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Dáil Éireann debate -
Thursday, 3 Jul 1947

Vol. 107 No. 7

Committee on Finance. - Vote 71—Health.

I move:—

That a sum not exceeding £411,350 be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending the 31st day of March, 1948, for the Salaries and Expenses of the Office of the Minister for Health, and certain Services administered by that Office, including Grants to Local Authorities, miscellaneous Grants and Grants-in-Aid, and certain charges connected with Hospitals.

I will deal first with the two conventions which have just been agreed to. Early in 1946, an invitation was received by the Minister for External Affairs from the Secretary-General of the United Nations Organisation to send an Irish observer to the International Health Conference which was to open in New York during that month. That was done. A delegate was sent and was later given power to sign any convention that he thought well, subject, of course, to the approval of the Government and to ratification by the Dáil.

The International Health Conference met in New York from the 19th June to the 22nd July, 1946. There were 51 States represented there, and as a result of the deliberations of the conference the following instruments were drawn up and separately signed: (1) Constitution of the World Health Organisation; (2) Protocol concerning the Office International d'Hygiene Publique; (3) Arrangements for the establishment of an Interim Commission of the World Health Organisation; and (4) Final Act of the International Health Conference. The Interim Commission was established to carry on during the interim period while the Constitution of the Health Organisation would be drawn up and the final Act which is referred to in (4) was merely a copy of the proceedings and of the deliberations.

Therefore we have only two important documents to discuss, the Constitution of the World Health Organisation and the Protocol. The Constitution of the World Health Organisation opens by enunciating principles relating to health, which it is stated, are basic to the "happiness, harmonious relations and security of all peoples". The functions of this organisation are to act as the directing and co-ordinating authority on international health work, to propose conventions, agreements and regulations, and to make recommendations with respect to international health matters. Membership is open to all States and States which were not present at the meeting can join by signing the articles as agreed upon by those present. The assembly may adopt regulations concerning sanitary and quarantine requirements, nomenclature of disease, causes of death and public health practices, standards for certain biological, pharmaceutical and similar products. Members may reject such regulations or accept subject to reservations.

So far as this particular convention is concerned, States may become parties to the constitution by (a) signature without reservation; (b) signature subject to approval followed by acceptance, or (c) acceptance. In our case the document was signed under (b), that is, it was signed subject to approval by the Government and by the Dáil. The constitution will come into force when 26 members of United Nations have become parties to it. The Protocol provides that, as between the signatories to the Protocol, the duties of the office under the 1907 Sanitary Convention will be performed by the health organisation and, in the meantime, by the Interim Commission. That is that the old organisation that was there under the League of Nations will now cease to operate and all the functions and so on will be taken over by the new organisation. By signing and accepting the constitution the Governments accept definite responsibilities and obligations. The new organisation will have authority to adopt conventions and agreements and such agreements will become binding on members, subject to objections or reservations being made within stated periods. But once we signed without reservation we took upon ourselves to bind ourselves by accepting.

I think it will be obvious to Deputies that there is a definite advantage in having an organisation like this. For instance, planes will be coming here from many countries and passengers may bring in, let us say, malaria which, as Deputies are aware, is spread by mosquitoes. If there is a very potent source of mosquitoes in a particular place it might be to our advantage to join with the other nations of the world to destroy the source of malaria rather than try to deal with it when a case crops up here.

The same thing applies to many other diseases. It is better to destroy the source so far as we can. That is one of the advantages of being in this world organisation. Having the advantage of the experience of these other countries through the various publications that will be circulated, the contacts made in meeting their representatives, and the interchange of information, will be useful in helping us in our health services. We should gain by the experience of other countries and we hope we may have something to contribute from this country and that other countries may gain thereby.

I am advised by the medical profession that participation in the organisation should have great advantages from a practical point of view and that is why I ask the Dáil to approve of it.

I now come to the Estimate. I had hoped that before this Estimate came before the Dáil we might have issued the White Paper that I have so often referred to. The Health Bill, of course, deals with a certain number of things which the Department are anxious to get after. The Health Bill deals principally with mother and child welfare, to a certain extent with infectious diseases, including tuberculosis, and with institutional treatment. But there are quite a number of other things which we have not dealt with to any great extent in that Bill. For instance, we have not dealt to any great extent with the ordinary treatment of disease, which has been carried on up to this in dispensaries and in county and voluntary hospitals. The White Paper will give an outline of the type of organisation that we think would be suitable in future and how these types of diseases and services should be tackled in time to come. The issue of the White Paper was delayed on account of the splitting up of the Department of Local Government and Public Health and the establishment of a new Department of Health. The preparation of the White Paper is very advanced and I think I can guarantee that it will be in the hands of Deputies during the summer holidays. If they wish, Deputies will then have an opportunity of discussing the contents of the White Paper when we meet after the summer holidays.

Some figures from the vital statistics might be interesting. For instance, Deputy Morrissey made a statement, which I think is generally believed, that the health of the country is disimproving and that the mortality rate is increasing. That is not altogether true, as the statistics for the last few years issued by the Registrar-General will show. First of all, as regards births, the number in 1946 was 67,547, which was higher than 1945 and 2,000 higher than 1944. The birth rate per 1,000 of the population in 1946 was 22.6. The rates in Northern Ireland, Scotland and England and Wales for 1945 were 22.0, 16.9 and 16.0, respectively. The number of marriages registered during the year 1946 was 17,575, which is also an increase on some of the preceding years. The marriage rate per 1,000 of the population was 5.9. The mortality for the year 1946 showed a decrease, the number of deaths recorded being 41,455, which is fewer than in 1945 and 3,673 fewer than in 1944. The death rate per 1,000 of the population was 13.9.

With regard to the principal infectious diseases, we have a rather encouraging picture, inasmuch as things are improving and on the mend. The position was bad about 1942 or 1943, but since that time they have been improving. The number of deaths from the principal infectious diseases, typhus, typhoid, diphtheria and scarlet fever last year was 163, as compared with 263 in 1945 and 400 in 1943, so that there is a good improvement which, I hope, will not only be maintained but will become still greater as the years go on.

Does that figure include deaths from tuberculosis?

No. That figure would be much greater and I will deal with it in a moment. The big item in the figure I have given is diphtheria which accounts for 135 deaths, but the position in that respect is also improving. The number of cases of diphtheria has gone down steadily for the past few years. There was no case of typhus in the past two years and only two deaths from scarlet fever in each of the last two years, so that we have a very good picture for these two years. If we could tackle diphtheria more vigorously than we have been doing, we would have a very low death rate indeed from infectious diseases.

Immunisation was being carried out when the war commenced and it reached the highest figure about 1941. Since then, it has not been so good, but the results of immunisation of the past few years are beginning to show and the incidence and the death rate are going down very satisfactorily. I have no doubt that if we carry out immunisation more vigorously in the next few years, we shall be able to effect a big improvement as regards both incidence and death rate. We should be in a position now under our new Bill to have immunisation more widely practised. We have got over certain irritations which doctors felt with regard to fees under the scheme. We have fixed more favourable fees for them and immunisation should be carried out more generally from now on.

With regard to hospital building, the programme was interrupted during the war. It was very hard to get materials, and, although building materials are now becoming available in greater supply, equipment and fittings are just as difficult to get as they were during the war, so that it is not as easy to get on with the provision of hospitals as it was pre-war. We are, however, going on with some building, in the hope that we may get the fittings and equipment necessary. One work sanctioned recently is the reconstruction of Loughlinstown, County Dublin, Hospital, the cost of which will be about £150,000. There will be 183 beds in the hospital, representing an increase of 54 general beds and 28 maternity beds on the accommodation at present available. This provision should do much to provide for that very populous area in South County Dublin.

Approval in principle has been given for a number of other buildings and the only thing remaining is to get going on the plans and start building. We have approved of the erection of a 60-bed county hospital in Wicklow; reconstruction of the county home at Castlebar; erection of a 50-bed hospital at Ballinasloe; erection of a 160-bed county hospital at Cavan; the erection of a 100-bed county hospital at Dundalk and reconstruction of the county infirmary to serve as a 25-bed maternity hospital; and works of improvement at the county home, Mountmellick. In addition to the foregoing works, we have some other work in hands, and I might mention in particular the reconstruction of the acute portion of St. Kevin's Hospital in Dublin. There are a number of other building works which are being examined at present, but I do not think I should delay the Dáil in detailing them at this stage, because I am sure every Deputy knows that, in his own county, an effort is being made to build or reconstruct hospitals and sanatoria of all kinds and. I can only say that we will try, so far as we can, to get these projects under way.

There were 17,585 patients in the mental hospitals on the 1st March, 1947, as against 17,736 on 1st March, 1946, a reduction of 151. The number of admissions during 1946 was 2,543, an increase of 237 on the previous year, but there was an increase in the number of discharges and there was also, unfortunately, an increase of 59 in the number of deaths. The death rate, calculated on the daily average number of patients in residence, was 5.7 per cent., as against 5.3 per cent. in 1945. There is one rather gratifying feature about these figures of admissions and discharges, that, in recent years, more are going out each year, showing that the treatment of mental patients is improving and that there is more hope now for a person of unsound mind going into a mental hospital than there was some years ago and quite a number of cures are effected.

There was a blood transfusion service in the city here during the war. We had considerable difficulty about keeping it on. We had to try several institutions and we found some difficulty everywhere we went. We must, however, provide the service, and I am sure we will find a solution in the very near future. We have a committee dealing with the whole question of the service, which is an advisory committee for the Minister and the Department.

I have referred before to the national survey into the nutritional condition and food habits of the people, with a view to providing data for the drawing up of standards peculiarly suited to our own people and which will, at the same time, be related to international practice, which is at present in progress. I am sure Deputies will agree that we cannot have a world standard of nutrition, because climate, possibility of getting certain foods and so on must be taken into account. We are doing our survey here, keeping world standards in mind, and when we have completed our survey, we can come to the best conclusion possible with regard to what recommendations should be made in regard to dietary and so on.

We have talked a good deal about mother and child welfare on the Public Health Bill, and it is scarcely necessary to go into the necessity for such a scheme, but Deputies perhaps are not altogether aware of our position with regard to infant mortality. It is much higher than it should be. We must try to see how we stand with regard to other countries and know exactly what hope we have of improving the position and to what extent we may hope for an improvement. For the ten years, from 1936 to 1945, inclusive, the death rate amongst infants for the whole country was 72 per thousand. For 1946 it was 63, so there is a slight improvement, but there is room for further improvement. For 1945, the rate was 68 in Northern Ireland—I have not the figures for the other countries for 1946—in England and Wales it was 46, and in Scotland it was 56. I read a very long article on this subject in one of the medical magazines recently and there it was held that, with the advance of science, it should be possible to get this figure down to 20 or 25, but there was no hope that it could be got further than that unless we keep people living for all time. There is quite a lot for us to do.

In the county boroughs the infantile death rate is much higher. For the ten years the average in Dublin County Borough was 106 against 72 for the whole country, and for 1945 it was 111. It is perfectly clear, therefore, that the infant death rate in Dublin, in particular, and in the county boroughs generally, is excessive, and we must have much more effective supervision in the first year of child life in order to try to reduce that death rate.

I mentioned here before that I have great hopes of a new scheme, the details of which have been practically agreed upon. Under our mother and child welfare scheme in the city the maternity hospitals will play a big part. The three maternity hospitals will divide the city. They will provide an ante-natal service for expectant mothers, and a clinic. They will provide treatment for expectant mothers. They will look after child birth, the delivery of those mothers and, a thing they have not done up to the present, they will extend their supervision over the babies until they are 12 months old. That will entail the provision of clinics, where the babies will be brought, and also a domiciliary service. They will provide a service of doctors and nurses to visit the homes of the people to look after the babies. They will provide a children's ward in each hospital for certain specific cases. With the great record these maternity hospitals have in Dublin, I have no doubt they will make a very big change in infant mortality in the city when they get this service going.

We have dealt with the mother and child welfare scheme so much in the Bill that I do not think it is necessary to go into it at any length again. It is proposed to make available to everybody in the country, if they wish to avail of it, a free service for mothers, and for children up to the age of 16 years. There will be treatment for expectant mothers during that period and during their confinement and treatment of the mothers after the birth and of the children until they reach school-going age and during the school-going period up to 16 years.

We hope to have more frequent school inspections, so that diseases of the young may be detected in time to treat them before they go too far. The number of children examined in school inspections in 1944 was 102,153. It is rather alarming to think that of that number of children, 48 per cent. suffered from dental defects of various kinds. If those children had not been inspected it is to be presumed quite a lot of them would have let these dental defects proceed until nothing could be done. Seventeen per cent. had defects in the nose and throat—that is, principally adenoids and tonsils—and 16 per cent. had defective vision, while 2.7 per cent. suffered from other eye defects. I think those figures are quite sufficient to convince any Deputy that school inspection is absolutely essential if we want to rear a healthy young generation from the children who are now there, and the same will apply as other children come on.

I come now to tuberculosis. There is in the Estimate an increase of £33,500, as compared with last year, for the prevention and treatment of tuberculosis. To give you an idea of what this service covers, I would like to give some details as to how this increase arises. There is an increase in the number of persons receiving treatment under the local authority tuberculosis scheme and a contribution is made to the local authorities by the Department. The number of patients treated under these schemes is increasing from year to year. That does not necessarily prove that there is more tuberculosis in the country, but it does prove that there are more people availing of the scheme. The only sure guide with regard to the other thing is the deaths from tuberculosis. In 1940 the number taking this treatment was 17,307 and that went up every year until 1945, when it was 20,622.

The next item under that sub-head is increased expenditure under the Dublin County Borough Scheme, consequent on the employment of mass radiography and the provision of additional facilities for institutional treatment. Deputies have heard about mass radiography and there is no doubt that it is a service that will be availed of more and more and I hope it will be effective in detecting tuberculosis in the early stages. The third item here relates to the increase in the number of nursing and domestic staffs employed in local authority and tuberculosis institutions, and improved diagnostic facilities consequent on the introduction of X-ray and screening apparatus. That is all to the good in diagnosing disease. There is an increased expenditure on the provision of extra nourishment, clothing and bed and bedding under the tuberculosis domiciliary welfare scheme. There is a very rapid increase of expenditure here. The increase went from £5,000 in 1943-44 to £51,881 in 1945-46; for the year 1946-47 it was estimated at £62,979 and for the present financial year, 1947-48, it is estimated at £68,000.

The next item of importance is that in the special institutions for the treatment of tuberculosis provided by local authorities, the costs of maintenance have risen in the last five years from £98,021 to £163,501. We all agree, of course, that tuberculosis has been the main problem in this country for many years. The death rate from the disease had, however, shown a continual fall for 30 years until 1938. In that year the number of deaths from tuberculosis was 3,216. Then there was an upward trend during the war for some time and in 1942 it reached its peak. In 1942, the number of deaths was 4,347 but last year it had come down to 3,333, which was slightly over the 1938 figure. There is, therefore, some hope that we are reaching an improved position in regard to tuberculosis.

I was asked by Deputy Byrne the position in regard to sanatoria. I must say that there were rather long delays in regard to getting the three big sanatoria built. The position now is that in Galway, which is the most forward, a survey is being made and it is hoped that the building will be commenced early in the new year. If there is no unforeseen hold-up, we should have the Galway regional hospital ready for patients in about three years. The Cork institution is not much behind that. The building of the Cork institution should be in progress a few months after that in Galway. Deputies are aware that we had to leave the site which was first selected for Dublin but I believe we have a better site now. There will not be very much delay because the plans that were made for Santry Court will be applicable to the new site which we hope to get. We have almost got it but unfortunately I am not at liberty to mention its location lest there might be any last-minute hitch in the arrangement and the owners who are selling it would not like the facts to be known if anything should occur and the deal was off. So far as we are concerned, the deal is on definitely.

I think I mentioned on a few occasions already we are doing everything possible in the meantime to increase the bed accommodation in the existing institutions. For instance, in Peamount, three huts are being built which will accommodate 120 beds. Another 80 beds are being provided in Newcastle. By the end of the year I think some of them at least should be ready. In fact, it is hoped that the first will be ready by September, so that I think that we shall have some further beds available in these institutions within a short time. It is expected that 60 beds will also be provided in St. Laurence's Hospital and an additional 43 beds are being provided at Our Lady of Lourdes Hospital, Dún Laoghaire. A further 64 beds in the Rialto Hospital are now ready. All these additions, some of which are ready at the moment and the latest of which will be ready within 12 months, will total 367 extra beds. They will make a big difference in the waiting list. Unfortunately they will not be all available for the city as in some counties the position in regard to waiting lists is also serious and we may have to allocate some of the bed space in these institutions for patients from some counties.

In the counties progress is also being made. Accommodation is being provided in Killybegs, County Donegal, for 60 patients and Woodlands Sanatorium, Galway, has been extended by the provision of 64 extra beds, so that in some of the counties at least extra accommodation is being provided. I do not know that there is anything else I should say at this stage but if Deputies should require further information I shall be only too glad to supply it so far as I can.

I move that the Estimate be referred back for reconsideration. I welcome, as I think the House generally will welcome, the fact, that this country is willing to become a member of the new World Health Organisation. I think that the contact and the experience which members of the medical profession here are likely to gain and the exchange of information which is likely to be available through the deliberations of the new World Health Organisation, are bound to be beneficial. I think it is no exaggeration to say that this country has long enjoyed a world-wide reputation for the skill and knowledge of members of the medical profession here. The staffs of the voluntary hospitals in Dublin and, for that matter, the members of the medical profession throughout the country because of the opportunities which they have had of spreading their knowledge and experience abroad, have achieved, and worthily achieved, a world-wide reputation. I have no doubt that as a result of the further contacts which our medical men will have through the new World Health Organisation, this country will continue to enjoy that high reputation and that the benefits of the fuller and wider knowledge and the more varied experience available from that organisation, must have fruitful results not merely for the medical profession but for the people in general here. I notice that the Minister said that the World Health Organisation would come into being on 26 nations ratifying its establishment. I suppose it will be possible to get 26 nations without Russia. It may be too much to expect that they will support it as well.

There was one matter in which the Minister admitted there had been delay, namely the question of the proposed provision of regional sanatoria. It is over two years since this House at the urgent request of the Parliamentary Secretary responsible for the public health section of the Local Government Department, passed within a fortnight the Establishment of Sanatoria Act. Under that Act we were informed that it was proposed to build three regional sanatoria—one to serve Dublin area, one in Galway to serve the western area and one in Cork. I know that it had not been finally decided at the time where some of the sanatoria would be erected, but it was intended to have three large sanatoria. I had the temerity to move an amendment to limit the expenditure in order to elicit from the Parliamentary Secretary some information on the future of the Hospitals Trust Fund. I remember that the Parliamentary Secretary at the time rose in indignation at the idea of anyone attempting for a moment to delay the proposed urgent work—undoubtedly urgent work, urgent work which every member was anxious to see expedited, to which every member of the House gave his blessing and which drew forth from all sides of the House an unusual number of compliments, in particular so far as the Parliamentary Secretary himself was concerned. These compliments and the manner in which the Bill was received augured well and the House was entitled to expect that rapid developments would take place. At that time the statistics showed that there had been a rapid rise in the number of deaths. I admit that the worst year was 1942, but the drop which has since been shown every year is not regarded as sufficiently satisfactory and even yet no adequate explanation has been given for the rise in 1942 and the drop which has taken place since. The House expected at that time that we would have had considerable developments and that by now, if one could have looked ahead at that time, some increased accommodation would be available.

At that time or prior to it the Dublin Corporation had invited applications for designs and plans for a proposed sanatorium to serve the citizens of Dublin. There was considerable expenditure and a prize scheme which offered attractive prizes was set up as a result of which a number of designs and plans were submitted. Finally a particular plan was selected. Under the Tuberculosis (Establishment of Sanatoria) Act the responsibility for the provision of sanatoria was taken out of the hands of the local authorities and placed on the Department. The cost, or portion of the cost, was to be borne by the local authorities; the maintenance portion and the running was afterwards to be borne by the local authorities. At that time the Dublin Corporation had in mind a number of possible sites. It was at one time considered possible that vast expansion would take place in the region of or to one of the existing sanatoria under the control of the corporation. Subsequently, another site was selected and, in fact, plans were being proceeded with when the Tuberculosis (Establishment of Sanatoria) Act was passed and the responsibility became a matter for the Department of Local Government and Public Health. Earlier this year, as a result of two Parliamentary questions, I elicited the information from the Minister who had taken over the responsibility that it was not proposed to proceed with the erection of a sanatorium at Santry Court. I may add that when the Bill was going through this House Santry Court was not considered, or certainly it had not at that time been selected as a site. For some reason which has never been given to the House, after the Act was passed Santry Court was selected. Although it was at that time handed over or was in the process of being handed over to the Grangegorman Hospital authorities, the Department swept in and selected Santry Court as a suitable site for the new sanatorium.

Some time at the end of last year or early this year work on the laying of a sewerage system was started and development plans undertaken so that the sanatorium might be erected. Then after, apparently, two years' experience and two years' delay, someone in the Department woke up to the fact that Santry Court is in close proximity to Collinstown Airport. Mind you, Collinstown Airport did not spring up overnight. It has been there for a number of years. The building at Collinstown Airport has excited and received the commendations of many people, not merely in this country but from abroad, as being one of the finest examples of architecture and, in fact, probably the finest airport terminal building if not in the world certainly in Europe. However, it would seem that the responsible people in the Custom House, either under the Minister or under the Parliamentary Secretary, had not noticed that an airport, whose traffic was growing daily and weekly and whose traffic had, in fact, grown substantially since 1945, was operating close to Santry Court. They proceeded, at the end of last year or at the beginning of this year, to undertake constructional development work. Then, after this work had been undertaken, after an expenditure of at least £19,000, the Department realised that the site was not suitable. The Department realised then that the fact that aeroplanes were in almost hourly transit in the vicinity if not over the actual land and proposed building site at Santry Court would be detrimental to the health of the patients and would hinder any possible chances which patients housed there might have of recuperating.

After a delay of two years, during the whole of which time the numbers of people looking for beds in Dublin and the rest of the country had increased, during which time the list was becoming longer, and during which time the state of health of many patients had seriously declined, the Department realised that they could not proceed with the building and they decided to abandon the site. Not only had a sum of £19,000 been spent but, due to non-insurance, when Santry Court was burned it cost the country £25,000. It is an extraordinary thing that Santry Court has been a most unlucky place for the State and for the people of this country. That was not the present Minister's responsibility, but there was some muddle, and eventually, after the burning down, compensation had to be paid, so that now we have to pay £19,000 on top of that for constructional work. It may be that some of the work which has been started there and portion of which possibly has not been completed will not be entirely lost. However, whether it is entirely lost or whether part of it is redeemed, the fact is that, due to incompetence, due to some carelessness —I think gross negligence is an adequate description of the lack of appreciation of the fact that there was an airport in the vicinity and that the constant coming and going of aeroplanes would render the place entirely unsuitable—even if there were no airport, the site is unsuitable. The Department comes along two years after the Bill was passed through this House and admits that there has been delay.

It is true that the Minister inherited a legacy of blame in this case, certainly if not the entire legacy the greater portion of it. It is possible that he may feel slightly aggrieved at the criticism and responsibility which he has to bear in this connection. However that may be, Government responsibility is collective and his predecessor or somebody in the Government was responsible for the fact that the citizens of this country have had to pay over £19,000 on constructional work and on the laying of a sewerage scheme to a site which has now been found unsuitable and unsatisfactory while at the same time the numbers of patients seeking accommodation in sanatoria have increased. It is a reasonable assumption that many of those patients have had their condition worsened by delay. I suppose it is not an exaggeration to say that, in the last two years, some patients have died who might have been saved if accommodation had been provided. We are told now that it is intended to provide 120 beds at Peamount, 80 at Newcastle, 60 at St. Laurence's, 43 at Our Lady of Lourdes and 64 at Rialto, and that it is expected that these 367 new beds will be available in the reasonably near future, but that the demand from other parts of the country will necessitate a number of them being set aside for places other than Dublin.

I think the House and the taxpayers are entitled to a fuller explanation of the whole circumstances surrounding the selection and acquisition of Santry Court as a proposed site for a regional sanatorium and that the House is further entitled to know why it was originally selected and the reasons for the delay in coming to the conclusion that it was unsatisfactory, when it was obvious to everyone that the amount of traffic was growing daily, almost hourly, at the Dublin airport. It is one of the best examples of Government incompetence and reckless waste of public money.

In the course of his survey of health in general, the Minister referred to the fact that the infant mortality rate in the City of Dublin was heavy and it was one of the matters which gave him and his Department most reason for consideration. One of the contributing factors is the excessive overcrowding. When we examine health statistics, we find for many diseases that there is very often either an improvement or no appreciable deterioration over long periods. People ask how it was that 40 or 50 years ago people existed without many of these diseases and enjoyed good health without many of the health services and benefits which we have at the present time. It is generally forgotten that, at that time, the cities and towns were much smaller than they are now. The rapid rise in Dublin City and the Dublin area over the last quarter of a century has militated considerably against the health of the people in that area and particularly against the health of the children. The overcrowding, the bad conditions in many parts of the city, the lack of sufficient accommodation, while they are inconvenient and possibly a source of ill-health to many adults, have not nearly the same adverse effect on them as they have on children.

Over the last quarter of a century Dublin has grown out of all proportion. The city has expanded into the county and many of the towns in the county are now expanding. One of the matters which merit serious consideration is that we now have one-fifth of the population of the entire country in the Dublin area. The health services, housing facilities, sewerage facilities and the other facilities incidental to an adequate housing system will have to be reviewed and altered radically, if the city is to extend much further. This is not entirely a matter for the Minister, but is one to which he must give attention in collaboration with the Minister for Local Government. Most of the housing amenities were set down at a time when Dublin was far smaller. In a number of cases some slight modification, alteration or improvement was sufficient to deal with the increase, but I think the limit has been reached now and, in view of the impact which the lack of these services has on housing accommodation in Dublin, the Minister should consult with the Minister for Local Government about this question.

I was glad to hear the Minister say that Loughlinstown Hospital is being extended and that the work is at present going on there. That is certainly a welcome improvement. That area and the entire South County Dublin has developed enormously and the existing hospital accommodation in Dún Laoghaire was in no way sufficient so the improved facilities in Loughlinstown will be of benefit. The standard of treatment in that hospital was of a very high character and any expenditure on work there is not merely welcome but long overdue.

In regard to dispensaries, in view of the fact that we have already discussed part of this ground on the Health Bill, it is difficult to deal with it now. Some dispensaries were built at a time when the system was portion of the poor law system and entirely different services were expected when doctors rendered and were expected to render a very different type of service to those members of the community partaking of that service. If the services under the new Health Bill when it becomes law develop in the manner in which the Minister has envisaged and in which the House expects them to develop, the existing dispensary buildings will be entirely unsuitable in many cases. I would be glad to hear from the Minister, when he is replying, what plans the Department have, either in conjunction with local authorities or under the Bill, for an improved dispensary service. Some of the buildings have been remodelled, reconstructed or improved in recent times, but by and large they are entirely unsuitable.

In places like Crumlin, Kimmage and other newly-developed areas, and in places like Blackrock, which has expanded very considerably in recent years, the dispensary accommodation is entirely inadequate. The buildings there, even where new, were never intended and could not possibly cater for the large population. Under the new provisions, we will have the mother and child welfare treatment and other dispensary services which the dispensary doctor and the local nurse are expected to render, and the buildings will have to be remodelled entirely or new ones erected. The Minister should pay some attention to this matter, and local authorities should be informed before they undertake further building work or erect new dispensaries. They should know the proposed usage of these dispensaries in the future.

There are services at present rendered to patients, either under the local authorities or under the public assistance authorities, under which many of the children receiving attention and medical care are obliged for a period to get special medical facilities. I have in mind a case where the local dispensary doctor or other doctor attending a child advises the parent to get surgical boots. In the case of poor parents a contribution is forthcoming and in the case of very poor parents the entire cost is met by the local authority. These boots wear out in a comparatively short time and there is a lapse of time before they are renewed or repaired. It has happened that children who have benefited considerably by such treatment relapse into their former condition as a result of such delay. There is a clash of interest between the manager who is anxious to restrict expenditure and the local doctor or county medical officer of health who is anxious to provide the treatment. Very often delay such as I have described wipes out any benefit that might have been derived by the child. The same thing applies very often in the case of children sent to hospitals. It applies particularly to children sent to Dublin hospitals for treatment of defective palate or some slight defect of the throat. The children are treated for a period. When they return for further treatment to the hospital the hospital has difficulty in ascertaining who is liable for the cost. Delay takes place while the local authority, who are anxious to conserve expenditure, pursue the usual inquiries and during that time the condition of the child deteriorates. I would suggest to the Minister that there should be instructions given that closer collaboration between the managerial side and the health side of local authorities is called for, and that every effort should be made to continue services which the county medical officer or the dispensary doctor considers essential. Where treatment is recommended by the doctor it is recommended because it is necessary, and any delay or interruption that takes place in supplying that treatment may hinder an improvement in the child's health if it does not render such improvement impossible.

The only other matter I should like to refer to is the new scheme referred to by the Minister for maternity and child welfare service. He stated that the three maternity hospitals in Dublin propose to provide the facilities and to divide the city between them. I do not know whether that will include the county or not or whether the county will be separate but I would think that the three hospitals would have a sufficient task in meeting the needs of the city. The needs of the county also are great and I would be glad to hear if there is any similar scheme envisaged for the county.

The Minister mentioned that it was proposed to improve considerably the acute section of St. Kevin's Hospital. I referred to this matter before and I think that very great improvements have taken place there but that hospital has a legacy which is portion of the legacy from the poor law system and that operates against the ultimate success, certainly of the hospital in its present form. I would suggest to the Department that the sooner the acute and chronic portions of that hospital are separated entirely from each other the better. I would be anxious to hear what plans the Minister has in connection with that matter.

Before the commissioners were appointed for Cork Street Hospital I understand that a number of the members of the staff there—not the medical staff but the ordinary manual staff— had pension rights. Apparently, some time ago a circular was sent around directing the attention of the staff to the fact that a number of these pension rights were not likely to be continued and that superannuation might not necessarily operate in future. A number of members of the staff, who have been there for a considerable time and who joined in the belief and in the full knowledge that they were likely to receive a pension at the end of their service, feel aggrieved. I think the Minister should look into that matter. This hospital, over a period, has superannuated most of its servants. When the system of superannuation is becoming more general and when it is likely that for the future the case where superannuation does not apply will be the exception rather than the rule, I think the members of the staff are entitled to be superannuated and to have their case considered. Certainly, the matter should be looked into before a final decision is taken.

I would point out to the Minister that the main obstacle in grappling with tuberculosis is the fact that we have long lists in each county of patients awaiting treatment. The Minister may reply that three new regional sanatoria to take the overflow from the counties are being erected but he tells us that the first that will be ready is Galway, which will be ready in three years' time. I am afraid that even then the increased accommodation in the regional sanatoria will not meet the problem.

There are certain causes that operate to keep tuberculosis a main problem in this country. One of them is malnutrition coupled with bad housing. There is a great deal of talk about slums in towns and cities. Very seldom one hears any reference to what I would describe as rural slums. If the Minister wishes to tackle the problem he should take up with his colleague, the Minister for Local Government, the question of providing larger grants and loans for the erection of dwelling houses in rural areas.

The Minister for Health has nothing to do with the erection of houses directly.

I agree but I am suggesting that bad housing is responsible for the spread of tuberculosis. The Minister for Health is not responsible for housing but I do not think I am over-stepping the rules of debate when I ask him to take up with his colleague, the Minister for Local Government, the question of providing improved houses in rural areas and in towns and cities. There is no use in the Minister for Health trying to eradicate that particular disease while the Minister in charge of some other Department has the key to the situation. It is the duty of the Minister for Health to see that the other Minister helps him in that particular matter. I move to report progress.

Progress reported; Committee to sit again.
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