatorship. Perhaps I should not use the word “dictatorship,” but I do feel that while centralisation may lead to a great deal of efficiency, in the long run it may not lead to the best type of efficiency. Of course, I am not an expert or a specialist in these matters. I cannot claim to be a specialist on medical matters, but I do hear a lot of specialists talking about this matter, and it seems to me that the first thing to be done is to convince our people that tuberculosis is a curable disease.
The tendency amongst a lot of our people up to the present has been to conceal the presence of the disease in their families, as something to be ashamed of, and the man or woman concerned tries to remain on at work as long as he or she can, with the result that when the doctors get the case, the patient is almost beyond cure. I think it will take a lot of educational work or propaganda to convince our people that this is not a disease to be ashamed of, and that, on the other hand, it is a disease that, if taken in time, can be cured. I understand that in one of the Scandinavian countries —Sweden, I think—drastic measures were taken after the last war to combat this disease, that a great many sanatoria  were built to deal with the disease, and that after about 20 or 25 years they were able to devote those buildings to other purposes. That would indicate, in my opinion, that if this disease were tackled by the provision of additional sanatoria and by other measures, it could be eradicated within the space of a few years. It appears to me that one of the great difficulties in this country in regard to tackling that disease is the convincing of our people that that is so. I agree with the Parliamentary Secretary when he says that of all the things recommended to him by the Red Cross Society, perhaps the most important is educational work of that kind. I think we also need education or propaganda with regard to effecting certain changes in the diet of our people— changes in diet which would not involve substantially increased costs. There is, certainly, a tendency, even in connection with the better type of houses which are available now, for people to use kinds of food which are not the best protection against tuberculosis. Whether or not anything can be done to change that habit of mind, I am not so sure. It is not difficult to pass legislation or to give powers to the Minister but it is very difficult, indeed, to change the habits of a people. One of the things that fall to be done in any tuberculosis campaign, if this money is eventually to be put to the best use and to bear the greatest fruit, is to convince the people that the disease is curable so as to effect certain changes. There are people much more qualified to speak on this matter than I am. I think that certain steps have already been taken to give teachers in vocational education schools some training in dietetics. In that matter, I think that a beginning is only being made although we have in this country and, I understand, in both our universities in this city, people highly qualified in that subject.
Another point that strikes one about sanatoria is this — it is a point which has come within my experience — it is one thing to treat the patient's body, but in the case of a patient suffering  from tuberculosis, ease of mind is almost more important than ease of body. That is a thing which is much more difficult, and, perhaps, much more expensive to give. I have known quite a number of cases where the head of a family, told that a certain period of rest was necessary in order to have the disease eradicated, simply could not give the time, or, if he was compelled to give the time, was compelled only by the disease, which was a very bad time for the compulsion to come. If a man is removed to a sanatorium, and if his wife and family simply get the benefits available under the National Health Insurance Acts and other such schemes, at a time when he requires rather more than he had been able to earn, that interferes with the efficacy of our sanatorium schemes, and will continue to do so. Another matter which runs hand-in-hand with that is the finding of suitable work for people who are affected, but who are able to work, or who have been cured and are unable to return to the type of work which they did before they were affected by the disease. Certain steps were taken in places like Peamount to provide work of that kind, but they were not continued. That should be an essential feature of any scheme devised for the cure of this disease. Unless, accompanying the sanatorium treatment and the erection of these sanatoria, you have measures of that kind, there is grave danger that the money will be wasted.
The sum of £1,500,000 seems to be a very large sum, and there is a natural tendency to feel satisfied with the knowledge that we are to spend £1,500,000, and put up three magnificent buildings. The erection of these buildings is an indispensable part of the scheme to effect a cure, but it needs to be supplemented by other schemes. The expense is well worth while, be cause the loss by tuberculosis is very great, and, as I have said, it has been proven in other countries that the disease can be eradicated. Whether the situation would be the same in our climate as it is in other countries, I am not in a position to say. I do not want to go into a general discussion of tuberculosis. This Bill merely gives power to erect sanatoria and puts the  matter completely in the hands of the Department of Local Government. Indeed, in effect, it puts the whole matter into the hands of the Parliamentary Secretary. It was a step in advance that public health matters were segregated, and put into a separate subdepartment.
That is all to the good. We have to welcome the proposal that sanatoria be erected but we shall, certainly, have to take other steps to relieve the economic troubles which arise from tuberculosis, as well as other illnesses. There is an immense difference in the position of a man who falls ill from tuberculosis and who receives from his firm pay for a year or sanatorium treatment with pay, provided by the firm, and the position of the man who goes out of his employment and knows that, under the various schemes of which he will have to avail himself, his income will be substantially reduced-and that at a time when he needs more money and when his anxieties are greater. It is only fair to say that we should not put the responsibility for all these things at the same time on the Parliamentary Secretary, but they are things which are important if a cure is to be effected. We have learned a great deal recently in connection with this matter. Bad housing was for a long time regarded as an important cause of tuberculosis, but it appears now that plenty of food in a bad house is much better than scarcity of food in a good house. Food seems to be the fundamental thing — which is part of what I have been saying. I think that we all ought to welcome the Bill.
Sir John Keane: I do not suppose that anybody in the House regards this Bill as controversial. I feel that it is a pity it is not part of a general scheme for the reorganisation of our medical services. The Parliamentary Secretary may remember that, some months ago, I proposed that a commission be appointed to survey the whole field of medical services and to put up considered recommendations. I am afraid that I did not get much sympathy from the Parliamentary Secretary. I do not know whether or not he was serious when he told me that we had a commission  already — the Hospitals Commission. Of course, that was not the class of body I contemplated. I do feel that, if a competent commission were to survey the medical field, it would probably put first in its recommendations efficient sanatorium treatment. To that extent, I welcome this Bill, but I feel that we must have regard to a number of other matters bearing upon this proposal. I come first to the effect the finances of this Bill are likely to have on our voluntary hospitals. I hope that the Parliamentary Secretary will deal with this point in his reply. There is at present £8,000,000, in capital, in the Hospitals Fund. The income from this sum, I understand, is just about adequate to meet the deficits of the voluntary hospitals. If £2,000,000 of that sum be diverted to the building of sanatoria, there will not be sufficient income in the Hospitals Fund to meet the deficits. How is that situation to be dealt with? Is the Minister likely in the near future to bring forward a scheme to deal with that problem?
Another matter which I feel has a close bearing on this question of medical services, including tuberculosis, is the totally inadequate dispensary system in the City of Dublin and, perhaps, in other cities as well. In Dublin the dispensaries are totally inadequate to deal with the very large number of the sick poor in each district, with the result that they flock into the out-patients' departments of the voluntary hospitals. If we had the system that prevails in the country in operation in Dublin things would be much simpler. In the country the sick poor attend the dispensary and the sick who cannot be dealt with locally find their way through the board of health, and on payment, to the specialist hospitals in the cities. I feel that that should operate also in Dublin. It would add greatly to the convenience of the voluntary hospitals. At present the matter is in a state of unregulated chaos. I know one hospital which is faced by a dispensary which is entirely unsuitable and in which, with the best will in the world, the medical officer would be unable to deal with the large number  of sick in that area. The result is that a large number of sick who are never seen about the dispensary flock into the voluntary hospital and take up the time of the specialist staff. That is altogether wrong and is a system that needs to be regulated in future.
I should like the Parliamentary Secretary also to tell the House how these sanatoria are going to be maintained. I see no difficulty in time in collecting together an adequate staff, but I hope generally speaking that the standard of staffing will be infinitely better than that which prevails at present in the county hospitals. Having got that staff, is the cost of upkeep going to be on the rates? That would appear to be unjust. I do not say that the rates should not bear a proportion, but I think the local ratepayers would have a strong claim on the Central Fund for a large portion of the cost of maintaining these sanatoria.
Would the Parliamentary Secretary say what he or his advisers have in mind in regard to those who refuse to go to sanatoria? I know, and the Parliamentary Secretary knows better than I do, of a very large number of old people living in small inadequate homes who are a constant source of infection to the younger generation.
They have no knowledge of the danger they are in. They are spitting all over the place; the young people are surrounded by infection, day in, day out. Is it possible to evolve any scheme whereby if these sources of infection are not compelled, at least strong pressure will be brought to bear upon them, to leave these houses and so avoid infection of the younger people?
Again, has the Parliamentary Secretary any considered plan for health education? I should regard health education in general, not merely in regard to tuberculosis, as very important. I feel that it would be possible, in co-operation with the Department of Education, the Red Cross and other bodies, to take some step in advance in this matter of systematic health education. I do not like making comparisons, but of course a great deal in this matter has been done in England. In certain respects what has  been done in England is definitely prohibited here, but I do not want to get on that controversial ground. I do feel that we require a systematic approach through the schools and the various organisations to this question of health education. When you come to the question of priorities, I think the Parliamentary Secretary is right in putting sanatoria in front, but only a little in front, of health education, and not far removed from the question of health education is the question of better housing. Bracketed in close conjunction with these matters is the question of how we are going to compel people who are a constant source of infection to leave places where they are likely to contaminate younger people.
I think the method the Parliamentary Secretary has in view to build these hospitals is best. Much as I believe in the freedom of local authorities, I do not think they are the best suited to build sanatoria, especially as there is only a limited number to be provided. I hope the Parliamentary Secretary is going to seek the free and ready co-operation of ordinary medical practitioners and that he is not going to be guided solely by the advice of his official staff. I do feel that there should be actively associated with those who are carrying out this work a small and vital body of working, active, private medical practitioners. To these few remarks, stressing especially the financial effect of these proposals on the future of the voluntary hospitals, I just desire to add that the Bill is one that should commend itself to this House.
Mr. McGee: Great minds sometimes think alike and I was rather struck by the truth of that saying when I heard Senator Hayes speak of the habits of people and Senator Sir John Keane speak of a system of educating our people. For quite a long time I have been listening to the Parliamentary Secretary's Department pressing upon us in County Louth the necessity of appointing an assistant county medical officer. While admitting that these medical officers do a certain amount of good, some of us felt dissatisfied with  the existing system in regard to tuberculosis medical officers. We think that a better arrangement could be come to. We are not satisfied that one medical officer of health living far away from a district and visiting a dispensary once a week is best. We think it an elaborate luxury and we sometimes think that the appointment of two such medical officers was perhaps an imposition. Many of us believe that far better results could be obtained if the Minister were more in consultation with the local dispensary doctor. Some of us would go so far as to suggest the elimination of these glorified gentlemen, the tuberculosis medical officer and his assistant, and the establishment of a number of fully qualified dispensary doctors to deal with every form of health service. The money spent on the present tuberculosis medical officers, amounting to some £2,000 in my county, could well be devoted to multiplying the number of dispensary doctors so that perhaps we could have one in every chapel area.
The inspection of schools is a subject that has gained our approval and if in future the Parliamentary Secretary seeks to develop that it would become, under the present system, very expensive. A good deal of expense would be avoided if there were a dispensary doctor in every parish. He would make contact with the homes of the people —meeting them day in, day out. If he were visiting the schools he would be in a position to visit the homes of the parents also and see them in their everyday health. Two or three years ago some of us appealed to the Minister for Supplies to give more petrol to dispensary doctors. I think it would be a great asset to us to have three dispensary doctors for every two we possess now, so that all the services could be conveniently done on a bicycle. At present it is quite common for a doctor to be called five or six or seven miles, on a red ticket, to a working man's home, and when the labourer comes in after his work he has to travel an equal distance to procure medicines.
Senator Sir John Keane mentioned something about the shortage of dispensary doctors. In my opinion, we have many remote rural areas in which  the presence of a dispensary doctor is highly desirable. Our dispensary doctor should be fully experienced in the treatment of tuberculosis — heaven knows we have universities enough and doctors enough turned out each year.
Mr. McGee: They may not, and when they motor ten miles or cycle, or even take a horse, they have to spend a certain amount of money in the effort, not to mention time. A greater number of dispensary doctors would enable the public to be better informed as to the best methods of combating tuberculosis. The people have not taken kindly to the tuberculosis officers. They do not like the idea of being associated with them as distinct from other forms of illness. If a common platform were found from which the doctor could dispense his various services, I feel that it would lead to much better results. The services would be more readily used, and people would be more inclined to look to their nearest doctor in their illness.
Some attention has been given to the sanatoria problem. Medical practitioners are in favour of big sanatoria rather than a number of smaller ones. The tuberculosis medical officer issues his report every year, and I am sure he is fully in earnest about it when he calls for an assistant, but I am still not satisfied that he is getting at the root of the problem. No doubt, he is doing his best, but he has not got a grip of the people sufficiently well to make them come forward in the earlier stages of this disease. I noticed a remark of the Parliamentary Secretary in the other House — such things always attract my attention—“I think we have to appeal to the local services and I think it is right.” Of course nobody said “boo” to that —it was all right, but when I remember the doctor in County Monaghan, he was not much in favour of striking rates; he wanted to get off as lightly as he could. As we all know, more and more services are falling on the rates, so many that we are hard pressed to collect them. In our county,  fortunately, they have gone up only 11 per cent. during the last three years, but some of us had to fight very hard to keep them at that level, and although we must view the future with concern, we wish every success to the efforts to combat this terrible disease which, I am sure, is only temporary. In fact, if it is properly tackled, 20 years may see the end of it.
Mr. S. O'Donovan: It is pretty difficult to say anything new on this Bill. If we confine ourselves to the subject matter, it is mainly a question of providing speedily new institutions to accommodate tuberculous patients. For portions of this week we have been discussing a similar scheme in respect of drainage——
Mr. S. O'Donovan: I think we are retro-active so far as the diagnosis of tuberculosis is concerned, because it is a chronic disease. It is not spectacular in its incidence like the other virulent diseases such as diphtheria, scarlatina and many others. The unfortunate thing in the disease is that it is of slow development and that, possibly, through deterioration in nutrition, or in housing or clothing, a patient gets a common cold as it is called, and it ultimately becomes a neglected cold. The neglected cold, as it is described in the country, is very often the case of tuberculosis, which is creeping insidiously for ten or 15 years after the tuberculosis bacillus has gained access to the patient's lungs or other organs of the body. If we had to deal with a disease more spectacular in its effects we would have made far more progress.
As I mentioned, the scheme we are adopting is similar to that adopted in regard to drainage. The State is not taking dictatorial duties. It is providing institutions and handing them over to the local authorities for maintenance and for the repayment of one-third of their cost. It seems to me to be simply a matter of the speedy production of finished institutions so that patients could be accommodated as  quickly as possible. I presume there is a considerable amount of equipment available in the country and once the institution is provided more equipment would become available.
I do not know whether the suggestion is new or not, but the only new thing that occurs to me in connection with tuberculosis eradication is its early diagnosis in the young patient. As far as diagnosing the disease in aged persons is concerned, we are up against the problem of maintaining the dependents of those persons while they are in sanatoria. The State must necessarily care for the older people who are affected, and looking at it as a long-term policy, what we should endeavour to do is to diagnose the disease in the younger members of the community. We would then quickly reach a stage where no adults with dependents would be affected. We would be treating the younger people at the initial stages of the disease, and they would not have any dependents. That should be our long-term policy. I grant that at present we have adults badly affected. They will have to get treatment in sanatoria, and, whether by voluntary organisation or by some other means, their dependents must be provided for, and provided for satisfactorily, because otherwise there would always be a tendency to conceal the existence of the disease. If it were an acute disease, causing death quickly, there could be no attempt at concealment, but as it is a chronic type of disease its existence would be kept from the public as long as possible. We should deal with early diagnosis, especially in the young patient, until we arrive at a position in which we will have obviated the necessity of having to provide for dependents. One and a half million pounds is certainly a large sum, and it is devoted practically entirely towards the provision of buildings. It will be money well spent if we achieve our object. Whether it is original or not, that is the only constructive suggestion I have to put forward in dealing with the long-term policy of tuberculosis eradication.
There is one other point which I must mention, and that is the question  of human tuberculosis of animal origin, mainly of bovine origin. Tuberculosis of bovine origin is practically entirely tuberculosis contracted through the consumption of tuberculous milk. There are people and there are doctors who say that there is no danger to the human subject through tuberculous milk. I could bring into this House to-morrow a sample of tuberculous milk, and I challenge anybody in this House to drink it. They could not drink worse poison than milk from a tuberculous cow. I do not want anybody to consider that that is a danger meeting everybody every day. It is not, but it is meeting somebody every day. Numerous children are getting milk from tuberculous cows, so there is and there must be a large percentage of young people affected by tuberculosis of bovine origin. In this country we have no definite statistics in this regard. A person might say to me: “How many cases are there of such a nature?” I cannot say, because there is very little confirmatory work done in this country relative to the comparative incidence of bovine tuberculosis and human tuberculosis in children or even in adults. But we know it is there. We know it is a very big danger, and the attack on tuberculosis generally in the human subject should at the same time be an attack with a view to reducing human tuberculosis of bovine origin. The Parliamentary Secretary might say that quite recently in this House we recommended the appointment of a tribunal. I only ask that that tribunal should be set up as soon as possible.
I think everybody is agreed that the Bill is a necessary one. I hope that by giving it a speedy passage here we will be helping toward the speedy establishment of the three institutions which the Parliamentary Secretary mentioned. I hope the Bill will be speedily enacted and enforced.
Mr. Baxter: I welcome this measure as evidence of a further awakening on the part of the Ministry to the necessity for better health in the country. I confess that my point of view on this matter is largely that of Senator Sir John Keane. I am not a medical man, nor am I a veterinary man, but as a layman I wonder how it is possible to  discuss this problem of tuberculosis and sanatoria separated from other problems of health. It does not seem possible to me. Confining the discussion to the matter dealt with in the Bill makes one feel that the problem of tuberculosis is something which is narrow in its limits from the points of view of cause, method of treatment and so on. The Parliamentary Secretary gave a rather long list of what might be contributory causes. I was rather struck by a reply which came from his Department. I am not quite certain whether it was a reply to a question in the Dáil or whether it was a communication sent down the country to some local authority, but in any case it pointed out a number of causes which it might be believed brought about this disease, and added something to the effect that the Department was not satisfied that anyone of those was really responsible. Of course, the truth probably is that no one factor brings about tuberculosis in any particular person. Probably bad housing alone will not do it. It is probable that malnutrition alone will not bring it about, without perhaps bad housing, poor clothing and a number of other contributory causes. But, while the Parliamentary Secretary, under this Bill, is going to make provision for the erection of sanatoria in a number of places in the country, I do not think that we will be tackling this problem really seriously, or have any hope of bringing about the desired results, until we give wider consideration to the whole problem of our public health services.
I have repeatedly said in this House that too little consideration is given to the problem of good health. The Parliamentary Secretary spoke of propaganda. He would not be a bad propagandist in certain respects, but I put it to him that the Minister for Agriculture has much more to say about the necessity of a balanced ration for animals than the Parliamentary Secretary or anybody else in his Department has to say about a balanced ration for human beings. There is no doubt in the world about that. Anybody who has any experience of tuberculosis, and  many of us have, would definitely have to come to the conclusion that if there is one factor responsible it is malnutrition. Malnutrition is by far the greatest factor, as well as lack of sufficient food to enable people to do the work which they have got to do, to overcome worry and enable children to attend school. On a previous occasion I brought to the notice of the House certain information that reached me. I do not know what the situation may be elsewhere, but I understand that in Cavan as a result of inspection of school children over the first year there was definite evidence of an improvement in their physique. That went on for a few years, and then changes came about in the economic situation. Instead of an improvement I think the tendency has since been the other way. I presume the Parliamentary Secretary has information on that. When talking of calcium, malnutrition and lack of housing as contributory causes, we have got to get to the root of things and ask how do children become ill, and to what diseases they fall victims?
There is a national school to which some of my own children went. The medical inspection revealed a rather surprising condition of health amongst the children. I was impressed by a point made by Senator McGee. If a medical officer of health came a distance of 20 or 30 miles he would not know much about the history of the children, the family circumstances the income, or what sort of houses or parents they had. If the conditions in the homes were known one could make a shrewd guess as to the health of the children.
If we are going to tackle this problem we have got to get to the roots of it. It is much wider than the problem of erecting sanatoria. I am convinced that all sorts of physical activity are good for health, but it is important that the children should be well fed to be able to play games and well shod to play football and hurling. Senator O'Donovan referred to the condition of cattle. I am sure the Senator could point to a number of instances of tuberculosis in cattle that had its origin in poor feeding. We see well-fed  bullocks weighing 20 cwt. When they are killed it is found that they are infected, but because they were well-fed they managed to resist the attacks of the disease. It is the same with regard to the human frame. I am convinced that the science of nutrition in relation to the human population is not given the study it ought to be given.
It is astonishing to go into homes, and not the homes of the poor only, where there is a lack of knowledge of the proteins, the calciums necessary to build up children. I urge the Parliamentary Secretary to get busy and take as much interest in the question of a balanced ration for human beings as the Minister for Agriculture does for live stock. At present there is treatment in sanatoria where patients do very well for a period, and then return to their homes, where there are mothers with three, or four or five children. At home patients are not able to get the attention or the feeding that they got in the sanatoria. The net result is that the improvement which has taken place does not last. Something has got to be done about that. I do not know what is going to be done with these buildings when they are erected, whether they are to be run along the lines of institutions in England where there are settlements, but that aspect of the problem will have to be considered. There is no point in having sanatoria, and then sending the people back into such conditions as will result in the disease taking root again. I do not know what the Parliamentary Secretary has to say on that, but it is an aspect of the problem that arises for consideration. If it is proposed to establish settlements around these buildings, I suggest that these have considerable advantages. I suggest that the bigger share of the problem which confronts us in tackling this disease is the providing of food. I suggest if the people are given enough healthy food to eat, or are provided with means of getting it, the treatment of tuberculous patients in hospital will be reduced to a very low figure.
This, I presume, is a means to an end: the eradication of the disease, and we have got to do this before we  get to the other point, which is part of the solution now. As I have suggested, the right way to solve this problem and eradicate the disease is to make sure that our people are properly clothed and well-fed, and no matter what the county medical officers of health or the Parliamentary Secretary, in his capacity, may do, or no matter what contribution is made by the Ministry to which he is attached, no amount of money spent here in this country will free our people from the plague of tuberculosis unless the problem is tackled in the way I have suggested, because, so long as people are not sufficiently well-clad or have not enough food they will always be subject to that disease. However, I realise that this is a step that must be taken towards the eradication of the disease, and to that extent I am prepared to support the Bill.
Mr. Honan: I join with other Senators in supporting the Bill. The Minister or the Parliamentary Secretary has taken on himself the responsibility of endeavouring to eradicate this terrible disease. According to the title of the Bill, its object is to try to bring about early detection and cure of the disease. As far as we are concerned, we are quite prepared to leave that in the hands of the Parliamentary Secretary and his expert advisers. The Parliamentary Secretary stated in the other House that he is satisfied that this disease is not hereditary, and we must accept that, coming from the Parliamentary Secretary, who has his professional advisers, but if the disease is not hereditary, there must be something hereditary about it. It must be due to the conditions under which people live, to the very houses in which they live, because I have seen the disease cropping up, generation after generation, in members of a family who have lived in the one house for a certain number of years.
Accordingly, it must be either hereditary in the people or in the houses in which they live, and I believe that suitable steps should be taken to eradicate the disease from these houses. I understand that in one foreign country it is the custom, when  once the disease is detected in a house, to have that house completely gutted, or, if not entirely destroyed, reconstructed in such a way as will ensure the destruction of every possible germ of the disease that might have been concealed in the house. The Minister has taken steps to acquire land, and so on, but I think he should also take power, in the case of a house where the disease is known to exist and where more than one generation, at least, of the family has been affected, to demolish that house or reconstruct it to the extent that the disease could no longer exist there.
So much for the treatment and cure of the disease, but very little has been said about its prevention, and I suppose that that is really more important, in a way, from the point of view of future generations, than the question of its cure. Now, as all knowledge starts in the primary schools, I think it would be a good idea to focus our attention on these schools. I am sure that the Parliamentary Secretary would have the entire co-operation of the Minister for Education on the matter. I do not know what amount of co-operation he would require, but I feel certain that he would require plenty. For instance, very primitive methods still obtain in country schools in the matter of sanitation, and I think it would be a good thing to have a couple of lessons a week on hygienic conditions delivered in these schools. The results of these lessons would be brought by the children to their homes and, in that way, people all over the country would get some knowledge or even some elementary ideas with regard to hygiene. That, to my mind, is very important. Of course, there is quite a number of bad schools and there always will be, but they will be got at after a time. I think it was Senator Baxter who was referring to opportunities being given for exercise in the schools when the Leas-Chathaoirleach, I think, intervened. In most primary schools they have no places for exercise at all except in the small yard attached to the school or on the main  roads, and you have children playing up and down along the main roads. Some playground should be attached to every primary school so as to enable the boys and girls to have proper physical exercise, play games, and so on, and if that were done I think it would go a long way towards the prevention of this disease.
There is not very much use in speaking about housing now, but that is also a very important factor, and the ignorance of some people in that respect is extraordinary. I remember that we had a clearance area in our town where there were some frightful hovels, and yet, when we built fine new houses for these people and tried to get them out of the wretched hovels in which they lived, we had to apply for the services of the local Gárdaí to get them out of their hovels and into good, sanitary houses. That will give an idea of the necessity for the education of some of our people in this respect. I am sure that the Parliamentary Secretary and the Government will do everything in their power to get the necessary material to start the building or reconstruction of houses as soon as possible. Some houses, of course, are in a worse condition than others. I happen to live in a town which is very badly off in the matter of housing, but if we had those houses, and if we had an opportunity of improvement and of education in elementary hygiene, taught in the schools and brought from the schools to the home, that would be a considerable help, in a general way, towards the eradication of the disease, and would make for the welfare of future generations in this country.
Mr. P.J. O'Reilly: I have been a member of a tuberculosis committee for a number of years and during that period I heard this question of the causes and cure of tuberculosis being discussed from various points of view. At one time we were very keen on building small shelters which could be erected in, say, the garden of the house in which persons suffering from this disease lived. For one reason or another, that was abandoned, and we had regional schemes, such as those  mentioned by the Parliamentary Secretary. I personally feel that it is rather a mistake to concentrate, as has been suggested, on a few large buildings. I should prefer to see one building of a smaller type erected in each county. Of course, I admit at once that the Parliamentary Secretary must have the results of world experience at his disposal, that his officials have not been asleep and have probably told him that those institutions are best, but I think it will be found that where those large institutions exist in other countries the population is greater and more condensed than in this country. In such cases the big institution might be admirable and, perhaps, more efficient, but at the same time I feel  that there is a good deal in what Senator McGee and other Senators have said: that there is something wanting in connection with the county medical officer of health. I suggest that what is wanting is an institution that would be under his direct control, an institution that, perhaps; would be specially fitted to deal with this disease. The county medical officer of health, of course, has to deal with all kinds of disease, but, so far as my experience goes, he concentrates a lot on this disease of tuberculosis. I now move the adjournment of the debate.
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