Dáil Éireann debate -
Wednesday, 7 Jul 1948

Vol. 111 No. 17

Committee on Finance. - Vote 68—Health (Resumed).

Dr. Brennan

Last night when the Minister was introducing this Estimate to the House, he divided his speech roughly into three parts, dealing with the prevention, the incidence and the treatment of disease. In dealing with the measures which he proposes to take for the prevention of disease, he enunciated certain measures which he contemplated putting into execution, to continue or to amplify other measures already in existence. He appreciated, as everyone else does, that the State has to regard medical attention to the mother and child as a fundamental obligation which it owes to its citizens. While he told the House that services to supply the needs of these great classes were already in existence, he must have realised, and no one better than he, that while his administration was directed towards that aim, it necessarily suffered a great disadvantage in that whatever treatment was given to the mother and child, he was faced with the fact that their environment in ordinary life is such that treatment was in many instances negatived. This was due obviously to lack of housing accommodation, to the sanitary conditions of such housing accommodation that existed, and indeed to a great extent to a lack of education as to the principles which govern the fundamentals of health.

He also referred to school inspection and on that subject he was followed by his predecessor, Deputy Dr. Ryan. It is rather surprising to hear that the school inspection carried out at the present time is altogether insufficient, that it would be possible for a medical officer to examine a child only once in three years. That is a rather sad state of affairs and it is rather contradictory of the Minister's interest in child welfare. By its lack of attention to the child's health, the State seems to have failed in this regard. If the supply of medical officers for school inspection is in any way inadequate, surely it is the duty of the Department to ensure that an adequate supply of medical men and nurses shall be available so that the children in the schools will be inspected regularly, at least three or four times a year.

The Minister touched on one aspect of school inspection to which I was very glad to hear him refer. I was also glad to hear Deputy Doctor Ryan on the same subject. I refer to the examination of mental defectives. Mental defectives are in a category by themselves. I do not want to repeat what the Minister and Deputy Ryan have said, but there is in the schools the child known as the backward child, who, though not quite a mental defective, may in some respects be regarded as a mental defective. In the course of a survey made some years ago in connection with this subject, Doctor Louis Clifford visited some schools. He refers to the backward child and pointed out that some difficulties exist in the matter of the proper treatment of that child. He said that parents object to their children being dubbed defective. "Backward" many of them tolerate, but backwardness is a respectable complaint. He went on to say, and rightly, that at home the child was able to deal with everyday problems, but was then suddenly precipitated into a new world where competition is the order of the day and this often drives the defective in upon himself, so that he is unable to stand up and he ceases to strive.

That state of backwardness is really a form of medical defectiveness, and I hope that the Minister, under his scheme of school inspection, will see to it that these children are examined not merely as to their physical condition but as to their nervous condition, and that, if necessary, he will inaugurate a system by which special doctors will be appointed to examine these children and to see that their health is encouraged to move on normal lines, that the child will receive the attention it needs and be made to compete in its own class with children similarly affected.

But school inspection is not enough. It is obvious that the facilities for school children to maintain their health are very meagre. No adequate provision is made for recreational activities and the insanitary conditions of some of the schools must have caused many deaths amongst children in this country. I suggest, therefore, to the Minister that the school medical inspector should view the conditions in the school in the matter of sanitation as well as the physical and nervous condition of the children.

It was rather pleasant to hear the Minister's figures with regard to diphtheria immunisation. As one who was rather sceptical about the procedure in that regard, it is comforting to be able to admit that one was wrong. The figures the Minister gave here last night prove beyond any doubt that immunisation against diphtheria is almost an essential amongst children. He made an appeal to parents and others responsible in this matter of immunisation and I hope that appeal will not have been made in vain.

The difficulty with regard to the isolation of infectious cases was a matter on which the Minister dwelt. Due to a fundamental want of proper surroundings, infection has become the rule rather than the exception — the rule, because hospitalisation is not developed and particularly also because housing conditions are as they are. The Minister referred to one aspect of infectious disease, which was also referred to by Deputy Ryan later, the disclosure of information with regard to certain diseases such, for instance, as syphilis. It is grand to know that the officials in charge of our administration have taken every precaution to ensure that secrecy will be maintained in regard to that dread disease. Deputy Ryan raised some doubt as to what would occur in the matter of the registration of a death from syphilis and how that death would be registered. I hope that the secrecy which prevailed during the patient's lifetime will be continued in death. The most interesting and hopeful statement by the Minister was his announcement of his intention to use the radio, the cinema and the Press to draw attention to the necessity for taking precautions to avoid certain diseases, and I presume he referred particularly to tuberculosis.

In connection with the prevention of diseases, perhaps the most important factor is the supply of good nurses. This question of nurses is one which, I am sorry to say, has been overlooked by the previous Government. I do not blame them, because it has been customary to overlook the work of these fine women, and I was pleased to hear the Minister announce his intention to introduce legislation to deal with the problem. The House may not realise what these nurses do. They go on duty each morning at 7.30, having reported for duty at 7.15. They come off duty at 7.30 or 8 p.m. each day. They get a few hours off in the middle of the day, and, once a month, they get a day off. Their pay is scandalous. The conditions under which some of them live are appalling and I hope the Minister will remedy these matters and will ensure that the hours per day which nurses work will be curtailed, so that their work will not interfere with their health. It would be interesting to know how many of these young girls die under the strain of nursing or who lose their health because of the onerous duties which they have to perform. I suggest to the Minister that at least one full day per week should be allowed to the nurses — that is what ordinary domestic servants are allowed — that they should be paid adequately for the work they do; that a pension scheme should be introduced to compensate them for their work and for their devotion to duty because, although a nurse may work for 12 hours a day, it is not uncommon to find nurses who work 24 hours. They sometimes sleep in a patient's house. They are called at all hours outside of their ordinary hours of duty and their attention and devotion to duty is really one of the brightest spots in the history of our civilisation.

In hospitals, at least, the Minister should ensure that probationer nurses and those who are undergoing training live in comfortable surroundings, at least, that they live under conditions such as they enjoy at home; that they should have facilities for study; that they should have their own rooms, that they should have facilities for instruction according to the standards and methods which prevail in higher education; and that at all times they should be able to realise that they are members of a community which regards freedom as one of its most cherished ideals. At the present moment in hospitals nurses are completely under the sway of the matrons and doctors. That may be good or it may be bad. It may be good training or it may be bad training but it is scarcely credible that that system is the right one. Its influence on a growing girl, between 19 and 21, is bound to have some effect on her nervous system, some effect on her outlook in life. I hope the Minister will see that nurses undergoing training will receive the attention which they deserve.

I am one of the administrators of a hospital and, if the Minister saw the conditions under which the nurses live there, he would be appalled. In the last two years, four of them have been overcome with tuberculosis and two with diseases that could not be diagnosed by the concentrated medical skill of several leading physicians. This was entirely due to the insanitary condition in which these girls lived. Last night Deputy Dr. Ryan chafed the Minister because of some pronouncements which he made during the election in regard to the responsibility of the late Government for the deaths of 3,000 people suffering from tuberculosis. I think the Minister was right and I will further charge the last Administration with the neglect that has caused this condition of affairs to occur to these four nurses who are suffering from tuberculosis and to these two who may be invalids for life because that Administration failed to provide the accommodation which would have saved them and made them good citizens and good nurses. They are now, unfortunately, invalids.

I hope, too, that the Minister, when he is considering his legislation in regard to nurses, will make provision for them if they become ill or prematurely unable to work and that he will realise that it is a fundamental obligation of society that society shall repay those excellent women who have done so much and who have received so little.

A thorny subject of discussion might be that to which I shall now refer — the question of the voluntary hospitals. The voluntary hospitals are the tradition in this country, a tradition of which the medical profession is proud, a tradition which they desire to cherish and to continue as it is. Not one of them, if they had the chance, would take remuneration for their services as such in the hospitals because they feel that by becoming paid servants they lose what to them is the most cherished treasure of their professional outlook. When the Minister was referring to voluntary hospitals last night and to the need for economy I do not think the Minister meant any more than what he said, but in case there might be at the back of the official mind some indication of a decision to withdraw help from the funds of the sweepstake to the voluntary hospitals, I should like to draw the Minister's attention to his own figures, as reported in the Irish Times. In 1946 the deficits for the voluntary hospitals amounted to £237,624. That was an increase on the 1939 figure of 51.4 per cent., and that occurred within seven years. On the same page of the Irish Times is a statement from the Minister for Finance showing that the expenditure on current services rose between the years 1938-39 and 1947-48 from £33,100,000 to £65,200,000 — 100 per cent.

These services are those which the Minister serves. With all the conscientious supervision over national funds, the most economic result that can be achieved by the Civil Service is an increase of 100 per cent.

The Minister points out that amongst the voluntary hospitals where a great many patients are treated free, there has been an increase of 51.4 per cent. Surely no greater tribute can be paid to the voluntary hospitals than the comparison of those figures. The Minister anticipates a still greater rise next year. Of course he must expect that. He must know, and does know, that the increase in the cost of certain drugs has added to the expenses of the voluntary hospitals, and that streptomycin is a very expensive drug. He knows that in the treatment of tuberculous meningitis this drug has saved hundreds of lives. He must know that the cost of administering it to a patient who pays an ordinary allowance of £2 12s. 6d. a week is something like £30, £40 or £50, or even more. Until recently, penicillin was a rather expensive undertaking. It surely is not the policy of the State to deny the right of the voluntary hospitals to supply these drugs in order to save human lives. If these figures are examined, a great deal of the increase in the cost of hospital expenditure can be traced to the cost of these drugs. That cost has been well worth it, as hundreds of lives which would otherwise have been lost have been saved. The amount of money which the voluntary hospitals want to make up the deficit is surely a flea bite in comparison with other items of expenditure which he asks this House to sanction. I suggest to him to go back a little and hand over again to the Associated Hospitals Sweeps Committee sufficient funds for them to administer. That was the practice until the Fianna Fáil Government came into power and no one can say that a single penny was ever misspent. Every penny being expended was given, as it should have been given, to the hospitals which needed help most.

I do not think the Minister will accept my proposal — I do not see how he can — but I suggest that he should consider it. If he hands over at least a proportion — for instance, the stamp duty which is taken from every sweepstake — to the Hospitals Committee, the voluntary hospitals will not worry him any more. The stamp duty which the Minister for Finance took, something like £180,000 a year, is and should be the property of the hospitals, but since the Fianna Fáil Administration came into power that has been entirely absorbed and the sick poor of Dublin and the country have been deprived of that £180,000 a year. If that had been used for the proper purpose, the 3,000 deaths from tuberculosis we hear about may never have occurred.

There has been some alarming propaganda against the hospitals controlled by religious orders. I challenge anyone —the Minister or his predecessor or his predecessor again, or any other Minister who holds the power of administration — to show me where the hospitals controlled by religious orders failed in their duty to economise. If the Minister will consult, I think, the second last report of the Hospitals Commission, he will see that special reference has been made to the fact that those which economised most were the hospitals controlled by religious orders.

There is a tendency also to overlook the fact that the members of these communities are citizens like ourselves, citizens who have the same right as we have. They are citizens who have taken the habit and followed their vocation, because that was their choice; but they go further, they work without fee or reward. Certainly, in the hospital to which I belong, not one of them claims one penny, if they could, for their work. If the Minister does not call that economy, I do not know what is. It is a saving of the payment of anything from 12 to 20 nurses per annum, and when these nurses wanted a roof over their heads during the last Administration, the Minister refused to grant their request. Surely these women who were working for the cause of humanity, who were not being paid any fee, who have no money but are perpetually in debt, should receive the recompense they desire, apart altogether from other considerations and obligations which this country owes to them and to their predecessors. Long before Florence Nightingale they had been working for the cause of the sick and the infirm.

Associated with hospitals is the excellent institution — the Hospital Library Council — founded, I think, by Deputy MacEntee — I am not quite sure. That is possibly one of the most efficient services which has ever emanated from the minds of the Department of Local Government. I happen to be vice-chairman of it. It is run by experts— I do not include myself among them— who, during all the years that it has been established, have devoted themselves without any hesitation in lending their aid to alleviating and comforting the sick by supplying them with suitable literature. It is customary always to criticise the Civil Service, but in all the years since the establishment of this council there never has been any difficulty whatever on the part of the Department of Local Government — now the Department of Public Health — in encouraging the work of this council. It has been a great comfort for patients. We are continually receiving applications to extend our work, but it is confined to the voluntary hospitals. May I appeal to the Minister if he can — I see that he is pressed for money — to extend that to the State-aided hospitals? It would, of course, involve the expenditure of much more money than is now paid, but I think it is good for sick people to be able to have literature. In some ways it has been extended to State-aided hospitals. It has been extended to tubercular hospitals and to some mental hospitals. I hope that the Minister, if he can, will see his way to extend the service to the county homes and to similar institutions.

Deputy Dr. Ryan last night made a most extraordinary statement. It was a statement really that took the wind out of my sails when he said that tuberculosis cannot be eradicated. Surely the Deputy cannot be serious about that. He twitted the Minister for his rash statement which blamed the last Administration for their neglect which had caused the deaths of 3,000 people per annum from tuberculosis. I substantiate everything that the Minister said. I accuse the Fianna Fáil Administration of more than that. I accuse them of neglect in regard to my own hospital, but I leave that out. I say that the Minister was perfectly right, because if the £180,000 which the Minister for Finance absorbed from the Sweepstakes had been devoted to proper hospitalisation, in the form of the erection of suitable sanatoria through the country, 60,000 people would, in all probability, be with us to-day. The Fianna Fáil Administration failed sadly, and they are responsible, and if my voice can be added to that of the Minister, I entirely substantiate what he said. Deputy Dr. Ryan said it cannot be eradicated. Was that the reason why Fianna Fáil neglected to provide treatment, because he thought it could not be eradicated? Has he ever read of the island of Bornholm — off the coast of Denmark, where tuberculosis is completely extinct? Has he read of the steps that have been taken against bovine tuberculosis in Norway and Sweden, where it has been completely overcome?

Deputy Doctor Ryan cannot fail to remember — I think he was present 40 years ago or thereabouts in one of the waiting rooms of a hospital which I was attending as a student and where he was a student — the morning when we were surprised to hear that at least one incurable disease had been overcome by Ehrlich and that syphilis was no longer the danger that it was. Surely, the Deputy must know that syphilis was then a much more grave disease than tuberculosis, and if it was not endemic I am quite certain that syphilis would have been eradicated in our country to-day. Does Deputy Doctor Ryan not know the value of the drug streptomycin which during the last few years has saved hundreds of lives from tubercular meningitis? Yet Deputy Doctor Ryan comes to this House and tells it that it cannot be eradicated. The reason is that the Fianna Fáil Administration refused to take steps to overcome that scourge.

It is also pleasant to note that the Minister has taken steps — so did his predecessor — to ensure that, as far as can be observed, mental hospital patients will be regarded by the public in the same light as those suffering from any other form of disease. When I read to-day's Irish Press and the heading “Hospitals Policy is Axed”, I began to wonder was there any honesty in journalism. The hospitals policy was axed long ago, but not by the present Minister. If any man can be said to be making an honest effort to remove the axe, it is the present Minister. The present Minister does not rely on reports or on civil servants to form his opinions. He goes and examines the conditions that exist and his record as a specialist on tuberculosis entitles him to speak with some authority. The suggestion that he has “axed” the hospitals is a disgrace to decent journalism.

With regard to State-aided hospitals, it has often been suggested by those who are in control of local bodies that voluntary hospitals spend too much money in their administration. I hope that the Minister will see that this is not true. I doubt if any State-aided hospital can keep a patient on £2 12s. 6d. a week, and if it can, does it compete with voluntary hospitals on the same basis? Has it to pay the same rates and the same rent as voluntary hospitals? I remember a pertinent instance of that some time last year, the case of an agreement which our hospital had made with the local authority and where we asked for some few pounds extra for penicillin and streptomycin. When they were told that there was an agreement to that effect between us and them, we were told that there was no such agreement and they were perfectly aware of the cost per patient per day. It was my privilege afterwards to find the agreement to prove that what we said was true, but there was no hint of an apology and no suggestion whatever of recompense.

The difficulty regarding hospital administration is entirely due to the fact that the officials in the Health Department view hospitals through their own spectacles. I doubt if any, of them has any experience of hospital administration. I do not think they have. They may be brilliant students, they may have brilliant records as doctors, but I wonder whether any of them has had a week's experience of the administration of a voluntary hospital. I hope the Minister will see that the administration of voluntary hospitals will be viewed through the glasses of those who are competent to view voluntary hospitals and that it would be wise to set up in his Department a special section to look after the affairs of voluntary hospitals.

There is one other thing to which I would like to refer. The Minister referred to the fact that there was in existence an International Hospitals' Association and that he had sent a member of his Department to take part in the deliberations of that assembly. What good is that to the ordinary administrator of a voluntary hospital? The Minister must not be aware of the fact that, even if it is moribund, there is in existence an Irish National Hospitals' Association, which endeavoured to request one of his predecessors to join that association so that a united Irish association could go to the International Hospital Association's meeting, could learn something from these deliberations, and possibly could contribute something to them. I want to assure the Minister that the then Department of Local Government turned it down. I happen to be secretary of that and I have taken upon myself — I am protected in this House I suppose — the risk of keeping that association alive. The money belonging to it is still in the bank and I hope that the Minister will change the attitude of his Department into the acceptance of that principle that there should be established in this country a complete and unified Irish hospitals' association which will be composed not only of voluntary hospitals but also of those over which he has control.

I was glad to see that he intends to alter the status of dispensary doctors and that he proposes to establish clinics where patients can be treated in the same way as they would be treated in a doctor's dispensary. I might point out to him — and he knows it well — that dispensary doctors, especially around Dublin, are under a great disadvantage. In Dún Laoghaire and Rathdown, which I represent, the dispensary areas are of such magnitude that it is impossible for a doctor to give adequate medical attention to his patients. Not only doctors but nurses are in small supply, and, in the new scheme of things, I hope the Minister will supply an adequate staff to comply with the needs of patients who need their services. In addition, I would suggest the establishment of what one might call a roving ambulance unit which could be transferred from one part of the country to another at different times of the year, for example, to seaside resorts — Tramore, Kilkee, Dún Laoghaire — where small accidents occur frequently and where it is difficult to get a doctor. It would be a generous gesture on the part of the Minister to establish ambulance units to deal with the minor, or sometimes major, cases which might occur in these places.

May I make an appeal to the Minister, to use any powers he may have or can get to see that medical students will be provided with accommodation suitable for them? The Minister is probably aware of the difficulties now confronting young students. They have to sleep two or three in a bed and I know one who has to sleep in a bath converted into a temporary bed, and they are at the mercy of unscrupulous landlords.

An Ceann Comhairle

Does the Deputy think the Minister is responsible for housing them?

Dr. Brennan

No, Sir, but these people come from the country, and I am asking the Minister to provide accommodation. I am not saying that he should get "digs" for them, but that he should try to make some provision for them as he would for nurses.

I ask the Minister to consider what I said with regard to the International Hospitals' Association and our own National Hospital Association so that our people can take their place in the world's deliberations and our association can be representative of medical opinion throughout the country. I have every confidence in the Minister. He is energetic and he has the will to succeed. Above all, he has youth on his side. Of course, according to our political opponents, youth seems now to be a disadvantage. The Minister is amongst those young people who have enthusiasm. May he carry on in the determined way in which he has begun his labours. I am confident that when he will have finished he will have contributed a vast treasure to the welfare and outlook of our country.

Mr. Briscoe

I listened with great attention yesterday to the statement of the Minister in introducing his Estimate. I also listened to the major portion of the speech of Deputy Dr. Ryan and to practically all of the speech of Deputy Dr. Brennan, three medical men who must have a very considerable amount of knowledge of the medical side of the main items under consideration in this Estimate. As a layman, my only experience of matters appertaining to health is that which I have gained as a member of voluntary hospital committees, specialised hospital committees, and committees of the Dublin Corporation. I have a few queries to put to the Minister and also some suggestions. The Minister has made it abundantly clear to the public at large and to this House in particular that he emphasises more than anything else and above anything else a large-scale attack on that menace, tuberculosis. Everybody is agreed that this menace should be attacked and brought under control and, if possible, eliminated in time. In connection with that, as the Minister is doing a lot of visiting, I should like him to visit the Dublin mental hospitals, to examine for himself the provision made for the treatment of tuberculosis patients and to see if he is satisfied that all that can be done is being done. From my examination of this matter and with what I admit to be my limited knowledge of the medical side, I am not satisfied that there is adequate segregation of tubercular from non-tubercular patients and that those that are suffering from tuberculosis are being treated as they should be treated. I am not saying this from the point of view of criticising or making any attack on the authorities of the mental hospitals. I say that it is possibly something that should be looked into by the Minister's Department with a view to seeing what suggestions they can make or what extra assistance they can give to bring about some improvement in the matter.

The Minister referred to the recent Mental Treatment Act and I should like to draw his attention to one section of that Act with which I am not in agreement. I should like him to examine the section under which admission is now made available for what are called addicts. I have examined a few cases of persons who were brought into Grangegorman Mental Hospital under that addict section and I am satisfied that that section can bring about very serious abuses which can interfere very seriously with the liberty of individuals. The position is that a near relative of a person can send for a dispensary doctor who may never have seen the person before or had any knowledge of the family and on the statement of that near relative that the person who may be under the influence of liquor at the time, is a drink addict, that person can be sent by the dispensary doctor into a mental hospital as an addict. The shock that that individual gets when he comes to his senses and finds himself in the hospital under these circumstances in my opinion has a greater effect on the state of his health than the bout of drunkenness which was responsible for his being there.

I think the Minister ought to consider seriously whether he should not amend that Act. At present a dispensary doctor is the certifying officer and, under the Act, the resident medical superintendent of the mental hospital cannot refuse to take the person in. That person has to be put through tests which may last from ten days to two weeks before the resident medical superintendent can decide whether he is an addict or not and requires treatment. I suggest that there should be a tightening up of that section in order to give a greater feeling of security to those of us who take the view that that particular section can be abused and, if handled without great care, become a menace of a different kind.

I do not know whether I am pushing an open door or whether the door has been finally closed, but I should like to direct the notice of the Minister to another matter, and that is that under the recent Health Act local authorities can benefit very considerably. When they now spend money in excess of previous expenditure on health services up to a certain amount the full amount is recouped to them out of State funds and, later on, the expenditure is to be on a 50-50 basis. Grangegorman Mental Hospital is one of the institutions which can so benefit. During the emergency, however, and particularly in the year which is called a basic year, the Grangegorman Mental Hospital Committee had to spend a very enhanced amount of money for fuel. We had to pay something like £20,000 extra in one year for heating. That abnormal expenditure, however, was incurred in what is called the basic year, and unless our expenditure is in excess of that sum we will not benefit. The Minister ought to take notice of what has been previously brought to his attention by correspondence. I think it was also mentioned to him when he was kind enough to receive a deputation about it. He ought to reconsider the matter and put Dubliners back in the position in regard to the institution for which they are liable, that that particular part of the expenditure in the basic year should not be taken into account, so that extra expenditure above what it should have been in those years will begin to count. The Minister will agree that on the backs of the Dublin ratepayers falls the very heavy burden of taxation which goes for health purposes. Therefore, he should consider the matter and if he can see his way to meet the point he will be doing the City of Dublin, and the Corporation of Dublin in particular, a very great service.

In his statement the Minister referred to his hopes that in time we would have available in all our health services — hospitals and so forth — the highest advice and the most efficient and up-to-date types of medical officers. I want to bring to his notice now that in my opinion he will have to consider permitting local authorities to pay somewhat better salaries to the professional staffs of their institutions. We must not forget that if we have extraordinarily able qualified professional citizens the attraction outside the State is to-day very great because the salaries and conditions of employment elsewhere are so much better than prevail here. I should like the Minister to consider the matter with a view to seeing how soon he can give permission to the local authorities to raise the maximum salaries which we are permitted to give when we take on professional staff.

Dr. Brennan spoke about the nursing staffs. It is generally accepted now that unless the conditions of employment of the nurses are made much more attractive — with particular reference to the salary side of it — we are not going to get the best types of nurses to stay here when they can get so much better benefits abroad. I should like the Minister to consider also the possibility of introducing into every hospital, voluntary or State-aided, a permanent pathologist. We have now reached the stage when each hospital should have attached to its staff its own pathologist.

The situation in connection with the working hours of doctors in institutions under the control of local authorities requires to be amended. Doctors are on duty in many cases for two and three days a week on what they call a "24-hour day". They serve all day tending to the inmates and doing whatever is required of them, and, in addition, they are on call at night. That means that the doctor may not leave the precincts of the institution during that period. That state of affairs was brought to my notice in particular in our Dublin hospitals. It is rather hard on the professional men that their conditions of employment are such that they must, in the course of their duties, do two or three 24-hour days in a week. I should like the Minister to examine that with a view to seeing if he can permit the institutions to take on additional staff and thus give these professional people somewhat easier hours.

The Minister is aware that in some of our Dublin voluntary hospitals the out-door dispensary side has grown tremendously. I should be glad if he would have the question examined with a view to seeing whether these voluntary hospitals can make extensions in order to meet the need of the very increased number of outdoor dispensary patients. At one time it was believed that we were going to have an amalgamation of the Dublin hospitals. For that reason many contemplated improvements were put in abeyance. It is now quite clear from the Minister's statement that not only has amalgamation been put in abeyance but that it has been abandoned — at least, abandoned for a considerable number of years. I would appeal to him to have the request of the Dublin voluntary hospitals to have grants made available to them for the purpose of extending and equipping their dispensaries for out-patients re-examined in his Department.

Dr. Brennan referred to the lack of accommodation in our hospitals for students or graduates. A new decision has been reached by the Medical Council of England — and I understand it is to be adopted by the Medical Council here at a not too far distant a time — that, from now on, when a doctor qualifies, his or her degree is not accorded until he or she has completed a post-graduate year in a hospital. That means that the hospitals will have to take in the post-graduates on quite a different basis than has been the custom in the past. In order to do that the necessary accommodation to house them will have to be available in the hospitals. I believe from what I have heard that the reason this system has not been adopted here is that the facilities are not available to make that possible.

The Minister for Health indicated that the voluntary hospitals should look very seriously into their expenditure with a view to bringing about economies in the cost of the upkeep of these institutions. I happen to be on the board of two hospitals and I attend the meetings fairly frequently. I have to examine the books almost once a month — the responsibility of seeing what is bought for the patients and what is bought for the nursing staff rotates — and generally to have an eye on how money is spent. I cannot for the life of me see how one penny can be saved by the introduction of any economies. We examine the matter very carefully because we know that when we have to apply for a grant to meet the deficiency which arises every year, a most critical examination is made of the expenditure of the hospital from beginning to end. Consequently we know that the suggestion, from the point of view of economies, would only react adversely on the treatment of the patients in the hospital. The cost of everything has gone up. Wages have gone up considerably. As Deputy Dr. Brennan said, the cost of supplies has gone up considerably. Upkeep and maintenance have increased. Under the bed bureau system every hospital has to show every week the number of beds that were unoccupied and the number of days during which they were unoccupied. We all know that every hospital to-day is packed to its limits. In my opinion it is impossible to bring in economies. If the voluntary hospitals were able to extend for the purpose of taking in private patients they could in that way make a certain income which would help to reduce the general overheads. In these voluntary hospitals at the moment accommodation for private patients is very limited indeed. As a layman with experience on the boards of some of these hospitals, it is my opinion that expenditure is likely to increase in the future instead of going down.

There are some matters which are not quite clear in my mind at the moment and I would ask the Minister, either in the House or by some other means of communication, to clarify them for me. The Minister has made arrangements to take over Coláiste Moibhí for the purpose of converting it into a sanatorium. That building is in process of being handed over to the Dublin Corporation. I understand that a sum of money in excess of £100,000 has been taken out of the Hospitals Trust Fund and transferred to the Board of Works for the purpose of paying the cost of conversion and of acquiring another building to house the school which occupies Coláiste Moibhí at the moment. A certain sum will also have to be spent out of these moneys in making the institution habitable as a sanatorium. That is one transaction. The Dublin Corporation is then asked to pay a rent of £2,800. I cannot understand why the Minister should place such a charge on the corporation when this building is being bought out of Hospital Trust funds. It is not being bought out of public moneys. It appears to me that the rent has been fixed on the basis of what the Department of Finance would regard as an adequate repayment charge over a period of years plus a proportionate rate of interest. The corporation will take this building over. The corporation will run it in the way in which the Minister expects that it should be run. We shall undertake our task in the spirit in which the Minister would wish us to undertake it. I think it is unfair to place this burden upon us while in other parts of the country local authorities are given assistance towards development in relation to health maintenance without any extra burden attaching to them.

With regard to hospitalisation as a whole, the Minister said that it is now quite clear that it is physically impossible to go ahead with the building of hospitals because of shortage of skilled labour and shortage of materials. The Minister in that respect cannot make the progress that he hoped to make. Our difficulty in relation to our housing programme is due to the same causes. I would like the Minister to make it clear whether, in the course of a year or so materials and skilled labour become more readily available, he will then proceed with his original scheme to the extent which he had in mind.

I do not suggest that the Minister should answer all these queries in his reply, but there is another matter which needs some clarification. We have in our mental hospitals infant mental defectives. Members on boards dealing with these institutions object very strongly to housing infant mental defectives with adult mental defectives. We think that is an undesirable practice. We think it is unfair both to the infants and to the adults. I would suggest to the Minister that the time has now come when infant mental defectives should be segregated from adults and treated on an entirely different basis. There are certain cases in which there is no hope of cure. There are others who can be brought to a certain stage of development by proper training. The numbers of infant mental defectives in the various institutions throughout the country are comparatively small and it might be possible to establish some system of regional institution for these young people.

The Minister said that tuberculosis can be attributed mainly to bad housing, malnutrition and bad working conditions. I agree that is the generally accepted opinion of the medical profession. But there is a type of case in which it cannot be suggested that tuberculosis infection is due to any of the three causes mentioned by the Minister. We all know of cases where people in exceptionally good homes and who do either very little work or no work at all have become suspects and, on examination, were found to be suffering from the disease. There must, therefore, be other causes apart from the three mentioned by the Minister. To what extent the disease can be acquired by contact with infected persons, as against other causes, I do not know. Apparently it is a problem upon which there can be no accepted opinion.

I was not here during the whole time that Deputy Dr. Ryan was speaking, but while I was here I did not hear him say that tuberculosis could never be cured. I am sorry Deputy Dr. Brennan is not in the House at the moment. I understood Deputy Dr. Ryan to refer to the fact that it was very difficult to eradicate the disease. That is a very different thing from saying it cannot be cured. Evidence that Deputy Dr. Ryan believes that it can be cured and even eradicated is the fact that it was he who introduced the sections in the Bill making provision for tuberculosis sufferers so that families would not suffer a loss in income due to inability to work on the part of tuberculosis patients. That is sufficient evidence that Deputy Dr. Ryan knew that in order to attack successfully this disease and eradicate it we should make provision for any possible loss of wages on the part of the patient. I have heard it suggested that these allowances are considered to be generous. I have not heard anyone suggest that the allowances were insufficient or that they should be increased. Not even the Minister, who is so alive to the ravages of this disease, made that suggestion.

I have made a few suggestions to the Minister and I have asked a number of questions. These are directed mainly to clearing up the position as far as laymen are concerned as representatives of local authorities and on subsidiary bodies of local authorities. I hope that the Minister will recognise that there can be a difference of opinion between laymen and medical men just as there are differences of opinion, which I have witnessed at board meetings, between medical men and surgical men. These gentlemen are sometimes very wide apart in their views about things, and it takes a layman to bring about a compromise which may sometimes get a job done that will be satisfactory to both points of view.

There is the point of view of the layman to be considered, and I mention that for this reason. Deputy Dr. Brennan seemed to think that unless every official in the Department of Health is a medical man certain things will not happen. I am not satisfied that that is so. As a matter of fact, the Hospitals Commission, which is charged with examining the plans of hospitals from the point of view of extensions or improvements, has as its members a number of medical men, and the medical men there are the hardest to satisfy from the angle of being generous in meeting a situation. The layman on these boards sees the ordinary members of the public seeking admission to a hospital, or seeking treatment as an outdoor patient. He sees the difficulties with which these patients have to contend.

The medical man is concerned purely with the medical side. There may be, perhaps, 100 people waiting to be attended by him, and he is giving his service to them in an exceptional and exemplary manner, but he has not the time to observe certain deficiencies. I visited the dispensary attached to one of our leading Dublin hospitals and to my amazement I became aware that patients were waiting for at least two hours and there were no toilet facilities for them, not even for their children. When I brought this to the notice of the medical men they were shocked. They had not noticed it themselves, simply because they were so busy attending the various dispensaries and the matter had not been brought to their notice before.

I do not suggest the Minister should bring into his Department no one but medical men. I think there are sufficient medical men to give him all the advice necessary through the consultative council. I hope the Minister will recognise that when public representatives make representations to his Department for certain amenities, facilities or conditions, they do so with the knowledge that these things are really necessary. I hope that in future we will have a very sympathetic attitude to all these approaches which are made from time to time by public representatives.

Mr. McCann

I was very interested to hear Deputy Dr. Brennan's commendation of the voluntary hospital system. He clarified the position to a large extent. I was sorry to hear from the Minister that the Hospitals Trust Fund, now approximately £10,000,000, must be invested to produce something in the nature of £340,000 to meet certain deficits. That is an unfortunate position but, nevertheless, I am glad the Minister made the statement. I would like him to make such statements more often, because you hear many people asking, for one purpose or another, "Why do you not get this sum from the Hospitals Trust Fund?" As the Minister has indicated, that money is tied up. It is there to produce the sum which must be paid to cover the deficits of the voluntary hospitals — £340,000 this year.

With Deputy Dr. Brennan, I would like to say that while I appreciate the amount of State-aid given to the voluntary hospitals, nevertheless I believe in the preservation of the voluntary hospital system. The system, as I understand it, is that physicians and surgeons voluntarily attend hospitals and give a lot of the time, which they could turn to great monetary account, free to necessitous people. The contributory or monetary side of the hospital system always called for attention. If anyone reads about voluntary hospitals in Dublin, he will find that they were in the first instance State-aided, but from time to time the State-aid lagged and raffles have had to be organised to assist them. As a matter of fact, the first public lottery was run in this city for the Dublin hospitals.

I would be very sorry if the position arose where the Minister could no longer be able to pay deficits. As a member of a hospital board, having had association with it for a number of years as a member of a local authority, I would like to mention that the position to-day is not quite what Deputy Dr. Brennan describes. He said that there was an increase in the amount allocated by the boards of health. The Dublin hospitals receive 10/8 a day from patients that are sent here by boards of health through the country. I was in touch with one of the larger Dublin hospitals early in the week and I was informed that the bed week cost is £6 10s. 0d. to the hospitals and they receive only £3 13s. 6d. from the boards of health. The Dublin Corporation make a contribution of £160,000.

I would like to see the voluntary hospital spirit preserved, and there should be less interference by local authorities or by the State. I have always maintained that point of view as regards the running of the voluntary hospitals. I would like them to be given the fullest freedom. My experience is that these hospitals are most efficiently run and not one penny goes astray. In connection with the out-patients' departments of the voluntary hospitals, it is true that a great many more people go there each year rather than to the dispensaries. In my opinion, the dispensary is outmoded. I am sorry to hear it is not possible to go ahead with the public health clinics and that they have been put in abeyance. I hope I am not misinterpreting the Minister and that it may be possible to go ahead with them, but on that subject I shall not press him for an answer.

As regards new hospitals, I hope I did not hear the Minister incorrectly. I think he said that £15,000,000 would be devoted to the building of hospitals during the next seven years. He said that while in Dublin the need to provide more modern buildings and greater bed accommodation existed, it would be agreed there was greater need elsewhere. Does that mean that the building of a new hospital in Dublin is to be stopped? I want a categorical answer from the Minister as to whether building of the new Coombe Hospital is not to go on or as to whether St. Laurence's Hospital at Cabra is not to be built. These are two projected hospitals and the need for them in Dublin City is well known and has been known for a good many years. The need for bigger maternity hospitals and, in fact, the need for subsidiary maternity hospitals in the new housing areas has been felt for a considerable time. Is the building of the new Coombe Hospital not to be allowed to proceed and is the new St. Laurence's Hospital not to be built at Cabra?

Unfortunately the Minister made a reference here again to county homes. He referred to the matter recently outside the House. I am not going to say anything more about that than that we in Dublin have not been remiss in that connection. I have here the demands from the Dublin Board of Assistance for the years 1930-31 and the years 1948-49. For the year 1930-31 we paid the Dublin Board of Assistance £273,208 and this year the demand from the Dublin Board of Assistance was £546,365. It is well known in that connection that many improvements have taken place under the Dublin Board of Assistance in the institution now known as St. Kevin's. I just want to say that because the Minister said that county homes which used to be called unions in the old days — St. Kevin's was known as the county home in former days — had not changed since 1847, when they were first built. These institutions were built long before that. The county homes were built under the 1838 Act.

I thought that the Minister also might have mentioned something in connection with the rheumatism problem. I missed a very small portion of his speech as I was absent from the House for a time, but from the report of his speech it appears that he did not deal with the rheumatism problem at all. I have been honorary secretary of the Dublin Rheumatism Clinic since its inception. We understood at its inception in 1942 that this clinic was to be the first of a series of clinics well spaced around the country. I quote from the first annual report of the Dublin Rheumatism Clinic Association in 1943, which reads:—

"General opinion holds that there is a lot of rheumatism in Ireland, but up to five years ago no measure of it existed. Then the National Health Insurance Society produced figures which gave some measure of the size of the problem here. These figures refer to the insured population, a total of approximately 500,000 people. Of all the claims for disease and disability in Ireland during the year 1935, rheumatism with a total of 16,000 claims and a total duration of 295,000 weeks, is the highest figure under both headings. Where cost is considered, rheumatism claims £131,000 or 21 per cent. of all incapacity. If the chronic claims are considered, 50 per cent. of the cost of rheumatism comes under this class. It is also easily first among all these incapacities, its cost amounting to 23 per cent. of the total."

I had hoped that the Minister might tell us something in regard to his efforts to deal with this problem. We in Mount Street can deal only with the walking cases, but there is need for bed accommodation. There is a small site there which could be utilised to put up beds to accommodate patients who would have to come up from the country. Many patients in country districts are beginning to learn of the good work done by the Dublin Rheumatism Clinic and we have quite a flow of patients at present from country districts. I had hoped that the Minister might have studied Lord Horder's advice in that connection as expressed in 1941 when he summarised plans for its treatment as follows:—

"If all cases of rheumatic disease were diagnosed in their early stages and promptly submitted to the treatment which present medical skill can suggest there would be a prompt and great reduction in the number of lives wrecked by its ravages.

The concentration at a few appropriate centres of specialist knowledge and equipment, with subsidiary centres grouped around them."

I should like the Minister when he is replying to let us know what he intends to do in connection with the rheumatism problem.

Deputy Dr. Brennan said that, in effect, we had done nothing for sufferers from tuberculosis. I want to tell Deputy Dr. Brennan——

Dr. Brennan

I did not say anything of the kind.

Mr. McCann

The Deputy said that we were responsible——

Dr. Brennan

I did not.

Mr. McCann

I shall withdraw then, but I should like to point out that in the year 1932 the Dublin Corporation expended only £50,000 on tuberculosis treatment, whereas in the year 1947 a sum of £159,000 was expended. In 1932, when we took over the total public health expenditure of the corporation as apart from expenditure on tuberculosis treatment was £157,415, whereas in 1947 we spent £524,568. I do not think, therefore, that we in Dublin can be accused, nor could the last Government be accused, because portion of that expenditure is made up of substantial grants from the Government, of having neglected either the health problem generally or the problem of tuberculosis.

I have the greatest admiration for the Minister in his concentration on the tuberculosis problem, but I find a lack of balance in his campaign. I know that it is a very commendable thing to make as many beds as possible available, but to my mind there is the other side of the question which has not been touched upon at all, and that is the prevention of tuberculosis. As a layman, I can only give my opinion, but I think it is substantiated, and has been substantiated, by many eminent medical men, that there should be in this country a number of chest clinics to which people could go just as they go to the rheumatism clinic. I suggest that they could be run in the same way and that a person could make an appointment by phone or by letter, or call in to make an appointment. That would render unnecessary the present system of having patients sitting around on stools at the dispensary awaiting treatment. Chest clinics could be established throughout the country to which people suffering from chest complaints could go for examination. Many of these persons might not think they have tuberculosis whereas actually every day they are disseminating millions of germs. Deputies may smile, but I read something to that effect in the Irish Medical Journal some time ago.

There is also a need for some protective measures in connection with milk supplies. I think the Minister said that the ideal system would be to have all milk pasteurised. Even the chemical process of adding water to milk may involve certain dangers. There is inspection of pasteurisation as it is done in certain places in the country, but, even so, I think a more rigorous inspection should be carried out to ensure that tuberculosis germs are not being added to the milk through the water.

Mr. Hickey

I did not understand from the Minister's statement last night what Deputy McCann has conveyed to the House. I understood from the Minister that it would take a capital sum of £10,000,000 to provide the annual income necessary to meet the deficit in respect of the hospitals and not that a sum of £10,000,000 has been earmarked to bring in that income. I agree with the Minister that the question of financing and maintaining these hospitals is a very serious problem, and I am inclined to think that we will have to give a little more consideration to this matter of the building of such huge hospitals, because I am at a loss to understand where the money is to be found for their financing and maintenance. I understand that the Minister has applications from 127 hospitals and that at present 55 hospitals are seeking funds from the Hospitals Trust moneys. I shall be greatly surprised if the Minister succeeds in building these hospitals, costing £15,000,000, in five years.

We in Cork had plans prepared and a site purchased for a regional hospital in 1933, and somebody from the Department came down and condemned the site. The local authority was asked to find another site and did so. After some time, the plans were drawn up, but the architect who drew up the plans for the hospital on the first site in 1932 and 1933 had to be paid £1,200 for these plans. It was then decided to build this regional hospital for £300,000, and a sum of £15,000, architect's fees, was offered for the plans of that hospital in Cork. Notwithstanding the fact that we paid £1,200 to the architect who planned the hospital on the first site, the same architect got the contract for this hospital. That was six or seven years ago, and when we got the plans from the architect, we were told that they could not build the hospital for less than £452,000.

If the Minister intends to leave all this planning to the architects, it is not a hospital built at a cost of £1,000,000 that we will have in Cork but one costing £2,000,000. There is a great need for having a number of architects employed directly by the Department to plan these hospitals, and not on the elaborate scale on which they were planning when all the money was available.

With regard to the mental hospitals, I agree with Deputy Briscoe that it is very desirable that there should be available some place near a mental hospital for these mental defectives. I have some experience of conditions in the county home in Cork where there are a number of mental defectives and it is the saddest thing in the world to see these young boys mixed with adults in these homes. I hope the Minister will give some attention to what Deputy Briscoe has suggested in this connection.

I agree with Deputy McCann that if we are to prevent infection from food and other things of that kind, one of the immediate needs is the supervision of milk. I think the way milk is handled at the moment — I am speaking for Cork City — makes it one of the greatest sources of tubercular infection. With regard to ice cream, I have seen ice cream being brought around the city and I have often wondered why there is no inspection of the conditions under which that ice cream is produced. Good food, good housing and good working conditions are three vital factors in reducing tuberculosis. I read recently in an English paper a statement by Dr. W.G. Pyatt to the effect that the consumption of milk by people in Cardiff rose from 11,000 gallons to 20,000 gallons since 1939, and he remarked that the children were so much healthier and bonnier than they were previous to the war.

We here are more concerned with the effects than with the causes of tuberculosis. A man is compelled to sign at the labour exchange every week in order to get the big sum of 30/- or 35/- to maintain himself and his wife and his three or four children. Will anybody suggest that there is any protection against tuberculosis there? We have also the regrettable position of the man with five or six children who is compelled to give up working because of illness, and who often has been struggling for weeks before doing so because of his financial position. We should concentrate more on the causes of tuberculosis than on its effects. I want to see the most modern equipment for dealing with disease and sickness in our hospitals, but I am inclined to think, from experience, that we are building hospitals the cost of maintaining which in the future will be entirely beyond the country's means.

I want to remind the Minister about our mental hospitals and those employed in them. There is a good deal of dissatisfaction among the staff for a long number of years with regard to the long hours. I understand that some demands have been in for some time and that there is a great deal of uneasiness amongst the staff about the manner in which these demands are being dealt with. There is a demand in for a 48-hour week, and I think everybody will admit that those in charge of patients in mental hospitals are as deserving of a 48-hour week as any other group in the community. I endorse what has been said about the nurses, but there is a special case to be made in relation to mental hospital nurses. The employees of one hospital who enjoy a 48-hour week suffered a reduction in respect of the last increase in wages they received because they have been working 48 hours a week for a number of years. I hope the Minister will deal with this matter as quickly as possible in order to remove any dissatisfaction which exists at the moment and will meet the wishes of those employed in these hospitals.

The Minister spoke about a nutrition survey taking place and Deputy Ryan pressed for the publication of the information gathered, stating that he saw no reason why the figures should not be published. I am at a loss to know which of the two statements I am to accept. A nutrition survey in this country is very necessary and I shall be surprised to learn that we are, as stated by Deputy Ryan, well looked after in the matter of nutrition. I admit that certain sections are fairly well treated, but I have in mind the poorer sections of the community and those on low incomes. I should like to know which statement is correct— the Minister's statement that the nutrition survey is in progress at present or Deputy Ryan's statement about publishing the results.

So far as county homes are concerned, I have been agitating for a long time for the removal from these homes of the old people there and the providing of accommodation for them in some such homes as the Nazareth home in Mallow and the home which we have in Cork where the nuns look after them. There are a number of big mansions around some of the bigger cities where these poor people could be housed and where they could receive proper treatment in a better atmosphere than exists in the county homes. Many changes are necessary in our county homes. In the county home in Cork, there is not even a lift to bring a sick person into the ward. I am glad that we now have a Minister who has a special care for this class of people and who is anxious to see the modernisation of our hospitals brought about. I hope that money will not be an obstacle in the way of effecting changes in these institutions in future.

Mr. S. Collins

I might preface my remarks by welcoming a young mind and a young man to an old and difficult problem. I can assure the Minister that, in so far as his public utterances have indicated his all-out onslaught on tuberculosis, both at the source and in its ultimate treatment, I have an unlimited admiration for his method of approach. I sympathise with him, however, that, in present circumstances, he may have to slow up on the building of hospitals, but I think there is a lot of concrete commonsense in the suggestion made by Deputy Hickey that in the interim period at least, an approach to the problem should be made by providing adequate medical personnel and equipment of a temporary nature to deal with local problems. I speak particularly for a rather troublesome type of constituency from the point of view of terrain, that is, the constituency of West Cork, where there are three separate peninsulas jutting out at tremendous length from the mainland and where there is a number of inhabited islands which hospitalisation must reach. We have the sad experience that in transit many people due for immediate surgical operation die on the way to Cork City. I would urge on behalf of my constituency that the Minister should address his mind to the problem of providing us with some kind of central emergency surgical station where patients coming from the Berehaven Peninsula or from the far ends of the other peninsulas in the Cork constituency might be dealt with in a central position in West Cork rather than have to travel the further 80 miles to Cork City.

They say "Sé a scéal féin scéal gach éinne", and that is my particular purpose in intervening in this debate. The Minister is aware of the position with regard to hospitalisation in West Cork. I am not urging upon him in any unfair way a preference for my constituency with regard to new hospitals. I think we will bear with him in reasonableness if he will give us some reasonable surgical facilities in that constituency to alleviate a pressing need.

There may be criticism of county homes and I am a rather severe critic of them, but I suppose, in present circumstances, it is very hard to find an alternative. I hope the Minister, in so far as he finds it practicable and possible, will elevate the tone of these establishments and make conditions a little bit more reasonable for inmates. I feel the heritage of the old tin platter and the tin mug should be gone from this country for ever. It is a heritage of a different régime. I do not blame any past Government or would not criticise a past Government for what happened. The county homes are an iniquitous legacy and, until such time as we are in a position to demolish them all and to give some kind of reasonable substitute, we will have to reserve criticism.

I would say to the Minister that he should continue to place his priority on the fight against tuberculosis. I would urge upon him, in conjunction with his colleagues, the Minister for Local Government and the Minister for Industry and Commerce, to see that housing conditions are improved so that one of the root causes of much of the germination of disease will be eradicated at the source.

I would urge upon him to treat his colleagues in the medical profession with the respect they deserve for their years of loyal service to the public of Ireland. I am a great admirer of the voluntary hospitals. I would urge upon him to continue in the course he has set himself, a course of co-operation with doctors and nurses, a course that leads to a future in which he hopes he will be able to deal with the immediate acute problems arising from surgical medicine and to deal with the problem of arresting at its source the spread of tuberculosis. I would urge upon him also in dealing with the problem of tuberculosis to collaborate with his colleague, the Minister for Agriculture, to see that no milk goes for human consumption unless it is properly tubercular tested.

Mr. P.J. Burke

I note from the Minister's statement the number of people who died from cancer during the last year. Cancer is a serious problem in this country to-day and many people die from cancer. In regard to the treatment of cancer, it is treated generally in all hospitals, but we have only two hospitals in Dublin catering exclusively for the treatment of cancer. These are totally inadequate. I would urge upon the Minister that he should regard this problem as a serious matter for our people. I notice from the Minister's figures that last year more people died from cancer than from any other cause. In the previous year the number of deaths from tuberculosis just exceeded the number of deaths from cancer. I would like the Minister to devote his attention to these major diseases that are fatal to our people. I am aware that the Minister has established a Cancer Council.

I would like him to go further. During war, nations join together and spend a great deal of money on the destruction of life and property. During peace, it might be possible here, as it has been in other countries, to spend more money on research. It is a very good thing that councils should be established and that there should be an exchange of views, but I would strongly urge upon the Minister that he should regard cancer as a national menace. Those hospitals that are specifically dealing with cancer should get an opportunity of carrying out more research. I would ask the Minister to take a special note of that submission. Through my association with a society, I have some knowledge of the number of people who have died of cancer. It has been very prevalent especially with the female sex and in both young and old male adults. This must not be allowed to continue, but must be faced by specialised doctors who have a reputation for dealing with this disease. They must have put at their disposal a research laboratory to deal with it and see what can be done to save life. Down the ages we have that scourge here, as in other countries. Quite recently I was speaking to an Indian doctor, who referred to the number of deaths from cancer and the causes. Many causes have been attributed to cancer here in Ireland from time to time, and I am not going to steal the bailiwick of the medical profession in dealing with them, but I have given it serious consideration. It deserves serious consideration, more so than some of those diseases that have been given a lot of publicity by political Parties. This is a disease of major importance.

Another disease I wish to deal with, and of which I have had a lot of experience, is rheumatism. We have 500,000 people suffering from rheumatism, neuritis or some kindred disease, but there has been no mention of that in the Department of Health publication on this occasion. It is so serious a matter that no hospital likes to take in a case of rheumatism, as they look upon it as acute and prolonged. Many of our people who become chronic with rheumatism become outcasts from society, unless their own friends look after them. We should do research in this matter and provide special hospital accommodation for research work to try to cure rheumatism. There is no job to-day, whether on the land or in the office, where you do not hear of people suffering from rheumatism, neuritis or some kindred disease. It is of major importance here, as we have so many people who contract certain types of rheumatism, due to tonsilitis and things like that, or due to fevers. The public health clinics envisaged in the Health Act, 1947, are very essential. I would ask the Minister to take special cognisance of Deputy McCann's statement and mine in regard to rheumatism. Only this morning I had to deal with two chronic cases. I went to the hospital, but they could not see their way to take them in until after the holidays. In my own parish I could point to at least ten people suffering from rheumatism alone. The clinics we have are very good, but they are totally inadequate. We have eminent doctors who have done their best and given their time in trying to combat these diseases. People who get rheumatism after certain fevers become invalids and you see them in bed for ten or 12 years, their joints distorted, and so on. I know finance is a big problem in dealing with these matters, but in the case of these major complaints something should be done, as they put other complaints into the shade.

Unfortunately, we have tuberculosis in this country. Any help the Minister can get to cure the sufferers or get hospital accommodation for them will be appreciated, as it is a very worthy cause. I have a distinct objection to people suffering from this dreaded disease having been made the play-toy of political Parties during the election campaign and since. Those who have infirmities or are afflicted in some way or another should receive instead sympathetic consideration and understanding. There was a public man going round my district trying to get elected and, though I know him for 40 years, I know he never took any hand, act or part in welfare societies to help his fellowmen. He was small and mean enough to come along and make tuberculosis a play-toy for the election. I would like to see £100,000,000 placed at the disposal of Deputy Dr. Browne, the Minister for Health, if it would enable him to save those who are suffering from tuberculosis. I have had experience of this disease in all forms. I know the dread those people have of going to hospitals.

We have an excellent medical staff in the County Dublin. Their experience is that it is often very hard to get patients to consent to go to hospital. One of the finest things in the Public Health Act passed by the last Government was the provision for the payment of maintenance to a patient while undergoing treatment. As the Minister and everybody else knows, a great many people suffering from tuberculosis are too far advanced before the disease is diagnosed or before they can be got to go to a doctor. They require a good deal more education on the importance of seeing a doctor so that they may get early treatment. If they could be got to respond to advice of that sort many a person would be saved from an early grave.

The scheme introduced by the last Government for the building of an additional room to houses to accommodate a patient waiting to get into a sanatorium was an admirable one. It has proved rather hard, however, to get some of the local authorities to adopt the scheme. I have tried to get rooms built in the County Dublin, but nearly always some objection is made. In one case it may be that the house is not suitable for the additional room, and in other cases some other reason will be assigned. I know that the Minister is genuinely interested in tuberculosis cases and, therefore, I suggest to him that he should encourage local authorities not to be too rigid in the enforcement of the rules governing the building of these additional rooms. If we had more of them I believe that many families would be saved from becoming infected.

We know the old feeling that prevails when a member of a family contracts tuberculosis. I know of a case where a child became infected and died. Soon after another child became infected and died. That is largely due to the fact that people do not want to go to hospital. In most cases they remain at home too long, and it is only when they get really bad that they are prepared to go anywhere. I hope that all these points will be brought under review when the Minister starts his publicity campaign. About three months ago I heard of a girl, the eldest of a family of nine, who contracted the disease. The mother would not let her go to hospital, and the girl herself did not want to go. It was only after a great deal of persuasion on the part of the local doctor and the county medical officer that they were able to get her to go away. She died within two months of going to hospital. Two other members of the family — they live in a three-room house —have since become infected. No matter what doctors or other people may do they find it very hard to get people to go to hospital. Therefore, I say again that our people require more education on this subject in order that they may be convinced of the importance of early diagnosis and consequent early treatment.

Another thing that is most important is the after-care treatment for tubercular patients. That should receive special attention at the present time when there is the possibility of building more houses. If possible, people should not be sent home from a sanatorium until they are cured. If they have to return home when half cured it will mean that they will infect the other members of the family. I know that the Minister will find this a very difficult problem to deal with, due to the fact that there are so many people finding it hard to get hospital treatment. Where it is shown that a person is reacting to treatment very well, every step possible should be taken to see that he will not have to return to a home where the conditions are not good because if so the good work done in the hospital will soon be undone. I suggest to the Minister that he should consider the setting up of after-care committees. In the Irish Red Cross Society we have anti-tuberculosis committees and the public health nurses who give advice. We have a lot of intelligent people co-operating in voluntary work of that sort. I do not suggest that they should interfere with doctors or professional people, but their advice and co-operation is often very necessary. They are often in a position to give very valuable help to these after-care patients. There are certain types of employment which we all know are not suitable for various classes of people. That is a matter that has an important bearing on this question of tuberculosis. There should, I think, be closer inspection of factories. If that work is done well, it will tend to improve the health of the people. I think that employers should see that their employees are provided with a meal at a reasonable cost. In many cases men and women have to travel long distances to their work. Very often, they get a wetting in the morning before they reach the factory.

An Ceann Comhairle

The Deputy is now dealing with the functions of the Minister for Industry and Commerce and not with the Estimate before the House.

Mr. P.J. Burke

I am dealing with public health and with matters that have to do with the health of the people. The Minister's Department will have to deal with them. In connection with the mental hospitals, during the last 20 years a good deal of research work has been carried out in some of them as to the cure of patients mentally afflicted. I would like to see a good deal more work done along that line. I am dealing now with one specific place, Grangegorman Mental Hospital. The committee some years ago took an intelligent view and sent some of their staff to the United States to see how treatment was carried on there. At the present time we have a mental hospital superintendent, a very zealous man, who with his staff carried out very good work at Portrane and Grangegorman. I would like to see more facilities given to these people to carry out their work. A lot of poor people and wealthy people who are afflicted for one reason or another — often for economic reasons, often through worry and often for hereditary reasons — go in there and lose heart. In other countries research treatment is being carried out. As far back as 1930 treatment was discovered for dementia præcox. The result of Dr. Dunne's visit to the United States was a number of cures of G.P.I.

There have also been new advances with regard to shock treatment and operations. I think the Minister for Health should take special interest in mental hospitals under the Mental Hospitals Treatment Act, for which I must pay a tribute to Dr. Ward for his interest in that Act. It is a very good Act, and the scope of it is very good, and we have established that it is as natural for the mind to be sick as for the body. A great deal of psychological work is done in hospitals. Men who are in the depths of despair are cured through psychological treatment. With regard to research, I would like the Minister for Health to bring together the eminent specialists we have in Portrane, Grangegorman and all over the country who have given their lives to the study of mental diseases, and give them the opportunity of carrying out research work and let them travel to other countries to see what could be done to cure those diseases. A number of people go in for voluntary treatment, and that voluntary treatment has been very acceptable under the 1938 Act. I think that one of the finest things about it is that it saved those unfortunate patients who want to get treatment from having to go in in the old way, through the courts. A number of small children are admitted to mental hospitals, some from county homes. Of course the Fianna Fáil Government considered introducing a Bill to deal with mental defectives. We have a number of them in our county home and also in the mental hospitals and I hold that that is not the proper place for them, that it is wrong to have mental defectives with grown up people. All mental defectives should be treated together in one home or hospital with special doctors and staff and then we might be able to do something about that inherited affliction. It is very sad for the unfortunate people who have to have their relatives in mental hospitals.

I am sorry that the Minister has gone. I want to deal with county homes. I want to pay a public compliment to Mr. Seamus Murphy, Chairman of the Dublin Board of Assistance. I see a big improvement in the county home. I am not going to say that county homes are as good as they should be, but I say that it might be well for the people who are talking about county homes to stay their hand and their criticism until such time as we are in a practical position to improve the lot of the unfortunate people there. It may happen to any of us to have to end up in one of these places. They are all human, all people and we would like to see them better off. My experience is that county homes have improved a good deal but I would like to see them improved a good deal more and it is a matter of cost. I do not know of any place which is as bad as the published statement I have seen regarding county homes. They are a big problem and an inherited problem. We are only a young country and I think that we have advanced reasonably far with the resources at our disposal during the last few years. I would like to see in these county homes as far as possible more segregation, as that would make it more pleasant for a particular kind of people who go there. That can easily be done by any local authority provided they are allowed more money. Finance governs all these things.

I hope that we will get as far as having up-to-date homes in our country, but I do not think that the homes we have deserve the strong criticism which they have received. It is easy enough to criticise a thing destructively, to talk of things which happened from time to time or to talk of somebody who did not do something else, but it is always better to try to improve them, to do the best you can without criticising unduly while you are not in a position to remedy them right off the reel. I would recommend more segregation of the various types of people in county homes, as it might make their lives more happy and make for better feeling generally. In the mental hospitals — if I may go back to them again — we have houses of admission and various wards for the different types of patients. If the authorities had money they would have a special house of recovery similar to an outside home, to places out in the world. While the patients' lives are made as happy as possible, while the wards are very good, I know if more money could be spent on these places the governing authorities would be only delighted to do this work.

I believe that some time ago the staffs of the mental hospitals applied for an increase in salary. The increase applied for was a small one and I believe it is still under consideration. I should like the Minister to intimate when he proposes to sanction this increase. The staffs in these institutions have very difficult duties to perform and they have always been underpaid for the work which they have to do in caring for patients suffering from mental diseases. They have now an opportunity of getting a few shillings extra which have been granted by the county manager, but the Minister stayed sanction to this increase for a long time. I therefore ask the Minister to expedite the matter.

Reference has been made to the question of cottage hospitals. That matter has been discussed on other occasions. Judging from the remarks of Deputy Collins, cottage hospitals are very necessary in certain parts of the country if they could be economically administered. In certain areas people have to be brought long distances to hospital. Under the Cumann na nGaedheal Government a number of local hospitals were closed. I am not saying whether that was right or wrong but, as I said, there are certain areas where people have to go a long way for hospital treatment. I know these decentralised small cottage hospitals are very expensive, but for the convenience, health and comfort of our people, if they could be run economically, I should like the Minister to consider establishing such hospitals in certain areas. We have heard of maternity patients, operation patients and others almost dying on the way to hospital. Cottage hospitals are necessary to deal with cases of that kind where the general hospital is a long distance away.

Some local authorities throughout the country have a reasonably good ambulance service. Again, it is a matter of expenditure, but I should like to see a more up-to-date ambulance service established by local authorities. Various organisations and some private individuals provide good ambulance services. I should, however, like to see some of our local authority ambulances brightened up a little. Some of them remind me of a black maria. They should be at least more cheerful looking and up-to-date so as to inspire patients who are carried in them with a little more confidence.

The Minister stated that he is going to spend £15,000,000 in seven years on the building of hospitals. I should like to see him spending the £27,000,000 to which he referred. In that connection I should like him to deal specifically with the two major diseases to which I referred in my opening remarks. He should consider that matter sympathetically and give all the assistance possible. I should also like him to put at the disposal of medical superintendents and doctors in mental hospitals special laboratories before the amount of money that he has in mind is spent some other way. I am pleased to know that that dreaded disease gastro enteritis has been curtailed a good deal. The blood transfusion service is a very admirable one and I am glad to know that it is going to be put on a proper basis. A lot of good work was done by that service through voluntary donors and others, especially during the gastro enteritis outbreak.

As to the question of dispensaries, in County Dublin the previous Minister and his predecessor, Dr. Ward, succeeded in getting a number of new dispensaries built. I should like to see our dispensaries turned into a kind of temporary consulting hospitals or public health clinics where people suffering from various diseases could be examined properly and not have dispensaries with only one room or two rooms, as happens in many cases. The provision of up-to-date dispensaries is very essential and should be speeded up. Nothing is more disheartening to an unfortunate patient who has to attend a dispensary than to have to wait his turn in a small room with perhaps 20 other patients. In many cases the doctor has no proper facilities for dealing with the cases. The Minister should see that proper public health clinics are provided where people can be treated in what I would call a semi-hospital way.

I welcomed the provision for a mother and child welfare service under the Public Health Bill of 1947. I should like the Minister to tell us what he intends to do in regard to that service. As Deputy Dr. Ryan said last night, if we are to have a healthy nation, we shall have to try to get at the root of the matter. If a child is treated for a particular disease or impediment when it is very young it may become a useful member of society. I am thinking now of the unfortunate mother who is possibly in poor circumstances. If such a mother and her child are properly looked after we would be able to get at the root of the trouble in this country and we would have an opportunity of making our people stronger and healthier. I should like to refer to the number of youngsters whom I happen to see in hospitals from time to time suffering from various impediments from which an intelligent mother or father could have saved them so that they would become decent members of society. I envisaged that this public health service dealing with the mother and child would be responsible for eliminating a great deal of the disabilities which we have seen, to our own cost, throughout the country. I should like the Minister to take special cognisance of that fact. It is very essential that he should expedite that particular section of the 1947 Health Act which deals with the child and mother.

I should also like to see medical services in our schools. Our medical doctors in each district really have too much work to do. I know that we already have a schools medical doctor, but it is the old story of expense. I consider these school medical inspections are wonderful. I recommend them to any mother or father, no matter how much they may hate interference from anybody. It is a fine thing to know that the child is healthy or, if there is anything wrong, that it will not be the old story of not going to the doctor until the condition has become serious. There should be a medical consulting room for the doctor near the schools. That would facilitate these poor unfortunate people who would not possibly go near a doctor otherwise. I should like to see that grand old feeling that has always existed in this country between doctor and patient fostered. The doctor should not have to say: "I will examine the child whether you like it or not."

I should like to refer to one of the sections under the Public Health Act which deals with Jubilee nurses. I have not got it with me at the moment. A number of Jubilee nurses are about to retire on a very small pension. I have met quite a number of Jubilee nurses by reason of the fact that I have been on various committees to organise functions to try to keep them in their jobs. The Jubilee nurses have rendered the poor of this country a wonderful service since the inception of that service. They have co-operated with the local doctors and they have assisted in a hundred and one ways in their districts. I shall be glad if the Minister will deal sympathetically with the Jubilee nurses.

I hope the Minister will give due consideration to all the other points which I have raised.

In conclusion, I want to say that I wish the Minister for Health luck. He has a big job to perform. I wish him luck, as I wished his predecessor luck and as I would wish his successor luck. It will take years to solve the big problem that is before us and our only hope of solving it is to be as sincere and helpful as we can.

Mr. McGrath

I am sure that the Minister realises that everybody in this country is behind him in his fight against tuberculosis. It is well, however, that it should be known that the drive against tuberculosis did not start on the 18th February, as some people seem to think. There are people in this country who have spent many years of their lives on boards and other bodies to help fight this menace. Naturally, I am dealing with this question from a Cork point of view. I can state that for a number of years tubercular patients were given free nourishment, free clothing and treated in every way. I am a member of the joint sanatorium committee of which Deputy McAuliffe is chairman. I am sure that if he were here now he would bear out my statement that that committee was facilitated in every way by the previous Government in anything they attempted. Naturally, a lot of things were held up because of the war. At the present time many people very conveniently seem to forget, when they are talking, that there has been a war. Deputy McAuliffe can tell you that last January a new annex for 22 patients was built at Heatherside Sanatorium, Doneraile, County Cork. I do not think there was much blowing of trumpets about it, but the work was done quickly and done well. As Deputy Burke said, under the last Government, a grant of £100 was made available for an extra room to house a tubercular patient on his return from a sanatorium. It is essential that when the patient returns home he will be carefully looked after and, if necessary, isolated. I would ask the Minister to appeal to the Minister for Local Government to give priority in housing to tubercular patients. Several cases have been brought to my notice of tuberculosis sufferers with large families who are living in one or two rooms. There is not much hope of maintaining the improvement they made in the sanatorium if they have to return to such conditions.

The greatest help that was given in the drive against tuberculosis was the special benefits scheme which was introduced under the last Health Act. That gives a sense of security to people who might not otherwise have availed of treatment. Before those benefits were introduced people went into hospitals with uneasy minds about their families. Personally, I should prefer if the benefits were somewhat greater but I think that even as things are the patients are being treated very generously. Under the scheme a single man receives 28/- a week; a married man with no children, £3 a week; a married man with one child, £3 8s. 0d. a week, and a married man with three children £4 1s 0d. In addition, there is a rent allowance up to 15/-. I think that scheme did more good than anyone realises but, at the same time, it has possibly made the Minister's job a little more difficult because people are now applying for treatment who would not have attempted to apply for treatment before. Hitherto they worked on to the very last until it was too late for treatment, but now they feel more confident, and the result is that the number of applicants seeking treatment has gone up considerably. I think tuberculosis has been fairly well handled in this country considering the size and wealth of the country. For some years past it has been incumbent upon public bodies to keep records. Last year the record of deaths from tuberculosis in Cork City was lower than it has been for a good many years back. It was the lowest since records were first kept.

School inspection is admirable. So is the care of children. By such means we shall go a long way towards eradicating those diseases from which our people suffer at the present time. As a Cork Deputy, I would like to pay tribute to the work done by the Red Cross in the campaign against tuberculosis. I know that Deputy Hickey could not very well speak on this matter since he is the chairman of the Red Cross in Cork. But I would like to pay a tribute to them and to the work they have done. Very shortly now they will open a preventorium for children. Last year they carried out mass X-ray of children from different institutions. They even provided the transport for the children.

As a member of the South Cork Board of Assistance I resent very much the statement made by the Minister in Galway about the county homes. Cork County Home and District Hospital is a splendid institution. It has a population of between 1,100 and 1,200. I am sure Deputies who have been over that institution will agree with me that the people there are treated as well as they would be in any hospital. That is equally true of the county home portion. In other days the people in that institution were supplied with timber beds and straw ticks. At the present time they have iron spring bedsteads with hair and fibre mattresses, which are periodically re-teased and re-covered. In other days they had a pauper's uniform of coarse tweed with the union brand on it. Now they have readymade tweed suits and caps of varied patterns. With regard to food, potatoes are supplied every day; fish is supplied on two days per week; roast beef is supplied on one day; meat soups are supplied on other days. Creamery butter is served in place of the old-time dripping and syrup. In fact, when the butter ration was reduced to four ounces no change was made in the ration in the county home. A stage was built in the male division and concerts are held regularly there during the winter months.

A wireless set has been installed in the female division. Inmates in receipt of the old age pension receive 4/- pocket money out of that pension. Prior to the Fianna Fáil Government such people were not eligible for pension. In fact old age pensioners could only draw a pension for 12 weeks if they were hospital patients and, on the expiry of the 12 weeks, they were disqualified. There are over 300 old age pensioners now in the county home and hospital. In 1932 they numbered 20. When people died in the county home they were buried in plain unmounted coffins. The coffins were not varnished. No priest attended the obsequies. Now they are buried in properly finished coffins, mounted and varnished, with a priest in attendance. I think that is only as it should be. I think it is a bad thing for any Minister to slander his country as the Minister did in Galway recently. Visitors to this country or people reading such statements will think that we are a very uncharitable people.

Mr. McQuillan

Will the visitors——

An Ceann Comhairle

Order!

Mr. McQuillan

The Deputy is speaking——

An Ceann Comhairle

The Deputy can speak if he wishes to later.

Mr. McGrath

I can assure the Minister that there are people on the boards of these institutions who had the welfare of the poor and the sick at heart long before he was born. They will continue in their good work.

I would like to ask the Minister what he is going to do about the voluntary hospitals in Cork. He visited them some time ago. I was present at the South Infirmary and we put a few of our requirements before him. We expected to hear from him in the matter. I think the voluntary hospitals are doing magnificent work. At least 40 per cent. of their patients are free. When a patient proposes to enter the district hospital his case is submitted to the home assistance officer. If the patient has the means to pay he must pay. I would suggest to the Minister that he should ask these bodies not to be quite so rigid in this because when people have illness in their family they are not in quite the same position as when things are normal. It may give a wage-earner enough to do to carry on. The local board cannot interfere. The matter is left to the county manager and it is often unfair to expect these people to pay.

The Minister may recall that it was suggested to him that the South Infirmary required a new wing and central heating. I would like the Minister to clarify the position as regards sweepstake investments held by institutions like this. For a long time I have been agitating that this money should be spent. There is something in the region of £39,000 invested, and the trustees say that this money was for endowment, and that it is illegal to touch it. This matter was taken up with the Minister's predecessor and, from his ruling, I took it that this money could be spent and that there was no necessity for depending on the interest from such investments to pay any deficit, as any deficits that did occur would be met by the Hospitals Trust. While that money is held on investment the Hospitals Trust will not make any further grant towards capital expenditure. The result is that institutions are held up and cannot carry out the very necessary works they would like to carry out. That was explained to the Minister on his visit, and I would like him to clear the position up as soon as possible.

We must all realise there is a big improvement in the position of nurses since last year, when the previous Government introduced increased pay for them. Since last year the nurses are being paid a fairly reasonable salary and their hours of duty have been fixed at 96 for a fortnight. Previously the hours were from 120 to 130 a fortnight. A couple of years ago, when the district hospitals were applying for probationer nurses, they could not get half the number of candidates they required. That was the case all over the country. Last month there was an examination for probationers for the district hospitals and for 13 vacancies they had 45 candidates. There is another good sign in the Mallow hospital, which will soon be opened by the Minister. A number of nurses who are at present working in England have applied for posts in Mallow. They are quite prepared to come back. There are 12 to be appointed and six or seven of the applicants for the posts are either working in England at the moment or were at the time of application. They are all anxious to come back. That shows that the conditions for nurses are considerably improved by reason of the scale of salaries introduced last year and the altered hours of working.

Something should be done to establish a nurses' pension scheme in the voluntary hospitals. It is very hard to see nurses who have given most of their lives working in the voluntary hospitals retiring without any arrangements being made to give them a pension. At the moment they go out without having anything to live on and many of them have been left pretty badly off. I trust the Minister will pay particular attention to that matter. When nurses work under a local authority and they leave to get married they get a gratuity covering their years of service, but in the case of nurses in voluntary hospitals they get nothing and I think that position should be remedied.

Deputy Dr. Ryan mentioned last night about completing Cork Fever Hospital. The position there is that the Cork Corporation have asked the Department to pay 100 per cent. of the cost. They say they are as well entitled to the 100 per cent. of the cost as was the Cork Regional Hospital. I am sorry that when Deputy Hickey spoke about the regional hospital he did not complete the story. Quite recently, when discussing the new regional hospital and the alterations, the county manager asked the architect when he would be ready to look for tenders, and he said he would not be ready for two years. I do not think the present Minister need worry very much about the cost of that hospital. As regards the fever hospital, I do not think that is a matter of urgency. There are other things far more urgent than the fever hospital. We have a North Fever Hospital in Cork and the average number of patients is eight or nine. I do not think there is any rush about this new fever hospital, unless it might be used for some other purpose. There are other things much more necessary.

I trust the Minister will consider carefully the points I have mentioned about nurses in voluntary hospitals. I would also like to point out that in the district hospital we have a number of male ward attendants and a couple of registered male nurses. These men are necessary for a particular type of old patients with whom they have to deal. It has been suggested that we should have more registered male nurses. It would be quite possible to train and qualify them in a hospital like the Cork District Hospital. Some of the visiting surgeons tell me that as regards the registered male nurses the people do not appreciate their value.

I should like to support Deputy Hickey's observations about the attendants in the mental hospital. These persons devote their lives to the care and nursing of the mentally afflicted. They are doing a great work looking after these unfortunate people and it is terrible that they are not paid as much as an ordinary labourer outside. I want to support the plea made on their behalf and as far as possible I will support the Minister in his drive for an improvement in the health of our people.

Minister for Defence (Dr. O'Higgins)

I think the Minister for Health, on the whole, should be very pleased with the trend and tone of this debate. There were very few of the speeches that were not entirely of a helpful nature. I am glad to see there is at least one subject around which there is not any controversy, and that there is a general desire all round the House to contribute as best each Deputy can by way of suggestions towards the betterment of the health of the country. It is a pity, however, that a discussion on the health Estimate could not be allowed to pass by certain Deputies without, in a rather clumsy and laboured way, bringing in highly political, controversial references. If every Estimate were to be made the occasion of holding post-mortem examinations on the election utterances of every Deputy when he was a candidate before the electorate, it might turn out to be very apparent that Deputy McGrath would be a better judge of slander than the Minister for Health.

Mr. McGrath

On a point of order, I was not discussing election speeches, but, as a member of a board of assistance, I resent the statement made by the Minister for Health about county homes.

Dr. O'Higgins

The Minister for Health and any decent colleague of his and any decent Deputy in the House is entitled to resent some of the Deputy's references to the Minister for Health. The Deputy reminded us that the campaign against tuberculosis did not begin on the 18th February, 1948, and that is perfectly true. Neither were all the nurses in the voluntary hospitals born on the 18th February, 1948. They have been in those voluntary hospitals for a great number of years rendering excellent service, unpaid, overworked, and without pensions. This is the first time in the course of the last 17 years that I have heard any of the Deputies opposite contribute by word or speech to a request for better conditions and for pensions for these nurses. I was a voice in the wilderness here for 16 long years, looking in vain and with very little hope in my heart over in the direction of the seats then occupied by Deputy McGrath and his colleagues. Never once did I get any response to any of the appeals.

Mr. McGrath

I was not here then.

Dr. O'Higgins

No. That was before 18th February, but the Deputy was giving valiant support to the people who were silent every time appeals were made on behalf of the nurses. He was working his passage to get in where he is now but he was not working his passage by advocating the claims of these nurses when he had one of his own Ministers to do something for them.

Mr. McGrath

How do you know whether I was or not?

Dr. O'Higgins

But even those converted at the eleventh hour must be welcomed into the fold. I am glad to have the co-operation and assistance of such a doughty ally in this particular cause, this new and mighty evangelist of the overworked, underpaid and non-pensionable nurses of our voluntary hospitals. I am sure there is a bright day dawning on the horizon for the nurses in the voluntary hospitals when we have this new appeal for support on their behalf.

In the course of this debate we had a number of requests made from various parts of the House for a number of buildings—hospitals, sanatoria, houses, dispensaries, public health clinics of one kind or another, extensions to the residences of tubercular patients and extended waiting rooms for people awaiting examination. All these things are highly desirable. We got a little lecture from Deputy Burke—very interesting, and I was rather intrigued to listen to it. I listened to him for some time criticising a great number of things that are not right. His criticism was perfectly sound and perfectly reasonable but, having spent some 20 minutes criticising a great number of things that are not right and that he himself says could not be put right for a considerable number of years, he turned round to give a lecture to others to the effect that it was foolish to criticise anything until you were in the immediate position to put it right. It is an old saying that it is advisable for people to practise what they preach and I think the Deputy should hearken to that old saying. There is no point in any of us here discussing such an important matter as health, the spread and prevention of disease and the cure of disease, in a situation such as that, blinking our eyes to the facts that are there, just because the facts are awkward or unpleasant.

Every one of us knows, no matter where we sit in this House, that there is unfortunately a very great number of limiting factors to the extent that building can be done in this or any other country under existing circumstances. The previous Administration had of necessity completely to shut down on certain lines of building. Commodities essential in the building industry are not in ready supply. You cannot at the same stop proceed to build unlimited houses, unlimited hospitals, unlimited clinics, unlimited dispensaries. There must be some kind of priority and if you cannot build, and if the need for hospitalisation is crying and urgent, the only other sensible alternative course is to use the walls, the floors and the roofs of existing buildings to provide hospital accommodation for those in urgent need, pending the construction of suitable buildings. The Minister for Health is doing that with great speed, with great energy and with enormous success. Perhaps one of the biggest efforts he has made in that direction was the taking over of St. Mobhi's in the Phoenix Park. Yet we had complaints from opposite with regard to the rental to be charged —not exactly complaints but notes of interrogation of a complaining kind.

Deputy Briscoe is a far better financier than I am, but St. Mobhi's Hospital, that is being transferred to the Minister for Health, is not just the part that was occupied by the college. It is the whole outfit, the portion that was a military barracks, the portion that was a 600-bedded hospital all during the last war. What the Dublin Corporation is getting there in the most excellent surroundings in the whole of Ireland, with square miles of pleasure ground all round it, completely isolated, is a 350-bedded hospital with ample, nearly unlimited, staff accommodation, with recreation rooms, with swimming pools, with all the Phoenix Park around it for pleasure grounds. To build a 350-bedded hospital with staff accommodation at the present moment would cost £700,000. To build anything like what the Minister has taken over in the Phoenix Park would cost, I believe, at the present moment nothing less than £1,500,000. No money could buy the geographical situation. Yet in that situation we have complaints with regard to a paltry rental—no cash sum being charged.

Surely that is a thing that should be welcomed? That is a thing that should be applauded. That is not the kind of Ministerial effort that should even be questioned. Even if those premises were far from being what they are, the position with regard to tuberculosis sufferers is such that every one of us should welcome any four walls and roof that would give shelter and facilities for nursing and hospitalisation, and not growl at the price. It will take gigantic efforts—and Deputy McGrath from his long experience knows it in one capacity and I know it in another just as many other Deputies know it in other spheres of life— within any reasonable length of time to provide anything like sufficient shelter, even for the number of tubercular patients there are remaining up and down the country awaiting treatment and hospitalisation, and who, while awaiting that treatment and hospitalisation, are infecting others all round them, like the stone thrown into the pool which sends out wave after wave after wave. Does everybody not know that, taking a line not from deaths but from cases, the increased number of cases year by year is breaking the back, if not breaking the heart, of every keen person in the public health service of this country? The unfortunate immediate cause at least of the spread is that we cannot get quickly enough away the infected person so that he may get suitable treatment and can be returned in an non-infectious condition and that, during the months and months of delay, of waiting for a bed, that person is infecting a considerable number of others, who in turn infect others, who in their turn infect others.

The average duration of delay in getting a tubercular case into hospital in the area where I was administering the public health service for the best part of 20 years, was nine months. Can any Deputy picture for himself what it meant when you had 30 cases waiting nine months for admission—the harm done to those waiting patients and their effect on others? If that is multiplied over every administrative area in Ireland, what could be expected, with that delay, between diagnosis and hospitalisation, but an increased and increasing spread. We hear a lot about prevention, but certainly the first and obvious step which must be taken is to get these cases in early, and not worry too much as to whether the type of building into which they are taken is exactly the ideal or merely a building which provides shelter, nursing facilities and treatment facilities.

One of the most spectacular achievements and one of the most encouraging achievements of any Minister in this country since the very inception of the State is the immense progress made by the present Minister in the direction of providing or of securing accommodation, no matter where or how secured, for tubercular cases, which have the sympathy of every one of us. I should not like to think that, in providing accommodation and hospital facilities for such, there is any Deputy or any person outside the House who would cavil at the price in pounds, shillings and pence. I want to assure Deputies that, in what I am saying with regard to what the Minister has done, I am not in any way, by direct reference or by implication, suggesting that very valuable work was not done in connection with tuberculosis before the present Minister for Health took over.

Mr. McGrath

It was not criminal neglect.

Dr. O'Higgins

I have not used those words.

Mr. McGrath

I know you have not.

Dr. O'Higgins

I am not a judge of the degrees of neglect, as to when it ceases to be a normal offence and begins to be criminal, but some offences are well-intentioned offences. We had a tuberculosis hospital Bill before us here some years ago and all sides of the House put that Bill through with acclamation. We got a guarantee that we would have the hospital within 12 months. The drain pipes on the foundations on the site where that hospital was to be, and never will be, are buried as effectively as Tutankhamen's grave, but there is no hospital. The daisies are growing there. There are probably a whole lot of explanations for that delay, but would it not be better business, rather than to have all these delays by architects and all the rest, to use any premises that are available at least pending building of the institution?

There were any amount of magnificent premises in the custody of the State since 1939. They were unoccupied, and I suggest to Deputy McGrath and other Deputies that there was a certain amount of negligence in not having tubercular cases in these buildings. It was better that they should be occupied rather than allowed to remain empty. They did not cease to be State property and it would have been better to have these cases in these buildings than around the homes of the people infecting others. It would have been better to have them anywhere, under treatment and away from others, while all these buildings, which are magnificent on paper, were being built.

We are in much the same situation now that whatever buildings may be necessary, it will take time to build them, and, during that period of building, that period of waiting, the way to face up to the task of remedying the appalling situation which exists is by using whatever premises may be made available. That has been the really spectacular achievement of the Minister in a few short months, and I merely intervened briefly in the debate to call the attention of the House to the fact that that has been done, and that, if more is done in that direction, it at least prevents spread and gives an opportunity for treatment. There should be no cavilling at the price in pounds, shillings and pence because, when money is on one side of the scales and human life on the other, there is no balance between the two which can be measured by human beings, and never will be.

Dr. Maguire

It is hardly necessary for me to say that the health edifice of the nation depends to a great extent on the manner in which the foundations are planned and laid. For that reason, I welcome in the 1947 Health Act the portion dealing with ante-natal, postnatal and child welfare services to be inaugurated. It is a section and a service that would be welcomed by every mother and every intending mother in the country. Child welfare services in other countries are already well developed but I am sorry to say that in this country, particularly in the rural areas, they are conspicuous by their absence.

Regarding school inspection, we all know that it has been the duty heretofore of the county medical officer of health. It is a most essential service and one which has proved invaluable for the length of time it has been in operation and the money that has been spent on it. Nevertheless, it has its shortcomings in so far as the county medical officer of health, however active and vigilant in his duties, could never hope to carry out those inspections oftener than every two or three years. For that reason, it became the duty of the dispensary medical officer, who, in his ordinary run of duty, came across cases of children suffering from the customary defects which one meets, such as tonsils, adenoids, eye defects, bad teeth, to have those defects dealt with.

In this connection, I would like to point out to the Minister—he probably is not aware of this—that when a dispensary medical officer came across one of these cases of a child needing attention, he first of all had to sit down and write a letter to the county medical officer of health asking him to send on a card for the child to be attended by the county surgeon, the eye specialist, or the dentist. I am sure the Minister will agree with me that that was a quite unnecessary formality to be gone through in connection with perhaps an urgent case and that it occasioned quite a lot of delay. I see no reason why the dispensary medical officer should not be in a position to have that child attended to straight away, directly, without going through the channels of the county medical officer of health. I hope that formality will be eliminated from the new scheme. The county medical officer of health was responsible in the past, and I suppose will be for some time. I would like to know from the Minister, when he is summing up, when he hopes to have this section of the Health Act implemented. We are all rather anxious to know what our position will be under the new scheme. Apart altogether from that, I hope, and I am sure the Minister will see to it, that it will be implemented at the earliest opportunity.

Regarding school inspection, I personally am glad that in future it will be the duty of the dispensary medical officer to carry out those inspections. I am not detracting from the ability of the county medical officer of health or from what he has achieved up to this in school inspection, but I believe the dispensary medical officer has a knowledge of the local people and their background and family history which has been denied to the county medical officer of health, and that knowledge will be very helpful to a dispensary doctor in the examination of those children.

While I am on the subject of dispensary doctors, where a dispensary medical officer is living in an urban area or in a large dispensary district, I assume he will be given the assistance of another man in the work, because from what I have seen since I became a dispensary medical officer, every year brings forth extra work from Government Departments and extra duties to be gratuitously carried out by dispensary medical officers. I know that in my district, which is a very large urban district, I expect the services of another doctor if my duties are to be increased to the extent promised in this Act. I visualise that the services of a nurse will be required and perhaps a maternity nurse or one trained in child welfare, if not both, and perhaps the Jubilee nurse, if there is one in the area, will assume the duties of one or other of these nurses. I should hate to think that the services of the Jubilee nurse would be dispensed with because I do not think there is anybody so appreciative of the help and devotion to duty of these nurses than I have reason to be. She has been absolutely invaluable and I understand that it is the opinion of everybody and every doctor who is fortunate enough to have a Jubilee nurse working in his area. Perhaps some arrangement might be come to whereby the Jubilee nurse might be absorbed into this particular health service. I would not imagine that there would be any difficulty about it.

If all these duties are to devolve on the already harassed and overworked dispensary medical officer, he must first of all be divorced from the slavery of filling up, weekly, fortnightly, monthly, quarterly, half-yearly, a multiplicity of useless forms, which have been the heritage from the past, since the dispensary services were introduced. They are quite useless forms. The most ridiculous questions are asked on them and I am sure, if the Minister will just have a look at some of them, he will agree entirely. There are other ridiculous demands made on dispensary medical officers in the performance of their duties. The dispensary medical officer, on the receipt of a consignment of drugs for his dispensary, is supposed to take powders, medicines and one thing and another, and parcel them up in various containers and send them to the public analyst for examination. He incurs a certain amount of expense, to say nothing of the waste of time, and he is not recompensed in any way, unless he keeps an account of his postage, which nobody ever does. About eight years ago I had an inspector down from the Local Government Department inspecting me. He asked me for these analyst's reports. Of course, I had not got them. I had not sent samples for examination except for a couple of years in the beginning, when I was innocent. I made a suggestion to him, and I would like the Minister to take note of it. It was, that a central analyst be appointed in the city who would periodically visist suppliers of medicines and surgical instruments. On any visit he would make he would find a consignment of drugs going off to Killybegs or Caherciveen or some place like that and there would be no trouble in taking a sample on the spot and having it analysed without further trouble. The inspector was so impressed by my suggestion that he wrote it down in detail. Since then I have heard absolutely nothing about it.

The Minister might consider making it unnecessary for a dispensary medical officer to be registrar of births, deaths and marriages. I fail to see why he should be apportioned those duties at all. It is supposed to be because there is a certain amount of secrecy attached to those documents, but there are other cases where dispensary doctors are not such registrars. It would be more dignified if a doctor had nothing to do in that line, as that work should be for somebody more accustomed to office work, and, anyhow, the amount of work involved is appalling. It is not compulsory on us to be registrars, but we have been asked to do it and we do not like refusing these things. Furthermore, in connection with our duties as registrars, when rationing was introduced and ration cards had to be distributed, they looked around for someone to do it and decided on the dispensary medical officer. In other countries, he is paid something for each ration card he gives out but, of course, we get nothing here.

When on the question of an assistant to the dispensary medical officer, I omitted to say that for another reason it would be advantageous— from the point of view of relief from work. Despite the fact that he is still termed with that misnomer "part-time" officer, he is 24 hours on duty. If he had an assistant, it could be arranged that he could get a day or a half day off in each week and an occasional Sunday. If that cannot be arranged or the doctor is working in an area too small to employ an assistant, it should be arranged with a neighbouring dispensary medical officer, as it is time that some consideration was shown for us in that respect.

I would also recommend the establishment of district hospitals in counties where there are none. In my county we have three fever hospitals. Years and years ago, a central fever hospital was contemplated for my county, plans were submitted and everything was prepared but nothing happened. A central fever hospital is absolutely necessary. I understood from two local government inspectors who came to inspect my fever hospital in Clones that this hospital was about to be transformed— this is ten years ago—into a district hospital. I was very glad to know of that and plans and suggestions were made on the spot, but nothing has happened yet.

District hospitals are most useful, if they are adequately staffed. They should be used mainly for maternity work and also in ordinary cases of pneumonia and accidents. Expectant mothers nowadays are very much inclined to seek attention in hospital for their confinement and it is an admirable thing to have a small local hospital to provide such facilities. When I mention adequate staffing, I hope it is unnecessary for me to refer to the under-staffing of hospitals, which has gone on far too long. I heard a Deputy the other day complaining of someone having to work for 43 or 44 hours in the week. My two nurses work 12 hours a day, if there are patients in the hospital, without a let up. I would like to add my tribute to our nurses—we have the finest nurses in the world. They are self sacrificing, not only here at home but abroad. I had an occasion to appreciate their work; and it was very gratifying for me, out in Germany, to receive tributes from administrators there concerning the ability, self sacrifice and generosity of Irish nurses who had offered their services in the postwar rehabilitation of Germany.

I notice that the Minister is rather perturbed about our county homes. There may be something lacking there from the aesthetic point of view, and perhaps they could be improved. Personally, I have quite a lot to do with them. I have visited patients there on many occasions and have visited county homes for other reasons. I believe that the change of name from "workhouse" to "county home" was rather an apt one, as it is really a homely place and everyone seemed quite happy. It is astonishing how well they are looked after. I do not suppose anyone sends so many people to the county home as I do, as I live in a town which is a sort of highway where the flotsam and jetsam come our way, possibly seeking the Border. I have never had any complaints about the conditions there. The day after the Minister's statement about the county homes appeared in the Press, I had one of my clients coming to the dispensary from the county home to tell me he was going to spend his summer at large. I asked him what he thought of it, and I wrote down what he said. He said: "It is a great thing to have a place like it for a person like me." I asked him what he got for his breakfast, and he said: "Plenty of porridge or milk and plenty of tea and bread and butter." He said that for his dinner he got soup, meat, potatoes and some cornflour. I asked him what he got for his tea, and he said: "I do a job of work, I help at the furnace, and they give me an egg with my tea: the others get tea and bread and butter." He said they also get porridge and milk for supper. "The beds and bedclothes could not be better," he said. "We get clean sheets and clean bedclothes every week."

The county homes are not so bad. I have patients who have been transferred from the county hospital to the county home to complete their convalescence and they tell me they prefer to be in the county home. I am sure the buildings could be made to look a bit cheerier but, frankly, I think there are more urgent matters needing attention. It is a pity that the county homes are regarded as a place for the reception of unmarried mothers. There should be a separate institution of some kind established for those unfortunate girls. I must say that, among the old people, we have a few mental defectives, but I think they rather add to the variety of the place. They are not too bad mentally. If they were they would be sent to the mental hospital, which is quite near.

I have a suggestion to make with regard to the building of new clinics. I happen to have one of them, and while I need hardly say it is a great improvement on the shanty in which I formerly had to work, there is still something lacking in it. First of all, it is not being looked after properly from the point of view of structural defects. I think it is rather a pity that the dispensary medical officer, who has to work in these clinics more than any other doctor, is not consulted as to where to build them and also on their design. For example, if I have to go there, sometimes in the middle of the night, in order to press the switch for my room, I have to walk across several chairs to reach it and occasionally I am not successful. I would suggest, therefore, that in future when new clinics are being built the dispensary medical officer should be consulted as to the site and also on the design. He would, I am sure, give some helpful hints.

We have heard a lot said here to-day about tuberculosis. I am sure it is quite unnecessary for me to impress on the Minister what my views are concerning it. They are that every preventive measure should be taken in connection with it. I did say when the Housing Bill was before us that, in my view, tuberculosis and good housing are incompatible. I would now add, good housing, combined with good food, plenty of nourishment and, particularly, plenty of good milk. I think that the manner in which milk is produced in the rural areas is pathetic. I would suggest that, in his fight against this scourge, the Minister would impress on the proper Department the importance of the central pasteurising of milk for urban centres. Until such time as he achieves that, I believe we will certainly never be able to eliminate milk as a possible source of tuberculous infection in children.

Apart from all preventive measures, I believe myself that the alarming incidence in tuberculosis is due, and has been due, to a lack of early diagnosis. I think that the early diagnosis of suspected cases is one of the great weapons which the Minister, and all of us, have at our disposal, if we are fit to make an early diagnosis. For that reason I heartily approve of the suggestion that was made by some Deputy — I forget who it was — for the mass radiography of the people. I have had occasion to use myself the service of the Swiss unit in mass radiography of displaced people in Germany. I am glad to know that there is the possibility of it being utilised in this country. I understand it is used to a certain extent in the city, and I hope the time is near at hand when its use will be available to the people in the country as well. Apart from preventive measures and early diagnosis, I do not think there is anything so important as the periodic examination of contacts. It is very difficult to keep in touch with contacts. I must say that a lot of them resent being contacted by me. I think that propaganda in connection with that subject would be of great use.

It is a pity, I think, that the sputum positive cases cannot be kept segregated and isolated, if possible, from the rest of the community. It is very hard to see at cinemas, dance halls, schools and even in churches sputum positive cases of tuberculosis mixing with the rest of the community and particularly with young children. It is to be deplored. I know it is very difficult to deal with a subject like that, and I hope the Minister will be successful in his efforts to try and segregate and isolate people who are carriers of the disease.

I approve entirely of the Minister's action in taking over all available buildings — no matter what they are and if necessary those which require reconstruction — in order to utilise them to isolate those unfortunate people, and apart from isolating them to carry on curative treatment. In connection with sanatoria generally, I would ask the Minister to see that foods of all kinds in sanatoria do not come under the rationing system. I think it is the least we might do for those people. There are certain items of rationed commodities which are essential for these cases so that there should be no stinting of food whatever.

Now regarding diphtheria, I have great pleasure in paying tribute to effective immunisation in connection with this scourge. My town, particularly, was a victim of a virulent type of diphtheria from which we had a number of casualties in the early stages. I am very glad that, as a result of immunisation, I have not had a case of diphtheria for two years. The immunisation still goes on. I want to assure the Minister that there is no let up in immunisation. Our scheme is still going ahead, and we are not giving this scourge any chance to recover. I think we can confidenly hope to wipe it out in a number of years.

I should also like to urge on the Minister, if he can possibly see his way to do it, to combine diphtheria immunisation with whooping cough immunisation. Whooping cough has become almost as great a scourge within the last two years as diphtheria had been previously. I think there would be no difficulty because it also is a one-shot method and it can be combined in the injection. With regard to infection generally, apart from tuberculosis and diphtheria, I would advocate that school teachers be instructed that where a child shows the slightest sign of having even a cold or that measles or whooping cough are developing he should send that child home at once. I know that the opposite actually obtains, that children are not encouraged to go home but are encouraged to remain in school even when they are suffering from those conditions.

I think that propaganda has been quite successful recently in connection with infantile paralysis and there is no reason why it should not be continued. I think lectures on personal hygiene should be coupled with propaganda on the danger of infection. I think they are most necessary, not alone for children, but for adults. During the period of the emergency when I was lecturing on first aid, I found that lectures on personal hygiene were very much appreciated and I think that they would repay the time and money spent on them.

Mr. Dockrell

I am very glad to see that this Minister has promised to do something for the nurses. Many of us here have felt that the position of nurses in this country was one in which we could certainly take no pride. These women worked very hard under difficult conditions and had nothing to look forward to in their old age. I am delighted that the Minister is going into the question of their whole status and I take it that he is also going into the question of pensions for them. In that connection I would like to mention that I assume that he is going to include nurses in private practice. Various Deputies have spoken of nurses in voluntary hospitals and nurses from time to time move out from hospitals into private practice, and it would be very unfortunate if these nurses in private practice did not benefit in any general pensions scheme.

I would like just to touch on the question of milk in Dublin. I would say at the outset that I get really incoherent when I start to talk about the milk in this city. In the capital city of one of the richest agricultural countries in the world we have a very poor milk supply. I, personally, have no knowledge of the milk that what I would call the poor people buy, but I would say to the Minister that every suburban housewife in Dublin spends her time ringing the changes on the various milkmen and finally goes back to the one she started with because one is no better than the other. I have had personal experience of milk which arrived in the house at 10 o'clock in the morning and was sour at 4 o'clock in the afternoon, and that was so-called pastuerised milk. It never was creamy and always had a distinctly stale smell. By the afternoon it was too sour to use and it was a question of waiting for the evening round of the milkman before anyone could have their tea. What must happen in the houses of the poor where there are no adequate larder facilities I do not know. Those are cases known to myself and I know that on the occasions I am referring to the weather was not particularly hot. The temperature was not over 55 degrees nor was it particularly sultry. It is impossible in Dublin for anyone to get the milk which can be got quite readily in the country. I know people who manage to get a certain amount of milk from a local supplier who has his own cows.

That milk is creamy. I know nothing about its bacteriological content, but certainly it tastes creamy and it is fresh. The next day perhaps they will get the milk which comes from the districts which supply Dublin and that milk will, to all intents and purposes, have no cream on it. I do not know what the reason is. I am only telling the Minister that that is how I personally have found it. I shudder to think what the position of the poor of Dublin is. If no money can buy better milk than that, what is the position of the unfortunate people who deal in half pints at a time from small shops where the standard of cleanliness is not as good as we would like it to be?

Another matter in connection with the milk supply is that regularly every winter milk becomes scarce and people who are accustomed to get large quantities of milk — over a pint a day for each member of the household, which is considered very large in this country —find that they have to cut themselves down. I would like to mention to the Minister for Health that a position like that in the capital of as fine an agricultural country as this reflects no credit on the public health of the country. I put that to the Minister in the hope that at some time he will be able to deal with that matter. It is a highly complicated thing: tribunals have sat to consider the milk question and no very satisfactory conclusion has ever been arrived at, but I hope that this Minister will be able to do something in connection with it.

Previous speakers have mentioned child welfare and I am particularly interested in child welfare in Dublin. Not many people realise the work that has been done here in Lord Edward Street by the Dublin Corporation. There is a very fine child welfare centre there where all sorts of activities are carried on in clinics of various sorts. Really splendid work is being done there under Dr. Reddin and a very efficient and devoted band of colleagues, both doctors and nurses. But that, for instance, is not one-half big enough or even one-third big enough. Not only is it not big enough, but it could be duplicated in various parts of the city. You could have three or four centres like that scattered over the city. However, child welfare work is comparatively new. It has only come into existence in the last 20 years, but I think there is a great future for it. Good public health is a matter for which we must make provision. Unfortunate people get tuberculosis or other bad illnesses and have to go to hospitals or sanatoria, but in early life we should see that we do everything possible to keep them healthy. In that respect I think child welfare has an enormous future by way of preventive medicine.

Some people looking at this problem of public health in Dublin say that it is very largely a question of food and housing. I have been told that many of the women who come to clinics with their infants are suffering from such bad malnutrition that the staffs there have on occasion to discourage them from feeding their infants themselves and have to put the infants on milk in spite of the risk of enteritis. Owing to the lack of food, if there are any other children in the house the mother gives the food to the children and herself goes hungry. Then, of course, she is not in a position to feed her baby herself. That is a big problem facing Dublin in connection with public health. We have these poor people who are underfed and badly housed, and if we could feed and house them properly a great deal of the public health problem would disappear.

Many Deputies spoke about tuberculosis. I should just like to say in that connection that I think the Dublin Corporation have done more than any other public body to deal with that problem. They fought for improved conditions for persons suffering from tuberculosis, sometimes with the cooperation of the Minister and sometimes without. They have always fought for that and, in the long run, they have won out. I think it is only fitting that that tribute should be paid to the corporation and its officials who have done very good work in connection with tuberculosis.

I was glad to hear Deputy Dr. Maguire mention the question of infectious diseases and attendance at school. Some parents, when they find a child has a cold, say: "I had better keep it away from school. It may be getting measles, whooping-cough or some other childish ailment which at the start looks like a cold." Ordinary people find great difficulty in distinguishing these ailments from a cold. When they keep a child at home they get blamed by the school-teachers for being unduly fussy. I think we have a long way to go in order to make people realise that a child with a cold is a danger to other children. It may be getting something more serious but, even if it is not, a cold may infect the more delicate child and cause that child a lot of harm. Therefore, I think there is a good deal of propaganda work to be done amongst parents and other people as to the danger of spreading infectious diseases and the necessity for care in the earlier stages.

I should like to say how much I welcomed the new approach to public health which the present Minister has shown. He is a very enthusiastic person and he is all out to combat tuberculosis and various other diseases. I wish him well in that work. We have to build up the health of our citizens and, above all, of our children so that we shall have a country the health of which we can be very proud of. I think the Minister is going to make a big contribution to that.

Mrs. Crowley

I think the section of the Health Act dealing with mother and child welfare is the most important section of the whole Act and I hope that the Minister will put it into force as soon as possible. It seems to me that it is an easy thing to do because no extra buildings are required. Surely suitable rooms can be found in towns or villages where these welfare centres can be set up. I ask the Minister to see that these rooms will be made cheerful with nice bright paint and everything which will attract mothers so that they will feel that these welfare centres are attractive places to go to and to bring their babies because to my mind there is very little follow-up service for the mothers. The mothers have nobody to ask about the ailments of a child unless it is very ill and has to be taken to a doctor. If they went regularly every week or every fortnight to one of these welfare centres where the baby could be weighed and instruction given by the doctor as to what to do with it when ill, a lot of childish ailments could be cured. At present the mother perhaps goes to another woman for advice and, with the best intentions, the other woman gives her advice from her experience of her own children which may be quite wrong in that particular case. These welfare centres could be made places to disseminate instruction on health matters. What better place can anyone have for giving information on health matters than such a centre where mothers, who are the guardians of the citizens of the future, can attend and be able to bring up their children properly with the knowledge gained on different matters of health?

I think instruction could be given in these welfare centres also on ordinary home nursing. There are very few women in the country who know even how to take a temperature or to read a clinical thermometer. Any information of that kind that would help the women of the country to look after their children and after other people would be very useful. The question of providing X-ray plants in hospitals has been raised. As far as I know there is only one X-ray plant in the whole of Kerry. That means that people from South Kerry have to travel long distances over the mountains to Tralee in order to get an X-ray. If the Minister could provide one in each of the district hospitals it would save many country people long journeys. I notice that he is advocating mobile X-ray units. I hope this is not only for tuberculosis. If the Minister could make it of general application I think he would get better results because people would go to be X-rayed for all sorts of other ailments and they would not then be afraid to go for tuberculosis as well.

With regard to the nursing staffs I should imagine that if the Health Act is put into effect very many nurses will be needed to operate it. I think the Minister will get all the nurses he requires if he gives them good rates of wages and good conditions of employment. Irish girls have an aptitude for nursing. This is true in any country in which they go. Patients in the hospitals invariably like the Irish nurses because they say that they are cheerful and always in good humour. Most people will agree that the nursing profession is the most hard-working of all professions and that nothing is too good to make this very difficult job as pleasant as possible. I would ask the Minister to see that the rates of remuneration and the living conditions of nurses are the best that can be provided.

In his statement the Minister said that he was going to cut down some of the building of hospitals. He did not mention any specific case but I hope that the Caherciveen hospital will not be one of them because all the people in the district are very keen to have it. It has been sanctioned and I hope the Minister will not put it under the axe.

Mr. Coburn

First of all I should like to congratulate the Minister on the very able statement he made covering the whole field of public health so far as it affects this country. I am conscious of that statement and I am also conscious of what he proposes to do. I should like to point out to the members of the House and to the Minister in particular that he will not accomplish all these things by unilateral action alone. It will require action on the part of the people. Acts of Parliament — no matter how good they may be — will not make the people healthy unless they themselves do something to make themselves healthy. Whilst I readily give the Minister credit for all he proposes to do I feel, nevertheless, that the people themselves will have to co-operate to the full with him in any measures he may take to eradicate the diseases from which the people of this country suffer at the present time. I am one of those old-fashioned people, possibly, who think that some of the diseases cannot be eradicated. I have heard a lot of talk in this House and elsewhere about how to cure certain diseases and about what should or should not be done. When I hear all that grand kind of talk my mind goes back to my early days and I wonder how we were reared at all.

The mothers who brought us up recognised the value of food. They gave us the food that suited us in those years and it built up a strong constitution which has stood us in good stead in after life. The people must realise that money alone is not going to make them healthy. Judging by the figures the Minister has given in regard to deaths from tuberculosis and cancer it will be seen that notwithstanding all that has been done during the last number of years the deaths from these diseases have been on the increase. Infant mortality has increased very considerably. According to the figures given by the Minister we compare very unfavourably in this country with the rates in Great Britain and Northern Ireland.

I understand from that part of the Minister's statement which deals with the erection of general, medical, surgical, fever and mental hospitals, tuberculosis sanatoria and so forth, that he is not inclined at the moment to proceed with his full programme. He intends to spend something in the region of £15,000,000 over the next seven years.

In speaking of the general, medical and surgical hospitals the Minister referred incidentally to the deficits that are accruing year by year in the participating hospitals of the Hospitals Trust. Very few Deputies have referred to this aspect of the situation in so far as the future hospitalisation of this country is concerned. I think the ex-Minister referred to it some years ago. He said at that particular period that some change would have to be brought about if his Department was to be enabled to proceed with the erection of the remaining hospitals that had to be erected throughout the various counties. I refer to the deficit which is progressively growing year by year which is incurred by the participating hospitals. I believe that it ran to £260,000 in the year 1946 as against £154,000 in the year 1939, and that this year, 1947, it will be in the region of £340,000.

If the increase progresses at the same rate, I expect that in 1948 it will be near the half-million mark. I want to impress upon the Minister and upon the Deputies of this House — to quote the Minister's statement here yesterday — that it will require the full £10,000,000 he has in hands to be invested to yield sufficient to meet the growing deficits of the participating hospitals. That, in effect, means that he will not have a penny for the building of the new hospitals about which we speak so much. Rightly or wrongly, I was under the impression that when these hospitals were built the local authorities in the particular areas would be responsible for their upkeep. I find now that year after year these local authorities are making demands upon that fund, with the result that it takes the total fund derived from the various sweeps to meet the annual deficit. If this continues, the Minister will not have a penny piece with which to erect new hospitals in the future. I know that there are participating hospitals who simply say, "Easy come, easy go", and they make these demands knowing that they will not be refused. In order to safeguard the interests of the people in the future, the time has come when the Minister must take steps to ensure that there will be sufficient funds for the erection of new hospitals and that the erection of these hospitals will not throw an undue burden upon the ratepayers in the respective counties.

I would like to remind the Minister that County Louth was one of the first counties to participate in the first sweep. When the Act was introduced the sweep was absolutely confined to certain voluntary hospitals of which Louth was one. After a certain time all the county hospitals and district hospitals were brought in. Prior to that, these had been maintained by the ratepayers. After 16 years we are now reaching the stage when we shall be told that there is no money for the erection of our hospital in Louth. The Minister should see that these trust funds are not absorbed in these annual deficits. By this time we expected in County Louth that our hospital would be well under way. I hope the Minister will read our history in that respect and I hope that, knowing our history and our background, he will place us very high in the priority list of new hospitals. We are a patient people in County Louth. We did not badger the late Minister as much as perhaps representatives of other counties did. I do not want the present Minister to think that we shall continue that policy. I understand that something in the region of £60,000 to £65,000 was invested for us. During the war years nobody would have advocated the building of a new hospital. The war is now over and we are looking forward to work commencing on our hospital in County Louth.

It will take time and patience to do all that the Minister intends to do. There is no hurry. The Minister's programme will take time and money. If the Minister were to carry out all the suggestions made to him here we would need treble our staff of doctors and nurses. In fact, there would be very few people left to do any work on the land at all, because we would all be busy attending the sick. This programme cannot be implemented in a fortnight. We shall have to bide our time. The Minister has told us that it would take £15,000,000, spread over the next seven years, to carry out part of the programme he envisages. In the ultimate he thinks his programme will cost something in the region of £27,000,000. It should not be forgotten, however, that in the main we are dependent for our revenue upon outside sources. Perhaps that is not something about which we ought to boast. Most of the money contributed towards the sweepstakes comes from outside sources.

I would like to pay a tribute to the people who have been running our county homes during the last 15 or 16 years. In doing that, I want to dissociate myself from the attack that has been made upon the Minister because of a statement he is alleged to have made about the county homes. I read that statement. I could see nothing wrong in it. The Minister did make certain comments but I think he took care to make those comments of general application. He made certain reservations and qualifications. I do not think for a moment that he intended to cast any reflection upon the way in which the county homes are run in so far as the officials are concerned. The Minister can do much and his Department can do a good deal to make our people healthy. The people, in turn, must play their part.

Mr. Davin

Like his colleague, the Minister for Local Government, I think the Minister for Health is very wise in visiting the hospitals throughout the country before making up his mind definitely on an official programme of construction or reconstruction in relation to our hospital system. Although he is a prominent medical man and must know a good deal about the health requirements of the people generally, he will be the first to admit that his tour up to date has helped to improve his education and will be very useful to him in the times that lie ahead. I have been present at some of these conferences along with the county medical officers and dispensary doctors and county council officials and I think the value of these visits by the Minister is immeasurable. The Minister gets the views of the various officials with whom he comes in contact and they likewise know what his particular views are. In that way a good deal of time and correspondence ought to be saved in the future on the part of both the Minister, county council officials and medical officers.

The Minister in his opening statement informed the House that his programme is one which will extend over a period of years. He said that it can be regarded as a fairly ambitious programme. In this respect I am sure that the Minister will receive the full support of Deputies on both sides of the House in carrying through that ambitious and vitally essential programme. I was amazed to hear Deputy Burke lay such emphasis on the financial side of this scheme. Surely, he does not intend to measure the needs of the people in so far as health is concerned in terms of money. We all know that there is a good deal of money floating about. I am sure that money will not prevent the Minister carrying out his programme for the improvement of our hospitals and our health services generally. The Minister has visited the two counties in my constituency and, as a result of his visit, I am sure he is aware of the reasonable requirements of the area so far as improved hospital accommodation is concerned.

It is nearly 14 years since I, in company with my colleagues for the constituency, had a lengthy conference with Dr. Ward, who was then Parliamentary Secretary to the Minister for Local Government. At that conference there was a very definite understanding between Dr. Ward, the medical officers from County Offaly and the parish priests of three electoral areas, Tullamore, Edenderry and Birr, as to hospital requirements. There was an agreed scheme whereby a county hospital, with an agreed number of beds, would be built, and in Edenderry and Birr, if they were not to be provided with new hospitals, the existing district hospitals would be modernised.

The Minister has had the advantage —and it is an advantage—of visiting these hospitals on a recent occasion, and I do not know whether it is too soon to ask him what he intends to do to meet the reasonable needs of Edenderry and Birr in regard to modern district hospital accommodation. I would not put my view against the view of the Minister in matters of that kind, but I think he will have to admit that some improvement is necessary. It would be the duty of the Minister to implement the agreement made nearly 14 years ago by Dr. Ward.

Before the recent visit of the Minister to Birr there was a good deal of whitewash used, I suppose to impress him with the healthy-looking condition of the institution. They did not use the same amount of whitewash in the Edenderry District Hospital. I think he will admit that these hospitals could not be classified as modern district hospitals. In Birr there is a large population and there is room there for a regional hospital rather than continue to rely on the limited facilities available in the hospital at Tullamore. Deputies in that area are fed up with the repeated requests made to them for 14 years to try to force the hand of the Minister concerned to implement an agreement arrived at in an honourable way. I hope the present Minister will make adequate provision — I feel sure he will — for the modernisation of these district hospitals in accordance with the programme he announced here yesterday.

I have no complaint against the Minister regarding his criticism of the condition of our county homes. I will admit that during the last eight or ten years, so far as I am aware of what goes on in my own area, there has been a slight improvement in the internal condition of the county homes as a result of certain reconstruction work, but is there any Deputy or Christian-minded citizen who will defend the existing institutions called county homes? These county homes and our whole hospital system have been handed over to us by the British authorities. They are a relic of the old poor law system which has been wiped out by the British Government from Monday last. A new scheme of social security has been brought into operation in Great Britain and this will wipe out of existence the poor law system which was in operation there for a long period of years. It is time that we made some attempt to copy the good example they have set us through the legislation which came into operation there last Monday. There are many people who say we should not copy anything British, but I think we can afford to take the good things and operate them to the advantage of our people.

Among the things very badly needed in the district hospitals in my area are modern maternity wards. I hope when the Minister takes a decision in regard to the modernisation of district hospitals he will insist on reasonable provision for up-to-date maternity wards. I wonder would he take the risk of saying what kind of maternity ward he found in Edenderry? I raised this matter some time ago and the answer given by the Minister's predecessor was that there was a maternity ward in existence in Edenderry District Hospital, but I knew there was not. I wonder has there been any change since his predecessor gave me that very doubtful answer?

One of the things that lends itself to the increase in tuberculosis in rural areas is the very bad type of hall used by our youth and given the title of dance hall. I am not a killjoy and I would not prevent people having innocent amusements, but I would be prepared to get the biggest bulldozer at the disposal of the national Army and destroy some of the buildings that are used as dance halls. They are definitely a menace to the health of our young people, especially in the winter months. I made inquiries from the local medical officer as to why the percentage of tuberculosis in a particular area was so high, and his opinion, confirmed by the county medical officer of health, was that the menace these dance halls were to the youth of the area, especially during the winter months, was incalculable. I am not sure whether that is right or wrong, but that is what was given me as the reason for the increase in tuberculosis in that area.

Some Deputies spoke about the need for an improved ambulance service. There is a special need in the Counties of Laoighis and Offaly for an improved service. There is only one ambulance in the central hospital in Offaly and that is not sufficient to meet the requirements of so big a county. There is a great wastage of petrol running the one ambulance and that means unnecessary expense. It is a disgrace that there is no ambulance at the disposal of a large town like Birr. The people there often have to wait long periods before the ambulance comes from Tullamore to take away a patient, who is possibly in danger of death. I know of the wife of a worker in the town of Edenderry, and her case is an interesting one. I raised the question of the cost some time last year.

This was a maternity case and the ambulance was summoned from Tullamore. It travelled empty from Tullamore to Edenderry. The patient was taken to the hospital in Edenderry and later to a Dublin hospital. This woman's hubsand received a bill for £7 1s. from the county manager to cover the cost of the ambulance. After a lot of correspondence the claim was wiped out because the person concerned could not pay. It is a queer kind of ambulance service that would waste so much petrol, probably at the expense of the ratepayers of the county. The Minister should consider reorganising the ambulance service not alone in my constituency but in several other constituencies throughout the Midlands.

I heard Deputy P.J. Burke appealing to the Minister to come to an early decision regarding the payment of increased rates of wages to mental hospital attendants. He suggested — and I was surprised at the suggestion because I doubt if there was any great ground for it — that these applications have been held for a long period without any justification by the Minister for Health. I should like the Minister, when he is replying, to state the dates when these applications came to his Department because very possibly when the dates are disclosed in this case, it will be found, as it was found in other instances, that it is not the present Minister who is to blame for holding up the applications but possibly his predecessor.

Mr. Beegan

I thoroughly agree with the statement of Deputy Coburn that Acts of Parliament in themselves are not of much use without the co-operation of the people for whose benefit they were intended. The same remark applies to buildings. Buildings are useful and very necessary in some cases. Up-to-date hospitals, the most up to date that can be provided, are all useful in their own way, but if the people are not prepared to co-operate and to take advice as to how they are to avoid colds, which in many cases bring on tuberculosis, I am afraid that a lot of money is being spent in vain. The last speaker, Deputy Davin, mentioned dance halls and attributed much of the ill-health in the country to their condition. I do not care how fine these buildings are, when people come out of these dance halls at night, we know very well they are very often in a state of perspiration. If they do not take the necessary precautions to clothe themselves properly and see after themselves, no matter how big or well equipped a dance hall may be, these young people will continue to be easy victims of various forms of ill-health.

The same is true of every other form of amusement. In the country we have young people taking part in games, whether G.A.A. games or any other games, who are sometimes very foolish. They spend, perhaps, two or three hours at very hard practice and instead of putting on extra clothing afterwards, you will find them lying on the grass for another hour. The result is that they catch cold. They take no heed of it at first but after a very considerable time, when a cough appears in a very pronounced way, they will go to the local doctor and they will expect either him or the county medical officer of health to cure them.

I think a lot could be done to counteract the foolishness of young people in this way if advice were given to them by people from whom such advice would be taken. I regret that, as far as the present generation is concerned, many of them are not inclined to take advice from parents in a matter of this kind. I believe they would take advice far more quickly and more readily from their teachers in the primary schools or secondary schools. They would also take it from the clergy.

I must admit that the pamphlets which have been circulated have done a great deal to educate people as to the precautions which they should take to avoid disease. I do not intend to speak at length on this subject because people with more expert knowledge and who are capable of speaking with more authority have already spoken, and I presume others will speak before the debate closes. The question of food, which has been mentioned by a number of Deputies, is also very important. There are not so many houses in town or country at the present time where milk and porridge are used to the same extent as they were 40 years ago. If we had stronger, heftier people in previous generations, I believe it was due to the good, wholesome, plain food that they used.

There is one small section of the community of whom nobody has made any mention so far in this debate and whose case I should like to bring before the Minister's notice. I refer to people who, through accident or otherwise, have had limbs amputated. Those of them who are entitled to claim assistance from the public assistance authority often have the cost of a limb partly or wholly defrayed, but it is the type of limb provided to which I object. Of course, wealthy people can make provision for themselves and can get the very best type of artificial limb available, but so far as individuals who have to fall back on the public assistance authority are concerned, they have to be content with the old crude artificial type of limb. These limbs are not very serviceable or very durable, and certainly I believe that we should have advanced very much beyond that now in view of the fact that there are plastic limbs, some in this country and many in other countries. Even though they may be more costly, I think it would be well if local authorities were instructed by the Minister for Health to see that, as far as possible, plastic artificial limbs should be provided for people who make application for them.

There is one other matter to which I wish to refer. It is a local matter, if you like, and it is a delicate matter in a sense, but we had better face up to it. A number of years ago a district hospital was sanctioned for Ballinasloe. At that time a 25-bed hospital was visualised. The land was purchased and paid for in 1937 but the building of the hospital, like that of numerous other hospitals, was deferred from time to time, with the result that no district hospital has been built there. An order of nuns came in and built a splendid hospital quite convenient to where the local authority obtained the site. They built it during the years of the emergency and they carried out very useful work. Of course the charge was somewhat higher than the maintenance charge in the central hospital and consequently, until recent times, public assistance patients could not avail of it. I understand that the Minister's predecessor, Dr. Ryan, agreed that the district hospital project should be cut out and that the land purchased for the site should be handed over to the nuns on payment of a sum equivalent to the purchase price and whatever costs were incurred in the transfer.

The present Minister has ratified that arrangement and we were asked recently to hand over the land. I raised a question with regard to the supervision and control of the hospital and was told that, while we were to endow it to the tune of £3 per week in respect of public assistance patients, the local authority was to have no control whatever and, furthermore, that it was to be staffed entirely by nuns, as is the present Portiuncula Home in Ballinasloe. I have no objection whatever to the nuns supervising the hospital. I believe they should be in every hospital in a supervisory capacity, but when the ratepayers of County Galway have to pay £3 a week for the maintenance of the public assistance patients in the 100-bed extension which is being put on to Portiuncula, they should have some say in the management. There is nothing wrong with that and it would be altogether wrong if they had not.

What I suggest, and what I believe was suggested on a previous occasion by the former Parliamentary Secretary, Dr. Ward, is that a committee of management should be appointed, or, if not a committee of management, a committee which would act as an advisory body, under the chairmanship of the Bishop of Clonfert, or his nominee for the time being, and consisting of five nominees by the nuns and five by the local authority. There would be nothing very wrong in that. I also object to a hospital of that kind being staffed entirely by nuns. When in the central hospital in Galway provision has been made for the training of a number of probationer nurses—and they have very fine facilities there, in view of the fact that the university is close by—a certain number of these probationer nurses should find employment in a hospital of this kind.

We hear outcries during election campaigns about all the nurses who have to leave the country. Here is a chance of providing for a small number of them and saving them from having to emigrate. When the ratepayers of Galway and the probationers, or their people, are paying for their training as nurses, it would be too bad to have them excluded altogether. I hope the Minister will take that into consideration.

I do not want to be misrepresented in any way, but, if I am, I will stand up to it. I am not one bit afraid of the unpopularity it may bring me, but I want to say that the establishment of the hospital there by the nuns has been a great boon and an immeasurable benefit to East Galway. It has relieved the central hospital very considerably, but it is quite another matter when it is to be extended and non-paying patients taken in, whose maintenace will be provided by the local ratepayers. In those circumstances, it is only fair that the local authority should have some say as an advisory body or as committee of management and also that a certain proportion of lay-nurses should be employed there.

Mr. Cogan

I congratulate the Minister on his introductory statement. I might say that the Irish Press was less than fair to the Minister when, in scare headings, it announced a reduction in the amount of money to be provided for hospitals and an increase in the amount to be provided for publicity. The Minister made his position perfectly clear —that he was estimating for a programme which was practicable at present in relation to hospitalisation— and, if we can, in the reasonable period specified, have £15,000,000 expended on the provision of new hospitals, we shall be doing very well.

The Minister has come in for a certain amount of criticism in certain quarters on the ground that he has committed the unpardonable crime of being a young man. I do not think the Minister can be blamed for that. Neither can he be blamed for the fact that he receives a certain amount of public sympathy in the task he has undertaken. When a young man is given a big task, and a very important task, to perform, it is only natural that the public should feel a certain amount of good will and support for him, and the Minister will be doing a great national service, particularly for those of our community who are afflicted with serious disease, if he harnesses all that good will in the fight to overcome tuberculosis and the other serious diseases which afflict our people. The fight against disease is a grim one. It is in many cases a disheartening one, because there are so many difficulties to be overcome—unforeseen difficulties and difficulties which can be foreseen, but which are very difficult to tackle— and the Minister will require all the good will and support he can get in his task, in addition to all the energy and activity he can put into it.

The Minister's predecessor set a good example in this debate by approaching the questions which are concerned in this Vote in a non-Party way and by putting forward a number of constructive suggestions. I believe that one of the first tasks the Minister has to tackle is the provision of the hospital accommodation which is so urgently needed.

I happen to be associated with two counties, as a Deputy for Wicklow and as a member of the Carlow County Council. In both counties, there is very urgent need for a speedy advance in the provision of hospital accommodation. I do not know that there is any county so badly provided as those two counties. I know that at present great efforts are being made to solve the problem but it will require the active consideration of the Minister and the co-operation of the local authorities in both counties to bring the matter to a satisfactory conclusion.

It has been more or less laid down that the type of hospitals required are local or district hospitals, some kind of central hospital and larger regional hospitals. As I have mentioned in previous years on this Estimate, the organisation of hospitalisation is a matter which requires attention. In many cases I cannot see how you will get the best type of hospitalisation unless the county boundaries are ignored. It is essential that there should be a district hospital in all fair-sized towns. Many towns are situated on the borders of their respective counties and it does not seem to be logical, reasonable or sensible to confine admission to those hospitals to patients from a particular county.

A district hospital should cater for the area it is able to cover irrespective of county boundaries. In the same way, it would be found in some cases that the larger county hospital could cater most effectively for portion, perhaps, of two counties. It is not feasible always to have regard to the geographical set-up of the county, or to provide the hospital in the exact centre of any county. In most cases the hospital is provided in one of the larger towns. In Carlow, for instance, the largest town is on the corner of the county and a hospital in that town should, in the ordinary course of events, cater for portions of Leix and Offaly as well as for a large part of Carlow. If a person is seriously ill within a few miles of the hospital, county frontiers should not be taken into account. In all cases of illness, it is better that the patient should be treated in the institution that is nearest to his home.

I have often felt that in the prevention of tuberculosis a greater amount of attention than has been given heretofore should be given to the question of contact. We see members of families stricken down and perhaps dying of the disease and very little being done for the remaining members of the family. In many cases there is no test carried out to discover if they are affected. I am not an expert in this matter but I thought that tuberculosis germs remain in the houses of persons affected. I have known a couple of cases where people went into a house that had been previously occupied by persons suffering from tuberculosis and almost immediately contracted the disease.

Doctors, who must know more about this matter than I do, tell me, however, that it is a very rare occurrence that the disease is transmitted in that way and that it is usually transmitted by direct contact. I would like to know whether there is anything in the idea that I have that houses retain germs for a considerable time. If there is, there certainly should be more effective steps taken to disinfect them.

I am told that one of the reasons that there is so much of this disease in this country and that it so often proves fatal is that so many of our people are completely free from the disease and when they become infected its effects are more serious than they might be in the case of persons who had been in contact with the disease and had developed a certain amount of resistance. We know from Press reports that our young people, particularly those from the rural areas, frequently contract the disease when they go across to large cities in Britain and contract it in a more deadly form than those who are born and reared in these cities. For that reason, it is absolutely essential that, after providing the necessary accommodation for tubercular patients, very far-reaching measures should be adopted for the carrying out of radiological tests on people who have any contact whatever with the disease. It would be better still if the majority of our young people could be tested after the school-leaving age, which is the most dangerous period of life. I think that would do a great deal to limit the scope of the disease. It may involve considerable expense but it would save greater expense in providing institutional treatment when people had become more seriously affected.

I am in complete agreement with those who have pointed out how strenuous and how difficult is the task of the dispensary doctor. Everything we do by legislation and by extending our health services tends to add to the burden of these officers. There should be some reorganisation of our dispensary districts so as to give a certain amount of relief to dispensary doctors. It is certainly a hardship that no doctor can feel completely free from duty. He may be called at any hour of the day or night. It would be a very great concession if some arrangement could be made whereby two or three doctors could group together and two dispensary districts could be grouped together so as to allow each doctor to have a little time off, even, say, one or two evenings in the week.

I do not know if it is possible to give improved conditions to our nursing staffs in hospitals and also to district nurses. They give an immense service to the community, working strenuously for long hours. It may be a delicate subject to mention, but I have often wondered if arrangements could not be made by which nurses would continue to serve in their profession after marriage. It is a hardship on a very efficient nurse to have to choose between her profession and marriage. Just as in the teaching profession, a nurse tends to become more and more efficient as she gains in experience and becomes fitted for a more responsible position in her profession. Therefore, a nurse who is very efficient and who takes a deep interest in her profession and is anxious to advance in it, should not be compelled to resign on marriage. I know the difficulties in that matter, but it is a subject which requires attention.

The future of our county homes should also be decided. The grouping of various classes of inmates into these institutions is not desirable. For the aged and infirm there should be some new type of home. Suggestions have been made that what is needed is not a county home for those people but a kind of housing colony where a number could live in close proximity and receive some sort of attention. Some people suggest a new type of home for the aged, neither too small nor too extensive, and not too far removed from the place where those old people always lived. Between these two suggestions will be found the ideal type of place. I do not think the county institution is the best. In a small colony these people would not be too far from their friends and relatives and at the same time they would receive the benefit of institutional treatment.

Perhaps one of the most important matters from the point of view of the ordinary citizen, is hospital treatment. To people of limited means, serious illness of the head of the household or of a member of the family, requiring institutional treatment, is a sort of nightmare in regard to expense. I was speaking some time ago to a young married man who had paid £100 for the treatment of an infant who lived only a short time after the treatment. That was a rather severe burden for an ordinary person of humble means. Some way must be found to ensure that treatment will be provided at a reasonable rate for all sections of the community. We have very few people so wealthy that they can afford to ignore completely all questions of cost in regard to medical or institutional treatment. It should be found possible to provide on some reasonable basis for cheap institutional treatment for people of moderate means and absolutely free institutional treatment for people of lesser income. For instance, small farmers have very little spare money. They manage to live and bring up their families decently, but they never accumulate much money to provide for a rainy day or for serious illness. Some contributory insurance method might be found to cater for them.

So much has been said about tuberculosis that it may not be undesirable to make a brief reference to another deadly disease—cancer. We should be able to diagnose and treat that disease more effectively than we have been doing up to the present. I can mention a case which might surprise some members of the medical profession here. I knew a man, fairly advanced in years, who went to one of the bigger surgical hospitals here in the city for treatment of external cancer of the throat or jaw. Having examined him, the surgeon told him he was unable to operate, owing to the situation of the cancer. He told him confidentially that if he knew of any good non-medical practitioner in his district he should go to him, but on no account to tell anyone that he had been advised to go by a surgeon. The man went to a local "quack" and was completely cured and lived for nearly 20 years afterwards. It may be that some progress has been made during the last 20 years. This particular incident that I have mentioned happened 20 years ago, and the result was as I have stated. It is an extraordinary thing that a leading surgeon should find himself unable to compete, in a matter of that kind, with an ordinary country man who had no medical or surgical experience and who was relying on a traditional remedy which may have been in existence for 50 or 60 years.

Very frequently cases of disease in this country are due to bad water, bad milk and second-hand clothing. The latter is very often a carrier of disease. In my opinion, it is a horrible thing that to-day second-hand clothing can be hawked around in packs to fairs and markets and sold to decent working people without, as far as I know, any precautions being taken to provide for its disinfection or even for the disinfestation of the garments. With regard to bad water, I was passing a public pump last week and was attracted by a notice erected beside it to the effect that all water taken from the pump should be boiled before being used. What amazed me and, perhaps alarmed me to a certain extent, was that, while that notice was publicly there, and while I was reading it, a woman, accompanied by her children, came to the pump for water. She got a bucket of water and gave some of it to the children to drink. I called her attention to the notice and told her the effect of it—that the water should be boiled and that the notice had been erected by order of the county medical officer of health. Her reply was that the county medical officer of health could go and boil his head. I think it is a silly thing to attach an order of that sort to a public pump that is in working order and expect children, passing along the road on their way from school, to obey and pay attention to it.

Knowing what I do of children, and looking back on my own experience as a small boy, I know that the natural tendency is to do the opposite from what is advised by an instruction of the kind. If youngsters see a notice on a pump not to drink the water taken from it, they will just drink the water to see what it tastes like. I think that wherever water is a danger to the public health—that it is the opinion of a medical man that it should not be used without being boiled—the correct thing to do would be to prohibit completely the taking of water from that well.

I have it on the authority of quite a number of medical officers that quite a large proportion of the milk used for consumption is taken from cows affected with tuberculosis, and that the disease is conveyed to human beings in that way. I think that steps should be taken to provide a better veterinary service, so that cows would be properly tested to see that they are free from tuberculosis and in order to safeguard milk that is used for human consumption.

Finally, I want to make this appeal to the Minister: that when he is engaged on a general hospitalisation scheme he should not neglect West Wicklow. There we have what may be described as a district hospital which also fulfils the function of a surgical hospital. We have there a first-class surgeon. The service that is given to the patients is the best that could be provided in any hospital. The building itself, however, is completely out of date. It is the disused, reconverted old fever hospital that was formerly attached to the county home. It is an institution which, I suggest, ought to be enlarged and improved. If that cannot be done a new hospital should be provided for that excellent surgeon and the exceptionally good staff that he has there.

Mr. Halliden

I wish very heartily to congratulate the Minister on the successful and excellent manner in which he is tackling health problems in this country. I can assure him that he has the good wishes and blessings of the people in his very noble and praiseworthy work. I would appeal to him to consider sympathetically the representations which have been made to him with regard to better hospitalisation for the North Cork area. We have in that area a public health committee. We have been asking for some time for cottage hospitals for Charleville, Mitchelstown and Mallow. So far we have not been successful, but we are hoping, now that we have a new and energetic Minister at the head of affairs, that these hospitals will soon be built. In the meantime, we want in that area an ambulance service for Charleville and Mitchelstown. It is a great hardship and loss and the cause of much suffering to patients who have to be taken a distance of 40 and 50 miles to Fermoy hospital from remote parts of Charleville and Mitchelstown districts. If we had an ambulance service it would help to mitigate the sufferings which, under present conditions, patients have to endure. I wish again to compliment the Minister and to assure him that he has our blessing and good wishes in his very praiseworthy and arduous work.

Mr. Little

The Minister last night made a fairly ample statement in which, I was glad to notice, he had the good grace to pay a tribute to the work done by his predecessor. Following upon that statement his predecessor, the former Minister, Deputy Dr. Ryan, emphasised especially that the big idea in the 1947 Act was preventive treatment—pre-natal treatment for infants, and treatment for growing children as the best way of safeguarding the health of the community.

That brings me to an appeal which has been made by my constituents in relation to the City of Waterford, and I hope that the Minister will give very sympathetic consideration to the proposals put up by them. The position in Waterford is very bad. With a population of 29,000, the facilities for maternity hospitalisation are very poor indeed. Waterford maternity hospital is a voluntary hospital and for over a century it has been mainly responsible for maternity work amongst the poor of Waterford City. The present premises are situated in a small side street known as Parliament Street, Waterford City. The residents are very poor and the streets narrow so that the hospital is closely hemmed in back and front rendering it airless in summer and very dark. The premises comprise two artisans' cottages and a small yard and are very old. The premises lack privacy. There is no garden and no means of extension or improvement. There are only 12 rooms, all small, with small windows, and there is a great absence of all the facilities which are absolutely necessary for a hospital of that kind. I need not go into details as the statement will be sent to the Minister in due course. The accommodation in the present hospital is 12 beds for patients and two beds for staff. The rest of the staff and servants live three-quarters of a mile or so away and that does not always make for the efficiency of the hospital.

With the exception of the Waterford Maternity Hospital there is only one other hospital in Waterford City which has a wing attached for free maternity cases. This is the county hospital and it is known as the "union" or "workhouse" at John's Hill. The number of beds available for maternity cases in this hospital is only 22. The number of beds required for city maternity cases only is estimated by the Medical Board as 60. There are two reasons why the county hospital does not serve its purpose; first, because many people dislike going into the county hospital and having the stigma attached of going into the workhouse. The other is that the rules in the county hospital are such that only the doctors attached to the hospital can attend cases in the hospital. In the other hospital any doctor can attend patients and an obstetrician can be called in if necessary. They have acquired a site situate in a very populous area on a hill at Airmount overlooking the city. It is an open space and easy of access and the property has been leased for the purpose of building a hospital. As the architect's draft plans show, a one-storey hospital built in Unit-Crete has been designed to have 25 beds in single and larger wards, a flat for nursing staff, domestic quarters and operating theatre and it will cost from £25,000 to £30,000. If the people have to wait until the larger hospital is built with a wing for maternity cases, they will have to wait four or five years, but this can be done pretty rapidly. I think that the Minister is willing to see a deputation about this so I need not go into details.

Deputy O'Higgins raised a curious complaint—by the way making a political speech while deprecating anybody else doing so. He seemed to deprecate all references to statements made before the election. I think that we are perfectly entitled to point out the injustice and misrepresentation of a considerable number of these statements where we were abused for neglect in the health services, while the fact of the matter was that the Minister for Health at the time built up the whole system, and did it in spite of the then Opposition. The setting up of a Department of Health was vigorously opposed by the Opposition during the period of the last Government and it is only fair and right that that should be pointed out. I know that possibly the present Minister was not aware of that. Many of these exaggerated statements may have been made in ignorance of the real facts, and the Minister had the grace last night to acknowledge freely that the previous Minister laid the foundation for the Department which I hope he will carry on very successfully. He can count on the co-operation of the Opposition; even, if anything, as Deputy Dr. Ryan said last night, he will receive every inducement from us to go further, to be more ambitious and to be more courageous in doing common battle with the Department of Finance. Undoubtedly, while the public purse has to be safeguarded, constructive imagination must be used if things are to be done properly. We have the sweepstake fund, the capital of which is about £10,000,000, but after the revenue has been completely earmarked it must fall at a later date upon the Government to supplement that income if our health services are to be adequately supported.

Mr. Davin

Deputy Burke did not agree with that.

Mr. Little

I did not hear Deputy Burke.

Mr. Davin

He said that we should go slow, that the money is the trouble.

Mr. Little

It always is. The Minister for Defence, Dr. O'Higgins, also said that he was a lone bird crying out in the cause of the nurses. That is not so, of course, because the late Deputy Dowdall, God rest him, had a motion down in our time drawing the attention of the House to the lack of pensions in the case of nurses, so I do not think he can claim a complete monopoly on that. He also objected to our criticism. I gather—I do not know whether I misunderstood him or not—that he said it was no use making any criticism unless you could remedy the defects. Of course it is the function of the Opposition to criticise. That is the Opposition's main duty, to point out defects and to try and improve by criticism. He also referred to the "spectacular achievement"—I do not want to detract from the present Minister—in getting St. Mobhi's, but when he referred to that as a "spectacular achievement", I wonder what adjective he should use in referring to the former Minister who established the whole Department. The Minister for Defence also referred to the former Government criticising them for not having taken over several premises which were in their possession. I assume that he meant for temporary purposes to use for tuberculosis patients. The Minister for Health, however, I think, would hardly agree to take premises for those temporary purposes because of the danger of infection remaining in those houses afterwards when they would be very difficult to use for other purposes.

When the Minister was talking about the lack of supplies and the shortage of labour, especially about the lack of supplies, I could not help thinking of the furious abuse heaped upon our various Departments, especially upon me in the Department of Posts and Telegraphs, for not producing the rabbit out of the hat and being able to erect all these various big buildings. We were blamed for the lack of supplies when supplies were extremely short. We are not going to pursue that unworthy line of propaganda. We know that supplies are short and we shall only encourage the Minister to get as much supplies as he possibly can and go ahead with building as fast as he can.

There are several Labour Ministers in the present Government and they represent pretty fully the whole trade union movement in Ireland. They cannot escape from the responsibility of inducing the workers to play their part in the national work of building, both in regard to hospitalisation and housing. I was glad to hear the Minister for Local Government, followed by the Minister for Health, making a very strong appeal to Labour to do their part and to try to induce their colleagues across the water to come back to help in this great national work. We all know that from time to time craft unions of skilled labour have been very conservative in allowing in apprentices and for that reason there is a shortage.

We cannot ignore the fact that, however we may want to stand for the rights and principles of trade unionism, there is a tendency to create a new aristocracy which is going to claim its own privileges to the detriment of the poorer workers and of the unorganised poor. I hope that the present Government, with its Labour representation, will be able to carry these responsibilities and to induce the workers to come back here to do what is perhaps the most vitally essential thing in the lives of the workers of this country.

In conclusion, I should like to tell the Minister that we are willing in every way to co-operate with and, if anything, to urge him to go out on a more ambitious hospital scheme. The former Minister made the high mark of his expenditure £37,000,000, which he hoped to spend within a reasonable period. The present Minister has fixed his expenditure at £15,000,000. If he goes out for £37,000,000 or £40,000,000 we shall back him up and encourage him to achieve his purpose.

Mr. T. Brennan

I think everyone will agree that the House is at one with the Minister in any effort he may consider necessary to eradicate, as far as possible, or at least control, disease in every way possible. I think it is admitted by the highest medical authorities that one of the fundamental essentials of a healthy population is healthy children and healthy mothers. In an effort to gain that objective the former Minister for Health, Dr. Ryan, embodied in the 1947 Bill a mother and child welfare scheme. I am sure the present Minister will do his utmost to ensure that that scheme will be fully and completely put into operation so as to gain that objective of healthy mothers and children and thus build up a healthy population.

Although I understand vaccination is still compulsory in this country, for some reason or other it is not being put into operation. Vaccination is a preventative against smallpox. Possibly a reason why a certain section of our people objected to vaccination was because it was made compulsory by the British when they were in control. There is also the question of immunisation against diphtheria, which I believe to be a very good preventative. I have known cases where there was an outbreak of diphtheria in schools and where the children who were immunised escaped the disease. I think that immunisation should be insisted upon. If there are any difficulties in the way, I am sure the Minister can find means to overcome them.

The question of local dispensaries has been referred to by a number of Deputies and also by the Minister for Defence (Dr. O'Higgins), who referred rather sarcastically to the fact that it had been dealt with by speakers from this side of the House. I have seen, particularly in rural areas, people who had to travel six or seven miles to attend a dispensary having to wait outside the door of the house where the dispensary was located. In most cases it was a private house in which only one room was available for the doctor, with the result that the people had to remain outside or in a small hallway, very often in wet clothes. I think that should not happen. I do not see why, if we want to control the roots that breed disease, we should not alone take steps to provide the necessary hospitalisation but to provide also these small clinics so that patients will not be placed in the unhappy position of having to remain in wet clothes while waiting their turn to go into the room occupied by the medical officer in the particular dispensary concerned. They are entitled to some form of a waiting-room with a fire. The necessary finances to provide such facilities for this type of person should be made available by the central authority, by the local authority or by some other authority.

Reference has been made to the building programme, as mapped out by the Minister, in regard to the provision of hospitals over the next seven years. The Minister has said that he hopes to spend at least £15,000,000 within the next seven years for the provision of hospitals of different types. Some Deputies have said that the scheme the Minister has in mind will not materialise because he will not be able to get the hospitals erected. I believe he will be able to carry out his programme. I was glad to hear the Minister state that after three years he is prepared to revise that programme provided that the necessary materials, skilled labour and so forth are available. However, even as things are at the present time I do not consider that that is an excessive amount of work when it is spread over a period of seven years, even taking into consideration the necessary amount of housing that will have to be completed during the same period. I think the Minister will have no difficulty in getting that work done. I do not, however, see why they should not both go hand in hand although the superstructure in housing and the superstructure in the erection of hospitals may bear no relation to each other. They may be built of different materials, as I believe they will be. So far as the necessary materials are concerned—with the exception, possibly, of the equipment when the hospital is completed—I think the Minister need have no worry that they will not be forthcoming because they are coming in every day now.

I should like to refer to the hospitalisation position in my constituency. For some reason or other County Wicklow seems to have been one of the counties that got a raw deal so far as its share of hospitalisation out of the hospitals sweep money is concerned. I suppose there are reasons for that. It may be due to the fact that the members of the local board of health were not alive to their responsibilities and that they did not move quickly enough in the matter. The fact, however, is that we in County Wicklow have been looking for a county hospital for the past 14 or 15 years. One of the probable reasons why greater progress was not made in the past two or three years towards the provision of the said county hospital was the difficulty of securing a proper site. Perhaps the local authority, as a body, found difficulties in agreeing on a particular site, and then there was the question of receiving sanction from the Department of Local Government in regard to the site chosen. However, we are now, let us hope, in sight of having that desired hospital that is so badly needed in the county erected in the near future. I do not blame the Department of Health —or the Department of Local Government, which was really responsible when the matter first arose—in regard to the delay in having this hospital in County Wicklow built. The delay was probably largely due to the causes to which I have referred.

In West Wicklow we have a district hospital. In that district hospital we have a medical officer in charge who is probably one in 100 or one in 1,000 medical men. He performs certain works in that hospital that his ordinary duties do not call upon him to perform. He caters for a large portion of West, South-West and South County Wicklow. Some two and a half years ago I was a member of a deputation from the county council who waited on the then Parliamentary Secretary to the Minister for Local Government, Dr. Ward, in connection with hospitalisation of the County Wicklow in general. Having dealt with the county home, I now want to deal with the district hospital. Dr. Ward was very helpful during his period in office. He met us in every way that he could and he even suggested that he would be agreeable to sanctioning certain alterations and additions and the provision of certain amenities in the district hospital, which it was our duty as members of the local authority to carry out. The local authority and the county manager set the matter going. The county engineer prepared plans. The plans were forwarded to the Department of Local Government and the Department wrote back stating that the plans should be prepared by an architect. I had no objection to that since I am interested in the building trade and believe that the drawing up of plans is an architect's job while the engineering side of such work is an engineer's job. The board appointed an architect.

Plans were drawn up and forwarded to the Department of Local Government. For some reason the whole thing is hanging fire. The plans have not been sanctioned. I do not know for what reason. I have come to the conclusion that the reason must be that the moneys are not available from the Hospitals Trust Fund to carry out the work. I would ask the Minister to tell us if that is so when he is replying. I know that these things take a certain amount of time but I think that the time lag in this instance has been altogether too long.

With regard to county homes, I take strong exception to the remarks of the Minister for Health in reference to such homes. As a member of a local authority I know that a great change has taken place in these institutions both internally and externally in the last 20 years. Those of us who know what the old workhouses were like when the Local Government Act was passed can congratulate ourselves on the present administration of these institutions. Deputy Cogan said he would like other premises for the aged and infirm. I agree with him that there is room for some improvement. With a little reconstruction the present buildings could be made very homely. Apart from that, provided there is good food, proper bedding and clothing, conditions are quite good. There are certain features of these county homes which could be removed with advantage. I suppose every Deputy knows the twin towers that stand on the roofs of these buildings. They are a permanent reminder of the old workhouses. I would suggest to the Minister that he ought to recommend the removal of those. They are a symbol of the British régime, which bring one's mind back to the famine years of '48.

Mr. Rooney

I admire the determination with which the Minister has faced the problem of the health of the nation and the provision of hospitals in this country in the light of our urgent need of such services at the present time. In his statement he has indicated that he has in mind a seven-year plan. During that seven years he proposes to spend something in the region of £15,000,000 for the purpose of providing hospitals throughout the country.

Progress reported; Committee to sit again.