Dáil Éireann debate -
Wednesday, 9 May 1962

Vol. 195 No. 4

Committee on Finance. - Vote 54—Health (Resumed).

Debate resumed on the following motion:

"That the Estimate be referred back for re-consideration."—(Deputy T. F. O'Higgins.)

Dr. Browne

When progress was reported, I was referring to the Select Committee on Health Services. So far, we have conducted this debate on a national scale. I do not propose to deal with it at any length because anything I have to say on the Estimate can be more effectively said at sittings of the Committee. I should, however, like to raise a couple of points on the general principle of the health services, arising out of the speeches which have been made by members of the Opposition. It is possible they may be able to clear up certain doubts which exist in my mind about their propositions because it is always open to reasoned arguments and it is possible they have reasoned arguments as to why they believe in a certain line concerning the organisation of the health services.

My uncertainty arises in respect to the means test to which I have referred and to the insurance principle. It appears that there are two broad propositions put forward by members of the Opposition. One is for a scheme based on the insurance principle with a means test and another, put forward by my friends in the Labour Party, for an insurance scheme without a means test. I should like to know, first of all, from the main Opposition Party how they come to their particular computation of the permissible income level which they would fix for their means test. Some figure like £800 a year, or £50 valuation, was mentioned by Deputy Hogan.

I should like to know on what grounds this £800 a year or the £50 valuation is fixed. It seems to me a very crude method of assessing a person's ability to pay for health services. A person may be a bachelor and may have £800 a year, while another may be a married man with eight or ten children on the same income. Similarly there may be any amount of variation within those figures. Why not, say, £801, £805, £809 or £810? Why not £700? This is the fixing of some mystical figure which seems to me not to relate to anything that has any rational basis. It is something which I have never understood in respect to this apportionment of a service based on a means test.

I do not understand it and nobody has ever tried to explain to me what is the necessity for a means test. Why should there have to be a means test? I have given my objections to means tests—the obvious one that as far as my own experience is concerned a means test in medicine means dividing the service into two kinds, one, a first class superlative service made available subject to a means test and, two, one on a lesser standard, even if it is not bad. Sometimes, in fact, the second one may be quite good. I never can see the occasion for insisting on the retention of a means test. There is a medical reason, I suppose. I think there are two standards of medicine usually in those circumstances.

Another objection is based simply on administration. It leads to the creation of an unnecessary bureaucracy; it is clumsy and it tends to appear unjust. It may be just and reasonable but it appears unjust in certain cases. It tends to provoke people into possibly mild dishonesty of one kind or another. It adds to the possibility of evasions and the return of not completely honest facts in relation to personal or family incomes. The whole thing is cumbersome and costly and, above all, it appears to be unnecessary. I have never heard anyone really state a case for the retention of the means test.

I can see the Fine Gael approach to the necessity for an insurance contribution. They are a conservative Party. They have never made any pretence of being anything else and, so far as I know, they are thoroughly honest in that respect. Their attitude is that the beneficiary of the social service should make a contribution and in that way effectively lighten the burden on the wealthy taxpayer. I imagine it is a rationale of their sponsoring an insurance scheme with a means test.

I have never heard it clearly put by the members of the Labour Party why they believe in an insurance scheme. On many occasions, Deputy Corish has, very rightly, criticised the recent trend by both major Parties to a fiscal policy which tends to shift the burden of taxation from direct to indirect taxation. The worker carries a tax burden in his tax contribution on beer, cigarettes, tobacco, bus fares, postage, and other things. He bears that burden to a much greater extent in recent years than in the old days when the wealthy were taxed to help the not so wealthy, and when there were super taxes, capital gains taxes and various other types of taxes by which it was intended, broadly speaking, to soak, as I suppose it could be called, the rich in order to pay for the people who could not afford to pay themselves.

Those are the two broad approaches. I have heard Deputy Corish criticise the Government for this trend. Indeed, it is logical criticism for him to offer as Leader of the Labour Party but I do not understand how they can rationalise the necessity for the introduction of an insurance principle in relation to the health services. In the first place, it has been the trend on the part of the major Parties on both sides of the House to increase indirect taxation, so far as the worker is concerned. That is a fact—it is there. I do not like it but it happens to be there. Consequently, what is happening is that the worker is paying already.

There is also the woolly-headed thesis that the worker must not get something for nothing. I have heard the thesis put forward from time to time that he must pay, and consequently some people believe he must pay by insurance. The facts of the matter are that he already pays in indirect taxation to a very great extent. He pays in indirect taxation every time he takes a drink, smokes a cigarette or in the one hundred and one ways we all know indirect taxation is collected. He also pays direct taxation under PAYE and most of the workers pay taxes in the form of rates.

I want to know why it is necessary to introduce yet another tax. I should like speakers from the Labour Party or the Fine Gael Party to tell me why they think it desirable or necessary to introduce yet another tax—a health insurance tax—because this, of course, will be a weekly tax or a monthly tax, just the same as PAYE. If they is to be a tax in respect of health, why not have an insurance principle introduced in relation to various other things like primary education or children's allowances, from which everyone can get benefits? The non-contributory old age pension is, of course, being made contributory. Why is it necessary to increase indirect taxation yet again by means of this insurance contribution?

The Fine Gael scheme is reasonably clear. There is a means test and an insurance contribution and a person pays an insurance contribution up to, say, £800 a year as is suggested. I should like a discussion on the proposal put forward by the Labour Party speakers for an insurance scheme without a means test. If there were no means test, presumably everyone would pay an insurance contribution. Under the Fine Gael scheme, people under a certain income level would not pay a contribution. That is fair enough, but if we have an insurance scheme with no means test, does that mean that the people who are now getting a free service, the old age pensioners, unemployed persons, self-employed persons, casual workers and small farmers, will have to pay for the services they get? Surely that would be a retrograde step. I want enlightenment on that matter.

If that is so, how are the unemployed persons, or the other categories I have mentioned, to make their contributions? It is conceivable, I suppose, that the old age pensioner will not have to pay but even the old age pensioners are themselves subject to a means test. It seems to me that it is nearly inescapable that in some way or other in our type of society the worker will have to pay both directly and indirectly if these people have their way. I could understand an insurance principle in an industrial society where there are a lot of weekly wage earners working in industries and factories. I could understand that it might be permissive in such a society, but we are living in a society in which the fiscal policy is directed to spreading the burden evenly over everyone. Everyone is made to pay in one form or another by direct or indirect taxation.

You could make an insurance scheme work in a highly industrialised society but in a country like ours, where there is a high percentage of rural workers, farm workers, casual workers and self-employed persons, I do not know how it would be possible to make it effective and, above all, I do not know why it should be necessary to introduce such a scheme. I do not know what justification there is for it. I should like to see some justification. There may be some justification and there may be a special case in Ireland that I do not know anything about which does not operate in other countries. There may be advantages in other schemes that other people know about but I have not seen a good case made for the insurance principle and, above all, I have not seen a good case made against the existing so-called free services which we get under the Infectious Diseases Regulations in regard to our fever hospitals and T.B. sanatoria generally.

Why does somebody not say: "These are the weaknesses we have exposed and because of these weaknesses, we propose to adopt a different scheme, an insurance scheme, because it will not have the weaknesses of our present scheme?" Why does somebody not justify this demand for insurance? It seems to me to be unreasonable that people should have a doctrinaire and unjustified, and apparently unjustifiable, belief in a particular idea and should not make any attempt to try to persuade us here why they believe in one particular scheme as against another. I do not know how the main Opposition Party can, in the light of their experience, put forward the proposal that a means test should be retained. Anybody with experience as politicians or doctors must know the big difficulty. Possibly the only real difficulty in existing health services is the means test and it is the people who do not get the services who are most annoyed about it.

I think the proposition was put forward by Deputy Kyne that there should be variations in the contributions made by persons in the very low income groups, if there was an insurance scheme. That proposal would appear to me to be more likely to lead to greater bedlam than exists already and there would be consequential means tests within the means test and it could stultify many of the hopes which I believe the Labour Party and other Parties have for the provision of proper health services. I hope, therefore, that some speaker will try to justify the approach to this idea of insurance schemes in relation to the health services, because, as I said before, fortunately we all believe the present idea is coming to an end. Everybody will be relieved and I hope we shall get good health services which will please the people and which we can all afford. My own view is that there should be an extension of the existing infectious diseases type of services.

I want to discuss for a while the question of the Minister's approach to the Report of the College of Physicians on smoking in relation to cancer of the lung and other diseases and his very offhand treatment of this very serious matter. I know well that this is a very difficult problem for a Government. It is a very difficult problem for individuals. It is a difficult problem in many ways because when a Government in a country as small as ours takes in something between £25,000,000 and £30,000,000 in revenue from a particular service, one cannot readily or easily expect the Government to wipe out that income, or take steps which will, in effect, wipe out that income, without giving the matter very serious thought, particularly where there is no readily obvious alternative source of income.

There are great personal problems involved also in this question of the consumption of tobacco in so far as there are very many people who have shares in this business. They used to be gilt-edged securities but they are now not quite as good currency as they formally were. That creates problems for people, I am quite sure. Also there is the very difficult individual problem involved for the person who smokes and simply does not feel he can give it up, or cannot give it up. I am afraid from my own experience I found that there are a number of people who cannot give up smoking. It was not an easy problem which can be solved simply.

The College of Physicians came out unequivocally on the general principle that they believe the two things were related, that there was a relation between smoking and cancer of the lung. At the same time, there is a certain element of doubt as to the exact causation, the cause and the effect. However, I think we can accept that one is related to the other and consequently some steps should be taken by the Government to deal with the matter.

The report is a remarkably well detailed one in dealing with such a complex subject. It certainly leaves no reasonable doubt that some steps should be taken by the Government. The record of cigarette smoking, as they have found it, is a very serious one, causing various not so serious illnesses, gravely serious illnesses and, finally, worst of all, lung cancer. It also causes bronchitis which is not so serious at the beginning, but ultimately is a great source of distress to many people and indeed causes the loss of many man working hours in winter. Coronary thrombosis obviously appears in many people also. The cause of all these serious diseases can be attributed to cigarette smoking and yet the facts are that all the media of communication in our society are used continuously and full blast to encourage people to continue to smoke, when we now know without any doubt that it shortens our lives, causes crippling bronchitis, encourages coronary thrombosis, delays the healing of gastric ulcers and in a number of cases, causes cancer of the lung.

I do not think the Minister should continue to allow the case to go by default, as he virtually has allowed the case against cigarette smoking to go up to the present. He must take more energetic steps to deal with it. Precisely what steps he should take is a matter which only he, with all the knowledge and information available to a Cabinet Minister, could be certain would be the wisest to take. He gave the impression in his opening speech that those of us who wanted some action taken, or some authoritative or autocratic type of dictatorial prohibition brought in would immediately lay down that cigarette smoking was forbidden in our society henceforward and must be stopped without any further delay or consideration. This is the Minister's usual misrepresentation of my whole attitude in politics as a socialist: that I believe in authoritarianism. Nothing could be further from the truth, which can be borne out quite easily by reference to a few of the things I was permitted to do while in office. On the contrary, it is the Minister who has been authoritarian in his time and has attempted to take very dictatorial powers, when he felt he should do so.

As far as I can recollect, far from believing in authoritarianism, my attitude has always been the true socialist one of believing in the good sense of the mass of the people and believing that, if the case is fairly and honestly presented to the mass of the people, they can be depended upon to act in the way that any of us would act in the same set of circumstances. As far as I can recollect, it was I who stopped compulsory vaccination for smallpox. I do not know whether that was right or wrong; but, as far as I can recollect, it was I who did it. I remember also at that time diphtheria was rather dangerous. It was suggested we should have compulsory diphtheria vaccination. I opposed that idea because I felt that if the majority of conscientious mothers were told it was desirable to have diphtheria vaccination, there are very few of them who would not go and do it in the interest of their children's health. On the whole, I think that the voluntary approach —we did introduce certain plans for education by way of posters and newspaper propaganda—is reasonably effective. I remember also that I opposed——

An Ceann Comhairle

The Deputy's record is very interesting but it is scarcely relevant to the debate.

Dr. Browne

I shall not deal with it at any great length. The Minister did deal at some considerable length with the approach and the immoderate suggestions that have been made or implied by persons like myself in favour of stopping cigarette smoking or causing people to cease cigarette smoking. However, I shall not deal with it at any great length, beyond just reminding briefly the Minister of his own 1946 Health Act, which was probably the most authoritarian piece of health legislation ever brought into a democratic parliament and which, of course, was ultimately thrown out.

In relation to encouraging people to stop smoking, one point has been made in this Report: that advertising is not the sole reason for people smoking. I accept that. There are other factors involved, apparently. But it makes the point that you cannot ignore the likelihood that advertising has an influence or does help people to start smoking and, having started, keeps them at it. Even if they have not made that point, anybody who knows the hardheaded businessmen who run the big tobacco corporations must know they are not going to spend £11,000,000—that was the figure spent in Britain last year on advertising—merely because they have not anything better to do with their money. They must have their own market research methods. They must have their own investigations which establish for them whether it is a good thing or not to advertise, whether it is desirable or not, whether it helps to sell the article.

It is generally accepted in our type of society that advertising is desirable and necessary and, above all, that it is effective in selling the particular product. I think we could accept that. The fact is that the State radio is used, the television service is used widely and the newspapers are used very widely by the top corporations to encourage people to smoke cigarettes, which we know now cause lung cancer. Surely the Minister must take some counter action? The obvious counter action is a simple prohibition. I see Italy has imposed that prohibition. They have said there shall not be tobacco advertising, that it shall not be accepted. I do not know whether that is the best way to go about it. I think it probably would be the cheapest way. The alternative, it seems to me, would be very costly for the Minister—I suppose he would have to think about it—and that is to counter the advertisements of the corporations, that he himself would take radio and television time and take newspaper advertisements. It would be very costly for him. He would be up against the finest brains in the business—the smoking advertisements are certainly extremely clever—and he would have to try to pit his wits against the tremendous organisation which has been built up over the years. As I said, the figure for Britain last year was £11,000,000—I have not got the figures for this country—and I certainly cannot see the Minister finding money on a comparable level with that being made available by the tobacco companies for their campaigns.

The Government have failed in this matter. There are various Ministries which could take action. The only one who has taken action—and I suspect that action, even though I welcome it and supported it in the Budget— is the Minister for Finance. He gave us to believe he was worried. The surprising thing is that, while he is worried, his colleague, the Minister for Health, seems to be relatively unworried. The Minister for Justice would not take any steps to see that children and juveniles could not have access to the slot machine type of cigarettes. The Minister for Posts and Telegraphs refused to intervene in relation to television advertising.

There is no good in the Minister trying to create the impression that he is the great liberal, that he feels society should be an unregulated jungle in which everything would eventually work out in the best of all possible ways. We have regulations in practically every aspect of our lives. Every Ministerial Department introduces regulations at some time or other—in relation to the children going to cinemas, censorship of books, traffic. Even in the Department of Agriculture there are certain regulations in relation to T.B. eradication. There is the Official Secrets Act. The age at which children attend and leave school is the subject of regulations and so is the care of old people. Obviously, practically the main function of every Ministerial Department is to devise regulations arising out of the legislation passed here. It is absurd for the Minister to suggest he does not think it would be compatible with his general approach and the general approach of his Government that he should introduce prohibition of one kind or another.

The Minister is the very person who recently, on the advice of some committee or other, quite rightly refused to allow the bakers to continue to include agene in bread because it was injurious to the health of our people. That was not an important or authoritative committee but I have no quarrel with their findings or the Minister's decision. Why did the Minister not act on this very authoritative report whose findings are very much more serious for the population? Very recently, there was opposition by the Opposition —I did not share their opposition to it—to the introduction of fluorine into drinking water, a proposal which was not getting support in many quarters. It was the Minister who brought in legislation to give us the power to regulate in respect of the introduction of fluorine into the water supply as a health measure. He has acted in these two cases but refuses to act in relation to this problem of advertising.

The Minister gave us to understand that he provided the health authorities with literature or that he has literature which is available for anybody who wants it. He says that is adequate. He has made a few speeches, a few references to this danger of cancer from cigarette smoking, and says that everybody had an opportunity of reading this report of the British College of Physicians. I do not think the Minister honestly believes that it is enough for him to make half a dozen speeches, to refer to this report that was produced and suggest that that could be an effective counter to the powerful and very clever advertising campaign of the tobacco corporations.

Does the Minister really believe that, in the face of the truth that consumption of tobacco has continued to rise along with the continued rise in the incidence of lung cancer? If the Minister were right, surely the results would show in a reduction in cigarette smoking and ultimately—I know it would take a long time—a reduction in the amount of lung cancer.

There is the suggestion that adults should tell the children not to smoke. That is not a particularly valuable suggestion. Any grown-up, a teacher or a parent, with a cigarette in his hand, a complete victim to the habit himself giving such advice could not possibly impress the children. The imitative quality in children tends to make them do whatever they see adults doing. That is one powerful factor in their starting to smoke.

Many people suggested that it was useless to concentrate on adults, that it would be more beneficial to concentrate on the children. In concentrating on the children and leaving out the adults, you are leaving out probably the most important factor, the person who initiates the habit. If any success is to be achieved, the adult must be encouraged to stop smoking so that the young person will not start to smoke. Therefore the Minister's campaign, however he would pursue it, should be directed not only towards encouraging young people not to smoke but towards helping the person who is already addicted to stop smoking.

If you issued an edict tomorrow telling people they must not smoke any more, it would not be worth the paper it was written on. I know a number of people who are trying very hard to give up smoking and they simply cannot do it. It is a very difficult medical problem as well as a financial problem. I would prefer if the Minister would say, even though there is a precedent against it in the other cases I mentioned: "I do not think we should suppress advertisements. I believe advertisers should be allowed to encourage people to smoke" rather than suggest that what he has said on the subject is sufficient to counter the advertisements.

The Minister does say in relation to opium, morphia or cocaine: "You may not smoke these, even if you want to." He does not allow these drugs to be advertised in the national press, on television or on the radio. I do not want to be misrepresented in relation to that; I accept that they must be suppressed but we know there is an element in cigarettes which comes into the dangerous drug category. I do not want him to rush into desperate action. It is a matter which will need very careful thought and I can merely put forward points of view to him which could possibly be of assistance to him. However, some positive action is badly needed.

The Minister feels he has discharged his responsibility in making literature available to health authorities or in having a few lectures given in schools. I do not think he has discharged his responsibility. As an illustration of his failure, I give him the fact that there has been an increase in tobacco consumption while that type of campaign has been carried out. I do not honestly believe, and I ask the Minister does he seriously hope, that his negligible type of campaign has been satisfactory or that it can adequately counteract the colossally clever, very expensive, very seductive newspaper, television and radio campaign carried on for the purpose of inducing people to continue smoking? I do not think the Minister seriously believes that it will.

The Minister knows quite well that if he, as a politician, were faced tomorrow with a choice of contesting his constituency, the only contribution to his campaign being merely an announcement that he intended to stand in that constituency, that he had a great deal of literature at home and, if one wanted it, one could apply for it and one would gladly be given it, while his opponents had access to all the main means of communication— radio, telephone, newspapers, television, and any other vehicle available for the dissemination of propaganda — he would not choose inactivity. Does the Minister seriously believe he would be quite satisfied fighting an election campaign in such circumstances? Does he not know that he could not possibly agree to any such proposition because it would be grossly unfair? It would leave him in the position in which he could legitimately plead that he was not getting a fair chance to put his point of view or his candidature properly before the public. There is, I think, a reasonable comparison between that and my suggestion that the Minister is not conducting his campaign against the possibility of an increasing incidence in lung cancer, as a result of cigarette smoking, really effectively.

To reverse the analogy: what does the Minister think the tobacco corporations would say if he went calling on them to tell them that, in the beginning of each year, they could draw up a leaflet inscribed "Players Please" or "Gold Flake Satisfy", make an announcement in the Press, deliver a speech about their products, and, for the rest of the year, do absolutely nothing in the line of newspaper, radio or television propaganda or advertising? Does he honestly believe that would satisfy the tobacco barons? I am certain it would not.

I naturally want the Minister to indulge in a serious campaign to try to reduce the incidence of lung cancer. Above all, I should like him to be clear in relation to his facts. I should like him to know what he is doing. I should like him to be honest about why he is doing it or, on the other hand, why he is not doing it. I should like him not to mislead. It is possible he has actually misled himself in this matter, but he must not be allowed to mislead the Dáil that he is, in effect, carrying out a serious campaign in relation to this very grave health problem of fairly recent origin.

When I read the report and appreciated the seriousness and significance of it, and when various Ministers made it quite clear that they did not intend to take any action in regard to it, or virtually no action in regard to it, my immediate response was one of indignation and surprise, particularly with regard to the Minister for Health, because this is his responsibility. The Ministers for Justice and Posts and Telegraphs may be forgiven because health is not their particular problem. It is unforgivable on the part of the Minister for Health that he will not take some effective steps to deal with this problem because it comes within the ambit of his responsibilities. Since my first reaction of indignation and surprise, it has struck me that it is conceivable the Minister for Health simply does not fully appreciate the significance; he is, after all, a layman and, like most other laymen, he does not appreciate the significance of these cold facts.

One of the things that helped me to confirm that impression in my own mind is the fact disclosed in this report that since 1958, when the idea was first mooted that cigarette smoking might be a cause of lung cancer, there has been a remarkable drop in the number of doctors who smoke. Half the number smoking then smoke now; only one-third of all doctors smoking, when this survey was made, smoke cigarettes. In the light of this very significant fact, it struck me that it might possibly be that the average layman is simply unable to grasp the significance of lung cancer. To him, it is just a certain number of letters on a piece of paper. As far as personal experience goes, it is not, perhaps fortunately, translated into actuality. That is true, too, of course of the Minister for Health, in so far as he is a layman, and he simply does not appreciate the very serious wrong he is perpetrating by his inaction, or by his wholly ineffective action, in this regard.

He has never seen anybody, as most doctors have, dying of lung cancer or of cancer of the throat, in the throes of asphyxiation and gradual death. He has not had that, in some ways, valuable experience. It is far more impressive than a book, or a report, irrespective of who makes the report. It would certainly stop most people smoking cigarettes. I think it is this experience on the part of doctors which has led to a decrease in the number of doctors who smoke. It is just as difficult for a doctor to give up smoking as it is for anybody else, but anybody who has had the experience of seeing a fellow human going through the frightful ordeal of finding out he has cancer of the lung, and then sweating it out until he finally dies—remember, it is virtually imoperable—has an experience which is denied to the layman; it is very difficult then, perhaps, for the layman to visualise the agony, the physical pain which follows. Knowing the indifference of the inexperienced average layman, and coming up against the apparent indifference of the Minister in his very responsible position, it is easy at first to be indignant. But, then, one comes to feel that this indifference is probably due to ignorance of the real position. One can only hope that the Minister will give the matter rather more serious thought henceforth than he has given it up to the present. I hope he will think over the whole matter again. He has a very grave responsibility.

When the report first issued, the campaign in favour of smoking stopped momentarily. That was noticeable. The newspapers, television and radio were emptied of advertisements for a few weeks. Now they are on again in full flood and the people for whom the Minister has responsibility have at the moment nobody acting on their behalf. I shall say no more on the subject. I sincerely hope the Minister will do something. I believe he has a conscience, and I think that eventually he probably will do something.

Mr. S. Collins

The time has come when we must face up to the fact that the health services throughout the country are not overall as good as we would like them to be. Furthermore, the time has come to make a concerted effort to find practical solutions to the multiple problems that have arisen under the Health Act, problems ranging from the question of entitlement to blue cards to the problem, dwelt on at such length by Deputy Dr. Browne, of the effect of cigarette smoking in relation to the incidence of lung cancer.

What we have to do is to consider the method of improvement, particularly on the basis of making available to all sections of our people, in the quickest possible way, every development in medical science that can be put at their disposal for healing or arresting progressive disease. I saw, in my early days in the Dáil, the initiation of our health legislation and I said then, and I still say, that we got off to a wrong start and that we have never been able to recover from that because subsequent legislation has been either a matter of expediency or patchwork to seal breaches that have become apparent in the system.

I may at times be inclined to say very harsh things about the Minister for Health but I believe he has come to the realisation that it is necessary to get a considered and constructive opinion from all sides of this House as to what form future legislation should take and as to the type of development which should be laid down as a basis for progress to the day we want to see when everybody in this State, irrespective of his income group, will have equal approach to all specialist treatment, operative treatment and every type of treatment necessary to deal with his complaints.

When Deputy Dr. Browne was asking hypothetical questions about the means test, it struck me that he was being a little more naive than usual, because he knows that the type of health service subscribed to by this Party is one in which anybody in this State who is unable to pay for health services, who is unable to pay for medicine or for any form of operative or specialist treatment, would not be denied it because of that inability to pay. We have always contended, and proudly asserted, that it is our responsibility to ensure that the least fortunate classes of our people, the old age pensioners, the widows and orphans, the unemployed and the unfortunate small farmers are entitled, absolutely free, to every benefit that can be made available to the wealthiest person in the country.

When one comes to consider any scheme which is to be a contributory scheme, one must arrive at a figure. Deputy Dr. Browne says that the £800 a year man may be a bachelor or he may be a man with ten children. Every scheme that is on a contributory basis must envisage the contribution that such people would make. We favour the contributory scheme for a number of reasons the most effective one of which is that when people make some contribution for the service, they are able to preserve their self-respect and to ensure that they get their rights. There is enough mendicity in this country already without encouraging any more. When we in the Fine Gael Party talk of a contributory scheme, we talk of one which the people can afford and one under which the people will no longer have to go to the homes of their county councillors or their Deputy in order to get their rights. We talk of a scheme under which it will be the de facto right of all our people to obtain what they are entitled to and what every one of us is hopeful to be able to give them, a first-class really worthwhile health service.

As this matter has gone to a Select Committee of the House, it is futile at this stage to argue what the health services should be. It might be better to leave that to the time when we will be debating the findings of that Committee but there are a few facets of health policy I want to refer to. In regard to some of these, commendation must go to the Minister for the manner in which he recently sought to enlighten the public. I am dealing in particular with the desire I have to see the Irish people educated to a proper psychological approach to the question of the mentally ill or the mentally defective. I was appalled on recent visits to large mental institutions at the amazing number of people who are allowed to languish and die in these institutions because of the fact that we have not been able to educate people to the knowledge that mental disease, properly treated, can be cured as rapidly and as completely as any other ailment from which the body may suffer.

I would be glad to see more virility put into the effort to show the Irish people, as we once had to show them about tuberculosis, that there are many factors that impinge on the nervous system so as to lead ultimately to a mental breakdown that can, with the proper approach, be cared for and cured as effectively as we have dealt with the one-time rampant TB among our people.

In the most deliberate way, I say to the Minister that I, for one, would urge upon him and welcome a greater effort to teach our people that there is nothing per se sinister or nothing per se of ill-repute in the person who, by reason of circumstances, may be overstrained, over-worked, or, by some vicissitude of fortune, may suffer from some temporary mental upset. There is no reason why they, in co-operation with the psychiatrist, should not be able to aid and help in the rehabilitation of that person back to normal circumstances again.

I should like to see a development in this country towards more psychiatric clinics. Having visited some of these institutions and met some of the people in them, I have got the impression, maybe erroneously, that some of them are far more qualified to be outside than some of us who are outside. It is an immense problem, particularly on the south-west and western sea-boards, that you have people who, because of their wrong psychological approach, will not have relatives back again or will avoid taking responsibility for them.

As well as that, you have a number of cases in these institutions who have virtually become lost and forgotten souls. I think that, with the recent impetus we have seen being given to the effort to deal with mentally retarded children or mentally defective children, we should, side by side, build up a campaign to teach our people what is being learned generally in the world, that, in so far as the brain and the mind are concerned, causes of troubles and disease can arise as they can in any of the other parts of the anatomy, that they can be dealt with in an effective manner and that rehabilitation in that respect can be, on the percentage basis, as high in its full recovery as any other type of the more dreaded diseases we talk about in the body.

We should unite on all sides of this House with the Minister and with my colleague, Deputy D. Costello, in the publicising and the sustaining of the effort to get more and more done for our mentally retarded or mentally defective children. I know it is not easy, within the wall of soaring health charges, within the difficulties we have of the impact of health services on the rates as well as on general taxation, to make available all the funds that might be necessary for the campaigns I envisage. However, I say in a very positive way to the Minister that in so far as that impetus needs the support and the help of this Party, we shall be with him all the way.

We feel that where the health services are concerned, where any one of our adult mental cases can be properly cured, where any assistance or any help can be given to the unfortunate retarded child, every £ spent by this State in giving that better lot to that person is not only well spent but is a fulfilment of a duty that we can never shed, namely, to be reasonable and fair within our constitutional concept of freedom to all members of the State. There are none who need our sustained support and our sustained help more than the classes to whom I refer. All I want to see is a quickening and a greater quickening of the conscience of our people in relation to these problems and what contribution they can, in their goodwill and in their support to these cases, make to the rehabilitation of so many people.

I shall not join in Deputy Dr. Browne's castigation of the Minister for not rushing into a series of prohibitive Orders to prevent tobacco companies from advertising or from the normal exercise of business acumen in relation to the sale of their products. Strangely, I still believe that if the Minister really wanted to put smoking on an upper spiral, he would only have to try prohibition.

Mr. MacEntee

Hear, hear!

Mr. S. Collins

The question of dealing with lung cancer, in so far as it is germane to the problem of smoking, is a difficult one. It must be. We had only to listen to Deputy Dr. Browne for the past threequarters of an hour rambling around, in ever decreasing circles, saying the same thing forty times, to know that he had not a clue as to what the answer was. I do not intend to suggest that we can give the complete answer but I do know that an awful lot of people, despite what reports are published, are yet far from convinced that there is a direct connection between smoking and lung cancer. Whether it is some subsequent breaking-down within the cell tissue of the body that ultimately leads to it, that may be an adjunct rather than a reality in the tobacco, is not yet known.

I think the Minister for Health might be well served in his effort to do something about this matter in having the tobacco barons, as they were described by Deputy Dr. Browne, divert some of their moneys now being spent on advertising to research funds in order to find out exactly what constituent of the tobacco might be the irritant that ultimately sets up bronchial catarrh or lung cancer. The Minister is in a very difficult position because everybody has his right under the Constitution. Legitimate traders have their rights in relation to the manner in which they will run their business or advertise. The general public have the right to decide whether they should smoke or not and the right to choose for themselves the brand of cigarette they smoke. I say in fairness to the Minister that if he started to make regulations to prohibit that, there would be howls on all sides of this House about interference with the liberty of the citizen.

That brings the question of smoking and lung cancer into the field again, and the question of letting the people assess the facts and letting it be known throughout the schools and homes of Ireland that there is the belief in certain quarters that there is an intrinsic danger in tobacco smoking—one that can lead to the consequences described so vividly by Deputy Dr. Browne. Deputy Dr. Browne should stop fooling himself that it is not within the power of a layman like the Minister or myself to experience an appalling sense of frustration on seeing a person die of cancer, particularly lung or gullet cancer. Many of us have had the misfortune of seeing relatives, friends and dear ones die as a result of cancer. To try to heap some kind of a threat on the Minister's head because he has not got some mad impulse to rush out and ban advertisements or disrupt established trading methods is, to my mind, unfair.

This is a problem in relation to which the adroitness of the Minister will be tested to the nth degree. There is no use fooling ourselves by denying that the tobacco industry has grown into an immense and powerful vested interest to say nothing of the fact that it has grown into one of the most freely accessible tax sources in the State.

When one looks back on the long history of smoking, it seems amazing that it was only in 1958 that the apparent connection between cigarette smoking and lung cancer was fathomed. It was only in the very recent past that the College of Physicians brought out their report in the matter. Unfortunately, the development of cancer research and the effective treatment of the disease have not made anything like the progress that every one of us would like to have seen made. We have not been fortunate enough yet to see developed some vaccine or antidote to the disease which could give us the hope that we would see in our own lifetime an end to this scourage. If the Minister has funds available it is into research and development against lung cancer that I should like to see those funds diverted rather than used in a counter campaign of advertising.

What is the Minister's responsibility in the matter? Deputy Dr. Browne seems to hand it all on a plate to the Minister and, for once, I do not feel that is justified. Each and every one of us, in so far as we believe tobacco smoking is likely to increase the incidence of cancer, has a duty to spread that knowledge among our people and our constituents. We have a duty to help the local authority in the dissemination of the information available from the Department of Health but whether we would be justified in introducing sanctions and prohibitions as a result of the report of the College of Physicians is another question. I would urge on the Minister that prohibition and sanctions should be the last approach to this big problem he should envisage.

We have seen in a short period an immense improvement in the methods and techniques of treating diseases. We have seen the development within this State during the last decade of some of the finest hospitals in Europe. We have been fortunate in that period to have been able to procure the very latest equipment and to build hospitals, the design of which is in advance of the times. We have been fortunate to have them staffed by surgeons of immense skill, physicians of tremendous capacity and, generally speaking, first-class specialists.

It is because we were able to do so much that possibly we are impatient to see that type of service made available to everybody in the country. Even though we can readily appreciate the fact that hospitals cannot grow overnight, that distinguished and competent personnel cannot be provided overnight, we still find our patience tested and strained by the fact that we see so many people for whom so much could be done if the advance in our health services had commenced a little earlier.

It is in the true spirit of wanting to see a worthwhile job done in providing the best possible health services for all of our people that we sometimes become impatient and intolerant of the administrative methods of the Department of Health and the local authorities when they come to deal with the health services. There is no doubt that a much better service could be given, if administrative anomalies and queer twists in regulations were smoothed out.

There is no doubt it is possible, within our present system, to give to all the Irish people an excellent general service, a superlative hospital and specialist service and a very good drug treatment scheme. They could be given free to the sections of our community who cannot pay for them, but a contribution could be sought from the income groups of, say, 1s. or 1s. 6d. per family per week. I am thinking of a service which would help the lowest and the highest—the small farmer in West Cork taking home his lock of turf on his donkey and butt, or the unemployed man in the city or in the country, or the old age pensioner, or the widow. I want every one of these to get the same medical care as the man capable of earning £5,000, £10,000 or £20,000 a year and who could afford to pay for top level services at home or elsewhere.

That is the standard I set for the Department of Health. Deputy Dr. Browne accused the Fine Gael Party of advocating a conservative and arbitrary insurance system with a means test. The only means test on which we base health is that those who cannot afford a full medical service should have it free and that others should make a reasonable contribution. Our problem is that we cannot quickly enough provide for everybody every possible method of pain alleviation so that nobody in this country, rich or poor, should suffer unnecessary pain.

Mr. Sherwin

I have only a little to say and the first point I would make is that the health services should be on a contributory basis with no ceiling. When you fix a ceiling, you will always have hardship in borderline cases. Everyone should contribute, except those in the social welfare classes or those who own land of low valuation. Under the existing system, people with over £800 a year are outside the scope of any assistance and must pay the full cost of hospitalisation. This creates grave hardships in many cases. I am speaking from personal experience in this matter because I happen to be a case in point.

As a Deputy, I am supposed to have £20 a week. That is less £1 which they take from me for pension purposes. But I also must deduct the cost of the last three elections. Do not forget that though I have been in the House for four and a half years, I had, in the meantime, to fight a byelection, a municipal election and a general election. All that expense must come out of my £20. All my telephone expenses and my postage costs must come out. Still, if you do not mind, I am classified as a fellow with an income of over £800 a year. One of my family, a child of ten, had to go to hospital and I got a bill for £7 for the child's two days three. I went to the hospital and to the local authority and they accepted it for the joke it was. They never pressed me and I was told by the secretary of the health authority that he had hundreds of cases like it—people who have £800 a year but who, in order to get that amount, must spend £300 or £400.

That is why I say there should be no such thing as a ceiling. It is a joke, unless certain allowances are made. In income tax, allowances are made. Members of the Dáil are not charged income tax on their whole salary—I think it is charged on half. I am not sure because I do not pay it. That is fair enough, but if there is to be a ceiling, certain matters must be taken into account before a person's means are assessed for the purpose of health charges. A person may have the name of having something but what counts is what he really has. You cannot get blood from a stone. When we are dealing with this matter at a later stage, I hope the Minister will consider a general contribution without any ceiling, and that he will make sure that certain charges that are out of the ordinary are taken into account before a person's means are assessed for the purpose of health charges.

I want now to refer to people who are in receipt of allowances because they have infectious diseases or because they are disabled. We all know, although little mention has been made of it, that persons in receipt of a disablement pension or allowance got an extra 2/6d. in the Budget. In my opinion, those cases are the worst cases of all. They are the most pitiful cases. In 1954, an allowance of £1 was granted to chronically disabled persons. Perhaps that was not bad in 1954, but for some reason or other, this House then forgot all about them. They were the forgotten people, perhaps because the money does not come under the welfare account.

Every year, there is lobbying for the old age pensioners and the unemployed, but the disabled persons are completely forgotten. The proof of that is that the first increase they got was in 1960. In other words, their allowance was fixed in 1954 and for six years those unfortunate people got nothing more. They got an extra 2/6d. for the first time in 1960. I am thankful to the Minister for it. I know it was because Deputy Desmond and I pressed this matter that the Minister softened.

So far as I can see, anyone who wants to get anything in this world must kick up a row. Other classes got certain increases because there was a row. If the farmers had accepted the increased rates lying down and not opened their mouths about them, they would not have got the £2½ million. The fact that the disabled persons were forgotten is no reason why they are not entitled to the same benefits as recipients of contributory or non-contributory allowances.

A blind man gets 30/- a week and an additional 2/6d. now. A non-contributory old age pensioner gets 32/6d. There is no reason why disabled persons should not get 32/6d. a week, except that they have been forgotten. When they did get an increase, it was the usual 2/6d. I can understand that and I am greatful to the Minister for that 2/6d. I am satisfied on this occasion but I want the Minister to bear those people in mind. I think I am morally entitled to make the case that they should get the same allowance as an old age pensioner. In many cases, they are crippled from birth and are bedridden. It is not as if they had had a job and had got some small pension.

A non-contributory pensioner can earn £1 a week and still get the full pension. His pension is not reduced, unless he earns more than £1, but obviously those who were born crippled have no additional money. They are a terrible nuisance to their families and themselves. We have to admit that, but for that reason, it is a shame that they do not get at least the same treatment as the non-contributory old pensioners. I am satisfied that they were not forgotten again this year, but I am asking the Minister next year at least seriously to consider bridging the gap and making their allowance similar to other allowances. The reason that has not been done is that they did not kick up a big enough row.

I want to say a few words on smoking and drinking because other speakers have dealt with those subjects. I do not drink or smoke, although I did at one time, but I certainly would not favour any ban. If people want to drink beer they will drink it; and if they want to smoke, they will smoke. They will go to the black market if there is a ban on beer or cigarettes and the Minister will lose revenue. I do not know to what extent smoking causes lung cancer. In my opinion, people who have lung cancer should not smoke but it is up to themselves. Normally healthy people can smoke without any ill effects, perhaps. I know that from my own experience. I have a touch of bronchitis and when I smoked, I had a severe cough at night and I was subject to colds. Since I stopped smoking, I rarely get a cold and I never cough. That is proof that anyone who has anything wrong with his chest should not smoke or he will aggravate the condition.

Drinking was banned in the United States and we all know what happened. The State got no revenue but the racketeers did. People drink to forget themselves. They have not all got the life of Reilly. Politicians may be able to make politics their full life, but the man in the street likes to drink beer in a pub. I would not stop anyone from having a beer.

We hear talk about the evil effects of drink. Drink is a curse but I would not ban it. Practically all evil occurrences are due to drink. Half the robberies are committed by people under the influence of drink and half the accidents in cars are due to drink. Some cases of venereal disease can be attributed to drink because decent people do not have dealings with the type of person from whom they are likely to contract that disease, unless they are under the influence of drink. Drink causes all sorts of evil but I would not ban it because worse evil might eventuate. We should try to educate people and get them to give up these things of their own volition.

I want the Minister to remember the points I have made: no ceiling so far as health in the way of hospitalisation is concerned and an allowance for certain costings outside the normal, and next year would the Minister remember to bring disabled persons' allowances into line with other allowances?

Mr. Colley

After the rather colourful contribution we have had from Deputy Sherwin, I am afraid my contribution will not be quite so attractive. There are one or two points which I should like to discuss. The Deputies who have contributed to this debate have, between them, covered the main points of the administration of the Department. I do not propose to go over that ground again but I should like to reinforce a plea made by Deputy Kyne that the House should not agree with the argument made in many parts of the country that health charges should be transferred to the Central Fund. I should like to support that plea, perhaps not entirely for the same reasons as Deputy Kyne. My main reason for doing so is that it seems to me that any effort to transfer the cost of the health services to the Central Fund would be merely a method whereby the cost of the health services would in the main be paid for by the city and town dweller. Already the State is contributing more to the cost of the health services than the local contribution and I think that——

Mr. Corish

It is exactly the same.

Sir Anthony Esmonde

It is the same, 50-50.

Mr. Colley

If you take into account other subventions referred to by the Minister for Finance, Dr. Ryan, the State is contributing more than the local authority. We should be careful about allowing that situation to develop any further.

The only aspect of the health services or the administration of the Department that I want to discuss, apart from that, is one on which the Minister has heard me before and I hope he will bear with me again. It is the subject of alcoholism. Deputy Sherwin referred to drink as being the root of all evil in this country. I do not know whether he is right or not but the subject I want to discuss is not drunkenness but alcoholism, which is a very different thing. Alcoholism is a disease. The alcoholic cannot help himself. He will keep on drinking although more than anything else he wants to stop drinking. It is not a question of exercising his will or pulling himself together. It is a disease and he needs treatment.

I want to put it to the House that this disease is a very serious one from the point of view of public health and that most of us do not realise the extent to which it affects the country. There are no official figures available to the Minister or anybody else to show the extent of the incidence of alcoholism in this country. There are certain figures but they are incomplete. Consequently, the suggestion I am going to make as to the incidence is merely an estimate based on experience in other countries. The first step I take in arriving at this figure is to consider some studies made by the World Health Organisation which seem to show that in those countries in which a study has been made the incidence of alcoholism ranges between three per cent. and seven per cent. of those who take a drink. In the United States of America certain studies were made amongst immigrant groups from various countries and they showed that alcoholism was more widespread amongst those from Ireland than amongst those from many other countries. Taking those two items together I calculate it is reasonable to say that five per cent. of the people who take a drink in this country suffer from alcoholism. I do not know the number of people who drink but I think the figure of 1,000,000 is not excessive.

Mr. Corish

It would not be. What about children?

Mr. Colley

Men and women.

Mr. Corish

That is about 40 per cent. of the whole population, is it not?

Mr. Colley

No.

Sir Anthony Esmonde

About 35 or 37 per cent.

Mr. Colley

Consider the number of your friends and acquaintances who drink. Remember these are not people who drink heavily but those who just take a drink. It includes all those men and women. If you work on that basis, that they amount to 1,000,000, then at five per cent. you get a figure of 50,000. I am trying to make it clear that this, if you like, is merely a guess and I have given the basis on which I make my estimate. It is the best we can do in the circumstances because we have not got any official figures. The trouble with this is that not alone does it seem to imply that we have something like 50,000 alcoholics but for every one alcoholic there are many people greatly affected in their lives and have their lives made miserable by the alcoholism of others. These include parents, husbands, wives and children. In addition, sometimes employers and fellow employees can all be deeply affected by one alcoholic. If you work that out the number of people affected by alcoholism in this country is, on that basis, not far off half a million people. At that stage we are reaching a problem which certainly needs to be looked into. I might say, as some slight confirmation of some of the arguments I have been advancing, that two well-known Irish psychiatrists have stated that amongst the cases they have treated of anxiety neurosis by far the largest proportion was caused by alcoholism in the parents of the patients. They are Irish doctors speaking of conditions in Ireland.

Another interesting fact that emerged from the study conducted by the World Health Organisation was that in every case the Government concerned, or the authorities concerned, had grossly under-estimated the incidence of alcoholism in their own country. I mention that in case the Minister thinks that I am laying it on a bit. When scientific studies were made these people found that they were grossly under-estimating the incidence of alcoholism. All of this is designed to suggest to the House that we have this problem and that it is on a very large scale. To anybody who knows anything about this problem the amount of misery, hardship, degradation and, indeed, ill-health caused is absolutely appalling. I think it would not be unreasonable to say the number of man-hours lost in productive work easily exceeds the number of manhours lost through industrial disputes. All of this adds up to the fact that we must take action to deal with this problem.

As to what action we should take, I suggest there are certain lines along which we can proceed. Before I suggest what those are, I am aware from the Minister that the Commission on Mental Health, which is sitting at present, is considering this problem. The difficulty is that this Commission is dealing with it because a section of the Mental Treatment Act says that, where a person by reason of addiction to drugs or alcohol is a danger to himself or others, he may be committed to an institution. This whole concept of alcoholism as a mental disease is one of the causes of our failure to deal with the problem. If you have an alcoholic in your family, you will not advertise it. Apart from the ordinary disgrace involved in it, if it is officially treated as a mental disease, you want to avoid that stigma, if at all possible. The result is that there are many doctors who, for the sake of the patient or the patient's family, certify people as suffering from bronchitis and all sorts of diseases but never mention alcoholism, which they know is the real trouble.

My contention is that this disease should not, unless in certain exceptional cases, be treated as a mental disease. The Minister might consider embarking on a very intensive educational campaign. If you think back to a few years ago and remember the situation which obtained in regard to T.B., you will get some idea of what I mean. At that time T.B. was regarded as a terrible social stigma. The result was that people suffering from T.B. were allowed to go on suffering without treatment because they would not admit what was wrong. I suggest the same problem arises here and that to overcome it you need, first, this extensive educational campaign.

This will make people realise, firstly, that this is a disease which requires treatment and, secondly, that it is a disease which is not a mental disease. If that is done, it will succeed in getting treatment for a number of alcoholics who will not get it otherwise. It will also promote the idea I am trying to propagate and will give a good deal of information to people who are alcoholics, as well as those who are not, as to the symptoms of alcoholism and, what is more important, of incipient alcoholism. As a result, people who are about to become alcoholics may be saved from this fate.

I would suggest it would be a very sound idea to provide units in the general hospitals for the treatment of alcoholism. I see two reasons for such a service. First, to overcome this stigma of treatment in a mental hospital and, secondly, to provide treatment throughout the country, for alcoholism is not confined to Dublin or Cork. You will find it throughout the country. Unless units can be provided to give treatment throughout the country, few people will come and get treatment.

The actual treatment itself—the "dry-out" as it is called—takes, I understand, only a few weeks but the problem arises afterwards when the patient is released. I have seen this myself. I know of a case where a patient, having got this treatment and having been released, was very depressed. Doctors will understand that the patient would be naturally depressed on coming out after treatment like this. The best thing the friends and relations of this patient could think of to cheer him up was another few drinks. I saw that happen and, of course, that patient was back on the same old road of degradation in a short time.

It is vital that some system of education be embarked on by the Department of Health so that this kind of thing cannot happen and to make people aware of the grave injustice they are doing if they administer drink to people who have been alcoholics and who have come out after treatment. The Minister might consider having out-patient departments set up in various hospitals to deal with people when they have got treatment. He could do a lot worse than model the treatment by the out-patient departments on the organisation, Alcoholics Anonymous. That organisation has done tremendously good work. Where medical science and religion have failed, Alcoholics Anonymous have succeeded. There is a tremendous debt due to that organisation and a good deal to be learned from its activities. If anybody thinks I am exaggerating the effects of alcoholism, I should like to mention that a Convention of Alcoholics Anonymous took place in Galway not so long ago at which two alcoholics spoke. One of them was a priest and he described his situation.

He said that alcoholism in his case had resulted in spiritual, mental and physical loss to himself, disgrace for his family and acute embarrassment for his co-religionists. Both his father and his grandfather had been rabid teetotallers, and he started drinking in order to prove that he could drink and do without it if he liked. But, before he knew where he was, he could not stop drinking. He was an alcoholic, and from then on he crashed cars, was convicted of drunkenness, stole money and went through a complete degradation, spiritually, morally and physically. This man came along to this association of Alcoholics Anonymous, testified this himself and testified what happened to him when he went in for treatment. He was 10 months in a mental institution before he finally admitted to himself he was an alcoholic. That, of course, is the first step in the cure. The person must realise himself that he is an alcoholic. This is one of the things that could be put across in an educational campaign. The actual technical details of the treatment are a matter for the doctors dealing with the problem. I would suggest to the Minister that some kind of programme on the lines I have mentioned—or perhaps on better lines if the Minister can provide it—is essential if we are to overcome this grave social evil.

Sir Anthony Esmonde

First, I should like to express my appreciation of the Minister's extremely comprehensive survey of the medical situation here. It is always an advantage when a Minister comes into the House and covers the whole picture from end to end. I do not think anyone can accuse the Minister of having left anything out. In his survey he referred to the fact that once again heart disease is the Captain of Death in this country. He said there are more cases of death from heart disease than from any other cause. He specifically mentioned the fact that coronary thrombosis is an ailment that is considerably on the increase. It must give us all cause to try to ascertain the reasons for it and see if there is any means by which it can be overcome.

Apart from the number of deaths it causes, which is as high as over 4,000, it is very disabling. People who get this disease are a long time out of work and very often, unless they are entirely freed from anxiety in any way, do not become fully functional again. The Minister gave us reasons in two of which I fully concur. He said higher standards in diet, richer foods, and the opportunities for acquiring such things were one cause, and the lack of exercise was the other. One cannot stress sufficiently lack of exercise. We have grown up in a soft age in which the majority of the people have given up walking altogether. In the City of Dublin nobody ever seems to think of walking anywhere. People take their cars everywhere they go. Lack of daily exercise ultimately means increasing weight and that, in turn, brings on the attack.

Another very definite cause of coronary thrombosis to which the Minister did not refer is anxiety neurosis. This disease is very prevalent among white collar workers, salaried people. It is due to the stress of modern times and trying to make ends meet. The high cost of everything and the high level of taxation which does not permit people to save are a constant worry to the breadwinner who feels that if anything happens to him his wife and family will be without provision. Such worry very often induces this illness.

I do not know whether the Minister can do anything about that except, perhaps, to ask his colleague, the Minister for Finance, to be more liberal to the white collar workers than he is already in regard to remission of taxation. Remission of taxation in respect of the payment of medical fees, for instance, might help to some extent to allay anxiety neurosis and result in fewer cases of coronary thrombosis.

The question of lung cancer has been very extensively dealt with by other speakers. It certainly must give us cause for reflection, that of 4,759 deaths from cancer registered in the last twelve months, 680 were from lung cancer or connected in some way with malignancy of the lung. I am inclined to agree with other speakers that the Minister cannot brush this matter aside without taking definite action, but I do not think all the speakers were fair to the Minister in suggesting he is doing nothing at all. He is doing something. He has set up the Cancer Commission and I am sure one of the terms of reference of that Commission is to enquire particularly into the position in regard to lung cancer.

As to whether the Minister can do more or not, I think he can. In the Report of the Royal College of Physicians issued in the United Kingdom recently it has been stated that tobacco smoking, particularly cigarette smoking, is a predisposing cause of cancer. They have not categorically stated it is the cause of cancer—that is the mistake most of the speakers have made so far—but that it is a predisposing cause and that is a very different thing from being a direct cause. It is also stated in this Report that cigarette smoking over and above anything else is a predisposing cause of lung cancer. It was further stated that the hot end of the cigarette produces the collection of nicotine poisoning which is this predisposing cause.

I agree with the Minister that he cannot stop people smoking, that he cannot say: "You may not smoke." It is a free country and people are entitled to smoke if they want to. I may say in passing that I do not smoke at all. Although the Minister cannot compel people to stop smoking, certain steps have been taken and certain suggestions have been made in other countries to deal with the situation. In fact, I read the other day that tobacco merchants—I think it is in England and in Italy—are considering the introduction of a cigarette with a trap or cache which would prevent the nicotine being absorbed into the system. This, of course, is only in the embryonic stages but the Minister could consider the steps they have taken, how far they have gone in dealing with this problem both in the United Kingdom and in Italy, and if it would be possible to have a consultation with the tobacco manufacturers here to see if they would be prepared to engage in the same type of manufacture so that the danger might be offset to a certain extent.

I do not consider tobacco smoking is the sole predisposing cause of cancer. In recent years methods of diagnosis have been very much better than before and whereas cancer has probably always been with us it may not have been diagnosed. With modern methods of diagnosis all cases of cancer can be diagnosed, which gives us a greater figure than before. There are, however, other predisposing causes of lung cancer, one of them being diesel oil fumes. There has been greater use of diesel oil within the last few years than before and there are statistics to show that cancer is induced by diesel oil fumes. Furthermore, it is in the built-up areas, in the cities, that the greatest incidence of cancer is found, that is where the diesel oil fumes from buses and other vehicles are to be found. The statistics of the British Navy, which are very carefully kept, in regard to the incidence of the disease, show that the rate of incidence of cancer of the lung is higher among stokers in the Royal Navy, who are dealing with diesel fumes in the engine room, than among any other section of that service.

If Deputy Dr. Browne's wishes were adhered to and the Minister were, in an arbitrary fashion, to issue a decree tomorrow to abolish smoking altogether—which of course he would have great difficulty in enforcing—it would be no guarantee of the abolition of the contributory causes of cancer. The Minister certainly has taken some steps in setting up this Commission. I hope the Commission will read the speeches of the Deputies of Dáil Éireann on the subject during the debate on this Health Estimate. Perhaps they could pool all our ideas and derive some benefit from them.

The Minister referred to smallpox. That is another disease that must give cause for acute anxiety. I wonder if we are not a little too complacent about smallpox here. If there were a case in Liverpool, I doubt if we would feel happy about it.

Mr. MacEntee

We certainly would not.

Sir Anthony Esmonde

Or if there were a case within the vicinity of the London Docks, Fishguard, or anywhere that has frequent contact with this country, I wonder if we would feel very happy. There have been several outbreaks of smallpox in the United Kingdom and we have been exceedingly fortunate that it has not spread here. Today there is wide travel. Our people are travelling all over the world. People from other countries are coming in here. Some come from countries in which there are no proper medical facilities, no proper sanitary arrangements, no proper medical statistics.

The outbreak of the disease in England was brought about through immigration from Pakistan. The type of disease brought in from Pakistan was very virulent. The disease could quite easily be introduced again. There could be an outbreak of smallpox in Liverpool. That would light up anxiety here and activate the medical authorities considerably more than are activated at the moment. The scare has died down, but it could flare up again. The type of smallpox in the recent outbreak is the most virulent type imaginable. Many years ago, I practised in Durham and it was not unusual to see as many as three or four smallpox cases a day. It was endemic in this industrial town of roughly 200,000 people in the North of England. It was not a very dangerous type of the disease because it had been there for quite some time and had expended itself. There was no compulsory vaccination. There were many so-called conscientious objectors to vaccination. There are always cranks here and there, but I think the highest percentage of cranks is in the north of England.

Mr. MacEntee

Except Wexford.

Sir Anthony Esmonde

No, the people in Wexford are very conscientious. I have been vaccinated myself. Eventually in the north of England something had to be done. There was certain propaganda. The medical authorities put up placards and posters in prominent places showing what the ravages of the disease could do. It is, of course, very disfiguring. Women were frightened out of their lives and, when women take the initiative in something, the men very quickly follow suit. I suggest the Minister should have some kind of propaganda about the risk of the disease and also about the effects of the disease. In that way, people would be made aware of the risks and the dangers. Practically 90 per cent. of those infected in England recently died.

Would it be advisable, I wonder, to introduce compulsory vaccination for children? We had it up to about 20 years ago, but, by a free vote of this House, it was decided to remove compulsion. Circumstances are radically different today as compared with 20 years ago and serious consideration should be given to the question of reintroducing compulsory vaccination for children. If people are vaccinated in childhood, there is far less discomfort than there is if people are vaccinated for the first time in adult life.

The Minister mentioned that domiciliary maternity is largely disappearing. Most women are now going into hospital to have their confinements. That is the present trend. It is putting a great strain on the accommodation available in both local and private institutions. I am told a long-established Dublin nursing home is closing down because of difficulty in carrying on. It is often difficult for people to secure private accommodation. Possibly this nursing home has to close down because of the expense and because patients are not prepared to pay increased fees.

That brings me to domiciliary maternity. What can the Minister do? I have unhesitatingly opposed the Health Act of 1953 here and elsewhere, but I acknowledge that the maternity services under that Act are a definite step forward. Those in the income groups concerned could go to any doctor for ante-natal treatment. The doctor was paid a fee. He did not necessarily have to take charge of the actual confinement, if a patient went to hospital, but he still got the same fee. That fee is well earned, but, in order to encourage domiciliary treatment and confinement, I think the Minister should increase the fee, provided the doctor attends the patient in her own home. That would relieve the health services of a certain burden because there would be a saving in maintenance. I suggest the fee should be increased from seven guineas to ten guineas. Patients would then be encouraged to stay in their own homes. Public expenditure would be saved. There would be an easement in the pressure on beds. The Minister might consider that suggestion. I think he could do what I suggest by ministerial direction.

There are three maternity hospitals which have been pressing the Minister for funds to enable them to extend their private accommodation. One of the things which have prevented the Minister acceding to this request for funds to extend private accommodation was the fact that he felt he might be injuring private enterprise, in other words, nursing homes. I do not think that problem arises now when one of the biggest private nursing homes in Dublin is to close down in the next few weeks or few months and be turned into a block of offices. The Minister should seriously consider the question of giving the hospitals the opportunity of doing the extensions they want to do and of taking in private patients. That would relieve some of his problems with regard to maternity treatment.

I now come to the question of mental health, on which quite a few Deputies have spoken. It is one of the greatest problems we have to face in this country. There is the problem of the mentally retarded child and there is the problem of mental patients. The question of the mentally retarded child is much more acute. Modern methods of treatment are now being used to a considerable extent in our mental hospitals and people are getting a better understanding of the whole matter. In some instances the walls are being taken down and people do not feel as if they were going into a jail. They appreciate the fact that they are going in for treatment. Sufferers from mental illness used to languish in mental hospitals for years whereas now they can be discharged in many cases after a short period of treatment, particularly where electric therapy is concerned.

Our problem with regard to the mentally defective child is that there is an enormous waiting list. I am not attributing any particular blame to the Minister for that. It is just a state of affairs that exists. We were, perhaps, a bit slow of the mark in dealing with the problem. It is not only a question of hospital accommodation; it is also a question of staffing and the training of nurses. Even if we had facilities for housing the patients and were able to relieve the anxiety of parents by taking the children off their hands and getting them into institutions we would not have the staff to deal with them. That is the greatest problem that faces the Minister.

The first approach towards dealing with that problem is to have some scheme whereby people would be encouraged to undergo psychiatric training so that they would be able to deal with mentally defective children. The Saint John of God Brothers and several orders of nuns have given most devoted service in that respect. They work at it for the glory of God and there is no question of trade union hours or trade union rates of wages. We are all proud of the work they are doing here but even they are unable to get postulants and they find themselves restricted in the number of patients they can take by the fact that they cannot get staff. The Minister should, if necessary, send people away to be trained in psychiatric nursing so that staff may be available to man the institutions when they are ready.

The second trouble is that in these institutions of the Saint John of God Brothers and the nuns there is not an outflow of patients equivalent to the inflow. They take them in and they have to keep them. There are many children who, after a certain period, do not need any further active treatment although they may need supervision. They are still not well enough to be sent back to their parents and they remain a liability of the devoted religious who have taken them over. The same position obtains in the Protestant homes. They, also, give very devoted service and I should like to pay a tribute to them for the work they are doing.

The Minister should think along the line of having some institution where cases of this sort could be kept. Some big estate could be bought in the country where these people could be usefully employed at farming work. One person would be able to look after quite a number of them. They would still be in charge of the experts but they would be able to lead happy and useful lives. In that way we would be freeing beds so that there could be a further inflow of new and younger patients. It is a difficult problem but the Minister may be assisted by the suggestion I have made on that point.

Representations have been made to me by people concerned with the blind. There is, apart from the blind pension, a certain allowance made to blind people. Most of these social service benefits are usually paid from the date of the application. These blind people tell me that when an application is granted it is not paid as from the date of the application but only from the date on which it is granted. I think that is a matter for the Minister for Health and perhaps he would look into it.

Mr. MacEntee

It is a matter for Social Welfare.

Sir A. Esmonde

Then I shall not go any further with it. Now I come to the vexed question of health cards. I think everybody knows that I have no time for this Health Act. I have always felt that there must be cut and dried regulations in regard to State medicine. It is the duty of the county manager to give out medical cards and I felt, when the Bill was going through the House, that it was an unfair imposition on the county manager that he should have to take sole responsibility for the issue of medical cards. He is bound by certain regulations. If a person has £9 or £10 a week he is not entitled to a medical card but if such a person has ten children, or even five children, I cannot see how he will be able to pay for a doctor, which he will have to do if he has not a medical card.

It is not so difficult to pay for the ordinary medical practitioner but there is always anxiety on the part of these people if they have to go into hospital. It is the duty of the county manager to decide whether they get the medical card or not and the county manager has no means of finding out what a person's circumstances are except through the home assistance officer. The home assistance officer sends a report back to the county manager and it is on that report that the county manager makes his decision. That may seem a beautiful system on paper but it is not. There are in rural Ireland and in the cities also certain idiosyncrasies of which we are all aware.

There are many cases of hardship. Managers may refuse cards in certain cases when they do not know the full facts. A very simple solution of that difficulty is the method of appeal. The Minister could establish the appeal board within his Department. Then, if anybody feels aggrieved in respect of a health card, there is the appeal board to go to.

Every Deputy is persecuted by people who come about health cards. I am continually being asked about that point. We may be told that certain people are not entitled to a health card because of their financial circumstances. The ordinary domiciliary circumstances do not seem to be taken into consideration in every case. The matter should not be one for the Minister as it would put an unfair burden on him. There are people in his Department who can look after the matter. The Minister may reply that if people in any constituency or in any county feel aggrieved with regard to health cards, an officer from the Department can be sent down to investigate the matter. I do not think that is as satisfactory as my suggestion of an appeal board. I appeal to the Minister to give it his serious consideration.

Mr. P.J. Burke

The Minister for Health has succeeded in making great advances in equipping our various hospitals and in ensuring as far as possible that sick persons will get the very best treatment. I want to deal with the subject just mentioned by the last speaker, the blue card. Each case is considered on its merits by the Dublin Health Authority. I have yet to find a case brought to my notice about which I could say there was a direct hardship on the individual. Recently I asked the Dublin Health Authority to give me the number of people who had received treatment free of charge in the city and county of Dublin and it amounted to something like 66,000. The number of ordinary insured workers who had to pay 10/- a day was very small. I am as close to the people as any other Deputy. If a man becomes ill and if no salary is coming into the house and if there is no other income, then invariably the charge is 2/- or 3/- a day, and possibly nothing at all in quite a number of cases.

The discretionary clause in the Health Act is very good. I know of a man who was earning over £1,000 a year and who lived up to it. He became ill for about six months. He was a commercial traveller and was paid on commission and while he was ill, he had no salary. If we have a hard and fast yardstick, such a man would be debarred, because of his salary, from benefit.

No matter what progress is made and even if we were able to do a good deal better and were able to do all the things which some members of the Opposition desire us to do—although they had six years themselves during which they could have implemented many of the promises they made to the people—the Opposition would still find fault with us. We are doing our very best. I would never like to see that discretionary clause deleted from the Act. It has been responsible for the elimination of a lot of hardship when people were not able to pay for hospital treatment.

Great advances have been made in our health services since I first came to this House. Much credit is due to the present Minister when he was Minister for Local Government and again as Minister for Health and to the present Minister for Finance, when he was Minister for Health.

Mr. Donegan

Do not forget to include Deputy T.F. O'Higgins.

Mr. P.J. Burke

I shall leave that to Deputy Donegan. I am dealing with the facts as I know them.

Mr. MacEntee

He does not want to take the words out of Deputy Donegan's mouth.

Mr. Donegan

Deputy P.J. Burke is a big, expansive man. He should be big enough to give credit to Deputy T.F. O'Higgins.

Mr. P.J. Burke

We are big enough to concede credit where any worthwhile contribution was made. Deputy Donegan has given me inspiration. It is nice of him to interrupt me. We have heard much talk recently from the Fine Gael Party about taxation. The health services are responsible for quite an amount of money. Large numbers of people claim reliefs and will try to have hospital bills reduced. Hardly a week goes by that I am not engaged on such work. We hear the Fine Gael Party say that the health charges are too high and that the rates are too high. They never tell the people that the Exchequer pays 50 per cent. of the charges.

It would be possible to make our health services a complete national charge by increasing the cost of certain consumer and other goods but the first people to vote against that proposition would be the Opposition. We cannot blow hot today and blow cold tomorrow. We hear talk about the free health services in England. There is no such thing as free health services in any country. While England has possibly more generous health services than we have, the people there, as a whole, contribute more to them. The Government in England are giving no such thing as free health services. If we were to ask our people to contribute towards the health services, how could we collect money from people who are self-employed? I will not mention any particular section. Who will ask them to contribute? That is the only way it can be done but it would be a huge job to do it. It would mean that the insured worker would have to pay a good deal more. I do not intend to deal with something which a Select Committee of the House has been set up to consider. These are the problems as we find them in the city and county of Dublin. We are all very anxious to relieve the burden of health charges but we have to be sensible as to how to approach the matter.

Let me now deal with the voluntary health insurance. That service has done a very good job of work and I should like to see it go even further, if that were possible. In regard to the voluntary health service, if you have a medical history, they are not too anxious to take you on at all. Of course, it is an independent board and they have to view the contributions they receive and see what can be done, but if there is any medical history in a family, they are not so anxious to take on that family. There are certain sections of our people who are nobody's children, and it is with that section of the community I am concerned. They have to be catered for. I should like to see that section of our people put into a particular category, if it is possible to do so. These people drawing a good salary are not possibly able to continue paying high hospital charges. However, we shall leave that aspect of the matter to the Select Committee and see what they will report to us on the matter.

I want to emphasise that there is no such thing as free health services except for the very poor and destitute who are not in a position to contribute anything. In the city and county of Dublin, we have done very well in regard to the weaker sections of our people. To say that in England they have a completely free health service is to state what is not a fact. They contribute generously towards that service. The workers have to contribute a good deal more than our people here have to contribute.

We have made wonderful advances in regard to hospitalisation and the treatment of T.B. patients. The CEO of the Dublin Health Authority, who is chairman of the National Mass Radiography Association, made a statement at a meeting of the Dublin Health Authority which perturbed many of us. He referred to the small percentage of people who avail themselves of the mass radiography service. From this House, I appeal to our people to avail themselves of this service. In certain counties, the number availing themselves of the services is as low as three per cent; in other counties, the percentage is seven; and in still other counties, it is 10 per cent.

When we are told of the number of cases of T.B. contracted by people of 40 years, 50 years and even 60 years, it is most essential for the wellbeing and good of our people that, every person should avail of the service, especially when it is made available in a particular area. A stitch in time saves nine. There are too many of our people who contract T.B. who do not know about it until it is too far advanced for successful treatment. Notwithstanding modern treatment, a number of them die. No person need stay at home now—all can be treated immediately and there are plenty of beds available. Our people should avail of the service for their own good and the good of their homes and families.

In regard to mental hospitals, the Minister has made a very big contribution during the past four or five years in the matter of rehabilitation and in the reconstruction of a number of wards in the mental hospitals throughout the country. We have too much overcrowding. There is no chance of treating people who are confined. They have got to be in congenial surroundings in order to encourage them to get better. As I say, great advances have been made in regard to mental treatment in recent years.

I must compliment the Minister on the special interest he has taken in that particular side of our hospitalisation service. I know he is fully aware of the conditions that exist in mental hospitals. He is trying to do everything he can to modernise them and bring them up to date and thus effect the cure of patients. Hundreds of patients are now discharged from mental hospitals. That was not the case some years ago. I am referring to one place in particular—Ballyowen. I might say that the Minister fathered that institution more than any other person. It is really a rest hotel for people suffering from mental diseases, so much so that the number of patients discharged, the number who have come back voluntarily for treatment and the number who have come back for consultation with the doctors is really edifying. These wonderful advances have taken place in our time.

If the Minister—I hope he will be with us for a long while yet—looks after the people who suffer from mental illness, which is as natural as physical illness, he will have the gratitude and blessings of many of our people. It will take a good deal of money. Any money that can be spent on such places to bring about complete segregation and give more room, is money well spent. In 1947, there was introduced the domiciliary service for people suffering from T.B. Prior to that, a man suffering from tuberculosis had to go to the sanatorium knowing that his wife and family had nothing to exist on. That was one of the greatest social advances in recent times and it has contributed more than anything else to curing men suffering from this disease, since it eased their minds to know that their wives and families were getting an allowance while they were in hospital.

A lot more might be done in relation to the demolition of old wings in mental hospitals and the building of new wings. The job would cost a great deal but it would be worth it. While on the subject of mental hospitals, I should like to deal briefly with the problem of retarded children. I recently attended with the Tánaiste the opening of a school for this type of child and I was amazed at the amount of work being done through voluntary effort for retarded children. This voluntary effort is more necessary now than ever, since the treatment of these children requires a very intelligent approach. Heretofore, such children were kept away from society, sometimes sent to mental hospitals by their parents, there to become as bad as the other inmates. That deprived them of the educational facilities which are now being made available in these special schools for mentally retarded children. I know the Minister has this problem in hands but I hope he will treat the matter of grants to such institutions as one of urgency.

Another group of people deserving of attention are those condemned to wheelchairs, the victims of polio or some other such paralysing disease. We have in Dún Laoghaire the Wheelchair Rehabilitation Centre which caters for a number of those people. The Wheelchair Association is an entirely voluntary body who do a tremendous amount of good work and they deserve the congratulations of this House. I hope they will get more support from the public.

An Ceann Comhairle

Has the Minister any responsibility in this?

Mr. T.F. O'Higgins

None whatsoever.

Mr. P.J. Burke

He has a responsibility towards all people who are ill.

An Ceann Comhairle

Then we shall have a discussion on everything—oh, no.

Mr. P.J. Burke

I do not want to say very much more, but I would point out the problem of people in respect of disability grants. We have quite a number of people suffering from chronic rheumatism, arthritis and other disabling ailments. They can be classed as invalids. They are treated very well in hospitals but they could be looked after at home if the disability grants were sufficient. I am not satisfied with the way city and county managers deal with applications for these allowances. They go too deeply into the means of applicants.

An Ceann Comhairle

Is the Minister for Health responsible for disability allowances?

Mr. MacEntee

I am responsible for disablement allowances.

Mr. P.J. Burke

I shall change it to disablement allowances, if that phrase allows me to get in. I find there is a very niggardly approach to this matter by the local authorities. Sufferers from rheumatism and arthritis, if they are over 21 years of age and living in their own homes, are a severe burden on their parents and brothers and sisters. If they were forced to stay in hospital, it would cost the Exchequer £7 or £8 a week. They would be far happier at home but the allowances should be sufficient to relieve their families of the cost of maintaining and looking after them.

In conclusion, I would say the Minister is doing a good job in the Department of Health and I hope he will be left there to finish it.

Mr. Desmond

I note that the Minister stepped into the breach to help Deputy Burke and made it clear that he was responsible for disablement allowances. It is well to remember that in future, because in the past, when county medical officers of health decided against an application for such an allowance, the unsuccessful applicant had no appeal. In the future, we shall be able to take advantage of the Minister's acceptance of responsibility in the matter.

Mr. MacEntee

Only for providing the money.

Mr. Desmond

The Minister did not say that, so we can argue that point again. Deputy Burke has now gone off, convinced that the Minister is the father and mother of it all. In any event, I would draw the Minister's attention to the very unsatisfactory system in Cork at the present time in connection with general hospitalisation. The Minister is well aware of it, but a red herring has been drawn across the trail. It is a disgrace to see that the efforts made over the years in St. Finbarr's are now being nullified by lack of decision. I do not want to go into any great detail because the Minister is aware of the whole position.

The fantastic, nonsensical suggestion which emanated from the Department in connection with the transfer of patients to Sarsfield Court is, in my opinion, nothing less than an abuse on the people. By now, the Minister must know that medical opinion is completely against it. The authorities of the University in Cork must themselves consider it a wildcat scheme. While the Minister can truthfully say when he is winding up the debate that he is awaiting recommendations or a decision from the Cork authority, he is equally in a position to know that hospitalisation is being held up and that the improvements so vitally necessary in St. Finbarr's to help to complete the good work carried out there over the years are being held up because of the latest red herring. That is unfair to the people there and unfair to all concerned. The sooner we get a decision that the famous, or now infamous, regional hospital proposal is a wildcat scheme, and the sooner we get the green light for the improvement of that hospital, the better.

I know the Minister will admit, as is admitted, by most critical people in the south of Ireland, that St. Finbarr's is one of the most up-to-date hospitals having regard to the amount of money available to it. The sooner the Minister's Department clears the path for us, and the sooner the work is finished, the better pleased the members of the health authority will be.

I should like to touch briefly on the question of dispensaries. I know that many people, members of the House and outside it, may be inclined to disregard the amount of work that can be carried out in dispensaries in rural Ireland. We seem to have moved into an era where we consider that nothing will do but the most elaborate hospitals in every part of the country. Some people in this Chamber come from rural areas and they should know that if we have properly situated, properly constructed, properly equipped dispensaries in the rural areas, the local people will be able to avail of the services there which will automatically mean less hospitalisation ultimately.

I am sorry that a few years ago the Minister considered it suitable to wind up the grant which had been made available for the erection of dispensaries. Even at this late stage, I again appeal to the Minister to offer to the local health authorities the advantage of financial assistance for the erection of dispensaries. I know, of course, that in Cork, in Dublin and in other centres, medical men can avail of fashionable plates on doors in fashionable centres in the cities and towns, but very often we can point to the dispensary doctors as being every bit as good in their attention to the patients in rural areas as many of the noisy people in other centres.

I wish to see our dispensary system improved, and I believe it could be improved. I would point out that in 1952, roughly, a deputation went to the then Minister for Health and it was finally agreed that in the Cork area, where possible, a nurse with midwifery qualifications would be appointed to each dispensary district. For years, that system proved to be a boon to the people in those areas and it was a help to the dispensary doctor who was interested in his work. Between the two of them, they were good to the people and gave a good service. Unfortunately, the weak link in the chain in certain centres was the lack of suitable dispensaries and lack of suitable equipment in some dispensaries. Therefore, I ask the Minister to reconsider his attitude towards dispensaries in rural Ireland and I hope that the proposals from Cork county which are in his Department in connection with the proposed erection of new dispensaries will receive the speedy consideration which we would all wish for them.

I shall not go into any detail regarding the matter of medical cards. Deputy Esmonde covered it in great detail, but, like many other speakers, I cannot say I am satisfied with the system now in operation. That system was meant to be fair and just, and unfortunately it is hard to pin it down. Even the manager of a health authority or a superintendent may be caught, because of the fact that there is so much discretion in the hands of the local assistance officers. On many occasions, because they favour certain families, they give advantages to those families and on many other occasions, because of some dislike or other they have of another family, they give no advantage but find out the last penny that is coming into the home. The result is that at present the system is undoubtedly working in many respects against itself, and against what was intended when the Health Act was introduced—a fair and just system.

While the Minister may say that the purpose of the medical card is to give a service to the person who is unable to provide for himself or his family, and while the manager of the health authority may say that each case is dealt with individually, we cannot forget that in any health authority area where a large number of medical card holders are involved, it is impossible to deal with them individually. I am not blaming the manager of the health authority for that. It is impossible for the superintendent at times to deal with all the cases and, therefore, they go back to the man who originally deals with the application, the local assistance officer.

If this situation is remedied and if the manager of the health authority, in consultation with the Minister and the Department, is brought to realise the difference in money values, and the necessity for uplifting the means test in connection with the issue of medical cards in general, then perhaps we in the Labour Party will again be able to say that we are satisfied with the improvement in the system we originally supported and never regretted having supported.

Progress reported; Committee to sit again.