Policy for Women's Health: Statements.

Minister of State at the Department of Health (Mr. O'Shea)

I welcome the opportunity to outline to the House the steps the Government is taking to improve women's health and to inform Deputies about the preparations under way for a plan for women's health. Why do we need a special initiative on women's health? It is disappointing to report that in spite of the dramatic advances in women's health since the forties, the life expectancy of Irish women at birth is one of the lowest in the European Union. The reasons for this are complex. Mortality from heart disease in Irish women is among the highest of any of the European Union countries and is currently 70 per cent above the European Union average. Adding years to the life expectancy of Irish women is one of the major challenges facing the health services in the next decade. Women's health deserves special attention because it is at special risk during pregnancy and childbirth. Women's health may also be undermined because of the multiple roles which many are called on to play as a result of their economic dependence and gender based violence. Low self-esteem linked to social and economic attitudes to women's place in Irish society inhibits many women's full development and this impacts on their health. The high incidence of depression among women is perhaps a symptom of a deeper social problem. Since women rely on good public health and social services to maintain their health. We must be aware of women's vulnerability to illness and disability and actively work to promote their health.

Many health services for women tend to operate independently of each other, without common objectives or links. One gets the impression that our services are geared to deal with a breakdown in the system rather than with promoting the concept of the "well women". We need to focus on the health needs of women over their lifetime to identify how health services for women could be improved and to take action to ensure that Irish women enjoy the highest attainable standards of health.

I acknowledge the role the former Oireachtas Joint Committee on Women's Rights chaired by the former Deputy Monica Barnes played in raising awareness about women's health. In 1991 a deputation from the committee led by Deputy Monica Barnes met the Minister to outline to him the concerns of many women about the health services and the extent to which they were not responding to women's needs. Following that meeting a women's health committee was established in the Department of Health. This committee collected the information and research findings on women's health which formed the basis for current initiatives on women's health.

The former joint committee's concern about the response of the health services to women's health needs was echoed in the 1993 report of the Second Commission on the Status of Women. It recommended that the Minister for Health should publish a discussion document on women's health, that there should be widespread consultation on the contents and that the Government should adopt and implement a plan for women's health. The former Minister for Health, Deputy Howlin accepted this recommendation and a commitment was made in "Health Strategy, Shaping a Healthier Future" to the publication of such a document, to consultation and to a women's health plan. This commitment was given a new significance when it was included in our Government programme, A Government of Renewal.

Last June, the first part of his commitment was fulfilled by the publication by my colleague the Minister for Health, Deputy Michael Noonan of a discussion document, Developing a Policy of Women's Health. At the same time he initiated the second part of the commitment, the consultative process which will lead to the adoption by Government of a plan for women's health early next year. I was particularly pleased that prior to the publication of the discussion document, the Council for the Status of Women now renamed the National Women's Council of Ireland, agreed to assist with the consultative process on the discussion document so that the plan for women's health will be informed by the authentic and representative voice of women. Over 130 organisations are members of the National Women's Council representing over 300,000 women in the Republic.

The discussion document looks at the health services from a woman's point of view. It analysis the health status of Irish women and pinpoints the main causes of morality and morbidity among women. The main causes of premature death among Irish women — that is deaths among women under 65 years — are cardiovascular disease, cancer, especially of the breasts and lungs and accidents. Following the principles of the health strategy the document looks at the scope for preventing premature mortality and increasing health and social gain. The document points out that there is great scope for reducing premature mortality in women, principally by a reduction in smoking, by screening for breast and cervical cancer and by good nutrition. The discussion document examines health issues particular to women, such as childbirth and gynaecology, breast and cervical cancer and violence against women. It commends the high quality of care in our maternity services but advocates a more consumer friendly approach by the hospitals and staff involved in the care of expectant mothers. The challenge to our health and education services of teenage pregnancy outside a stable relationship is highlighted in the document.

The document identifies health issues which predominantly affect women, such as family planning and support for carers, and issues which affect women differently from men, including drug dependence, mental illness and dental health. It records recent initiatives on these issues and suggests where further action is needed. The problem of accessing health services by disadvantaged women such as women with disabilities, traveller women and women in advanced old age is discussed. The need for greater consultation and representation of women in the health service is highlighted and suggestions are made as to how the voice of women could be more clearly heard on the health services. The discussion document concludes by suggesting priorities for tackling the main health problems of women to be addressed in the plan for women's health to which the Government is committed.

In choosing priorities for inclusion in the plan for women's health, it is clear that the most serious causes of mortality and morbidity among Irish women should receive attention. There is no doubt that cigarette smoking is the single greatest cause of premature death and preventable illness among Irish women. There is a direct link between smoking and the very high level of mortality from heart disease among Irish women. I realise that smoking is not usually seen as a "women's" health issue but, given the scale of harm it causes to women, we must give a high priority to persuading as many women as possible to stop smoking and prevent as many girls as possible from taking up the habit. I will refer later to the most recent initiative on smoking.

Cancer claims the lives of thousands of Irish women each year. A proportion of these deaths could be prevented. We could wipe out most forms of lung cancer by persuading women to stop smoking. We could reduce deaths from breast cancer in women over 50 by one third by screening women aged 50 to 64 for the disease. We could prevent about 40 of the 75 deaths from cervical cancer each year by a programme of screening of women aged 30 to 50 years.

A further priority suggested in the document is making our maternity services more responsive to the expectations of mothers and partners for more individual care and greater involvement in decision making. Our services must also respond more effectively and in a more co-ordinated way to women who are the victims of domestic violence and rape.

We know that the health of women in the travelling community is much worse than that of other women and the document suggests that their health needs should receive particular attention in the plan for women's health. The under-representation of women at most levels in the health services also needs to be addressed, and more research is needed about women's health needs.

While there is much to be done in this country, the health problems of women in many countries of the world are so great that they demand our attention and assistance. Ireland has a long and distinguished record of aid to the developing world, much of which has benefited women. The discussion document suggests that we need to strengthen our commitment to improving women's health in the developing world and the emerging democracies of Eastern Europe.

These priorities were identified in the discussion document to focus discussion during the consultative process which will lead to a plan for women's health. I have no doubt that these priorities will be modified and possibly changed as a result of consulting women on what they consider to be the most important issues affecting their health.

The consultative process on the discussion document began immediately after publication. The first step in this process was a conference held on Friday, 30 June 1995 on the discussion document organised jointly by the Department of Health and the National Women's Council. Representatives of every organisation affiliated to the council were invited, as well as representatives of health boards, professional organisations and many voluntary bodies active in the field of health. Over 200 people attended the conference, which I had the pleasure of opening. Contributors included Noreen Byrne, Chairperson of the National Women's Council, Dr. Freda O'Neill, the Department's medical adviser on women's health, Maureen Gaffney, Chairperson of the National Economic and Social Council, and Deputy Frances Fitzgerald.

The conference was most successful. It confirmed the positive way in which the discussion document has been received by all those interested in women's health. Participants made useful suggestions about the way in which the consultative process should be carried out. They also identified issues which were not included in the discussion document but which they felt should be addressed in the plan.

Following the conference, the Secretary of my Department wrote to the chief executive officer of each health board about the discussion document and the consultative process. Health boards were asked to consider the discussion document at one of their regular meetings, to actively pursue consultation on the document and to nominate a senior member of staff to act as a coordinator for the consultative process. Each board has since appointed a coordinator to ensure that the consultative process is as wide and deep as possible. Each board is taking steps to consult women by way of well publicised public meetings, seminars and workshops on the document or issues in it. Women have been invited to make submissions on the document through local newspapers and local radio. A number of boards are consulting their own female staff on the document. As women and employees of health boards, they are a particular source of expertise on women's health and women's experience of the health services. I am glad that two health boards, the North-Eastern and North-Western, have, independently of the discussion document, consulted women about how health services for women can be improved. In these two boards, consultation on the discussion document will take place on a strong foundation.

My Department has also agreed with the National Women's Council on how consultation with women at regional and local level can best be organised. The aim is to tap the resources of the boards and women's organisations to make sure that as many women as possible are given an opportunity to comment on the document and identify priorities for the plan. The council is particularly keen that marginalised women are consulted and that the consultative process is as participative as possible.

With assistance from my Department, the council has employed a project officer to work closely with member organisations of the council and the health boards to ensure that the expectations of the National Women's Council of the consultative process are met.

Consultation is also taking place with other groups concerned with or involved in women's health. Submissions have been invited on the discussion document from interested organisations and individuals. On Friday, 20 October, the Department of Health, with the Congress of Trade Unions, held a joint conference of women's health which provided women trade unionists with the opportunity to examine the document in detail and express their views on the contents of the plan for women's health.

Following consultation on the discussion document, the Department of Health will begin developing a comprehensive plan for women's health for adoption by the Government early next year and implementation over the next few years. This plan will provide a focus for improving the health of Irish women, addressing the needs of women who are vulnerable to ill health and improving the responsiveness of the health services to women.

I stress that this document is not an excuse to hold up developments which will promote women's health or reduce illness among women. Even since the discussion document was published, decisions have been taken on some issues where there is general agreement that progress should be made. Funding has been allocated for counselling women with crisis pregnancies and research has been commissioned on the reasons women with crisis pregnancies seek terminations abroad. A tribunal to assess compensation on an ex gratia basis of women infected with the hepatitis C virus as a result of receiving anti-D blood products is being established. On 6 October last, the Minister for Health, Deputy Noonan, announced the expansion of the breast cancer screening programme which has been piloted by the Eccles Street project. The first phase of the expanded programme will, it is hoped, be commenced by the end of this year. It will cover the Eastern, North Eastern and Midland Health Board areas. It will target 120,000 women in the age cohort 50 to 64, which represents 50 per cent of the national target population.

The Department of Health is putting in place the organisational structures and arrangements to support the commencement of the first phase.

I was pleased to honour a commitment in the health strategy, "Shaping a Healthier Future", when I launched the health promotion strategy in July last. It was the first document of its kind to be launched in Ireland. The health promotion strategy targets premature mortality amongst women and men. Most importantly it identifies goals and targets and it is in pursuit of these that a significant improvement in the health status of the population can be achieved. Improving the health status of women will receive a high priority in the implementation of the health strategy. It addresses the prerequisites for the success of a national strategy.

In this context it is vital to acknowledge that many people and organisations have a role to play in achieving improvements in health status. Health promotion takes place in the home, school, community and workplace and it is by co-ordinated, targeted actions in these settings that improvements will be made. Achieving better health status is in the interests of a large number of key organisations in the public, private and voluntary sectors.

Whilst the health promotion unit of my Department will play a pivotal role it it only by multi-sectoral involvement and participation that the healthier choice will become the easier one to make. It is the individual, equipped with appropriate knowledge and skills and supported by a healthy environment, whom I want to see enabled to exercise the healthier choice as a result of this strategy. Not only will individuals be more likely to enjoy their full potential in life but our country will benefit economically and socially. A multi-sectoral consultative committee on health promotion has been established and will soon begin to make a vital contribution to health promotion.

In recognition of the importance this Government gives to health promotion and the serious risk posed to the nation's health by smoking, I was pleased to launch a comprehensive action plan to reduce smoking in May this year. The five main features of this plan are: a reduction of 5 per cent in the advertising and sponsorship budgets of tobacco companies in Ireland from January, 1996; a strengthening and widening of the regulations which prohibit smoking in certain public places; a review of the voluntary code on smoking in the workplace — this initiative was put in place last summer and the feedback is being received from various companies from which a report should be completed in 1996; implementation of supports for the retail sector to assist it in observing the law on the sale of cigarettes to children. I look forward to the initiative in this area which will be launched later in the month by the health boards' chief executive officers with the support of the Irish Heart Foundation. There will be a continued development of health education programmes designed to increase awareness of the dangers of tobacco. Steps have already been taken with the development of the Smokebusters programme which is being made available to selected primary schools and the SCRAP programme for secondary schools which I launched recently. Both programmes us a peer-led education approach with a view to encouraging children and adolescents to develop the skills necessary to resist the pressure to become a regular tobacco user and to take responsibility for their own health.

As part of this plan, I launched a new media campaign last Monday which aims to persuade smokers to stop smoking and young people to avoid taking up the habit. The theme of the campaign is "say what you like — smoking kills!". The campaign is targeted at three groups of the population — young girls, smokers aged 30-45 and smokers in the lower income groups. We attach particular importance to stemming the uptake of smoking among girls and young women. We want to counteract the peer pressure on young girls to smoke and the inference of some tobacco advertising that it is sophisticated for women to smoke. We recognise the difficulties of persuading women in the lower income groups to give up smoking. For women on low incomes it is more than just a habit; it may be one of the few sources of pleasure in their difficult lives. We have engaged the Centre for Health Promotion Studies at University College Galway to undertake an indepth examination of the effectiveness of the campaign so that we can gauge the results and inform our decisions on future initiatives in this area.

I am proud to say that the discussion document, Developing a Policy for Women's Health, is the first of its kind to be produced by a Government of the European Union. The publication of this document opened, for the first time, a major process of consultation on the health needs of women and the capacity of present services to meet them. It represents an important step towards positive equality of women in the health sphere to which they are entitled as a matter of social justice. I am pleased that there is full and active participation in this process by a wide variety of organisations and people interested in women's health. I look forward to hearing the many views and observations the document will provoke and to seeing them reflected in the plan for women's health.

Mrs. Geoghegan-Quinn

Ba mhaith liom ar dtús mo comhghairdeas a dhéanamh leis an Aire as ucht go bhfuil tuarascáil bhreá den chineál sin againn inniu agus go bhfuil díospóireacht ar siúl sa Teach mar gheall air, an chéad uair, sílim, go raibh aon díospóireacht againn chomh fada is a bhain sé le cúrsaí sláinte na mban. Creidim gur dul chun cinn é. Tá sé tábhachtach go gcuirfí na moltaí atá san tuarascail i bhfeidhm agus beimid ag brath ar an Aire len é sin a dhéanamh agus ag faire air go speisialta go ndéanfaidh sé rud cinnte ina thaobh sin.

It puzzles me that when people talk about the progress women have made it is always in terms of their careers, roles and positions. For example, they tend to talk about women in politics, the fact that there is a female President and women in management. What is more important is that there should be a widespread general sense among women that they are more in control of what they do with their lives and their health. Rarely do we have an opportunity to discuss women's health issues in the House other than discussing a specific aspect during Private Members' time or at Question Time.

This debate is welcome and timely because of the ongoing concerns regarding hepatitis C and other health issues. It arises from a commitment in the document Shaping a Healthier Future which was published in 1994 by the previous Government of which I was a member. It is an important document because it charts a future course for the health services generally. There was provision within the health strategy for various discussion documents to be brought forward as a matter of priority. This document was promised as part of that strategy.

Women's health requires special attention because of the major role women play in society. Until now there has been neither sufficient debate nor action on the issue. Even though women make up over half the population, issues concerning their health do not tend to receive either the media coverage or discussion time they deserve. Some of this stems from the broader problems in society regarding women's issues: they are slotted into a male driven agenda. Hopefully this document will mark a turning point and from now on they will be placed at the top of the agenda. It is important that this is so.

Women play a key role in society. Their reproductive role places them at a considerable health risk. They work under great stress fulfilling many roles at the same time. We all know women who are economically dependent and they will ensure their children's or partner's health is taken care of before their own. In some cases by the time they get around to taking care of their own health it is too late. We need to educate women and empower them to take control of their health.

A broader issue which must be discussed is the representation of women in the health services. Most of the top management posts in the health sector are occupied by men and the absence of women at senior levels in the health service means pressure groups are often the only bodies that articulate women's perspectives. The representation of women in health service posts is an important and urgent matter that needs to be tackled. Who better to know the types of health services necessary and how those services should be managed than women?

This discussion document makes disturbing reading. It quickly dispels the popular myth that Irish women are among the healthiest in Europe and that the health care provided for them is adequate. The document shows that the life expectancy of Irish women at birth is one of the lowest of any member state of the European Union. For women aged 40 Ireland has the lowest life expectancy of any EU member state. This discussion document rightly notes that there is considerable scope to add years to the lives of Irish women. One of the recurring themes in the document is the importance of education in terms of women's health. Education is necessary in regard to diet and lifestyle so that there can be a reduction in the mortality rates of women. At present the main causes of death among Irish women under 65 are cardiovascular disease and cancer. Deaths from heart disease are higher than the EU average. This emphasises the importance of education in terms of risk factors such as smoking in particular, hypertension, high fat diet and sedentary lifestyle.

The discussion document notes the higher prevalence of cancer and depression among female general practice attenders than among men. It highlights that women in lower socio-economic groups are more likely to be admitted to psychiatric hospitals, have a higher prevalence of chronic conditions and are more likely to develop cervical cancer than women in the higher socio-economic groups.

The report notes the absence of good research on the health of women in low socio-economic groups. It must be a priority therefore to establish the state of women's health generally and the socio-economic factors that influence it. Since women in the lower socio-economic grouping are very often economically dependent they almost always take care of everybody else's health problems, in the same way as they take care of other problems, except their own. By the time they get around to looking after their own health problems it is often too late.

There is great scope for the Department of Health through the health boards and health centres — which have a network although it is not as efficient and widespread as we would wish — to establish in conjunction with all the voluntary women's groups which exist in every area and do much good work, a health education policy that gets through to all women. For instance, in the past the Department of Health under various Ministers implemented very effective health education policies particularly in regard to smoking.

This debate is timely as we have recently witnessed one of the biggest health tragedies in the State, that is the infection, between 1970 and 1994, of more than 1,000 mothers with hepatitis C through the contaminated blood product anti D. As we now know, there are other infected groups such as haemophiliacs and those who received blood transfusions. We do not know at this stage how many of those will come forward or will be detected under the national screening programme. Hepatitis C is a serious and potentially life threatening virus for which there is no effective cure. As we are aware from the report of the expert group that examined the Blood Transfusion Service Board, contamination occurred because the Blood Transfusion Service Board failed to follow its own standards for donor selection and to heed clear warning that the product was contaminated.

The discussion document, Developing a Policy for Women's Health, makes a two page reference to contamination in this case and outlines the historical position. It is a presentation that needs radical rewriting in view of the findings of the expert group. The Miriam Hederman O'Brien report is a very valuable document and we have yet to discuss it either in this House or in the Select Committee on Social Affairs. I hope the Minister gives us an opportunity to discuss that report at some time in the future.

The Minister's document refers to the "comprehensive counselling programme" of the Blood Transfusion Service Board. That is the service strongly criticised by women who turned to it for help when they found they had hepatitis C since they were questioned about their lifestyles whether they had their ears pierced recently, whether they had tattoos applied to any part of their body and so on. The expert group believed that service was not an appropriate one from the Blood Transfusion Service Board. There are many counties — Cork, Limerick, Clare, Kerry, Waterford, Tipperary, Roscommon, Leitrim, Carlow and Longford — that still do not have an independent counselling service for infected women and their families. Nearly two years after this terrible tragedy unfolded there is no designated independent professional counsellor in those areas to whom women can turn for the help they need. The Minister will agree that is totally unacceptable. It highlights a failure to fulfil the commitment to meet the needs of infected women.

In his policy document the Minister states that services for persons identified under the national screening programme will be available for as long as they are required. That is a laudable aspiration but it lacks the clear guarantees needed which infected people deserve. I would be the first to admit it is impossible for any Minister or Department to say now what the future health needs of this group will be, but just as the seriousness of the health problems these women will face cannot be determined, neither should they be dismissed. Some women have already died as a result of the hepatitis C infection. The State has an absolute obligation to meet all the health needs of infected women.

The document also refers to the Government's commitment to establish a tribunal to pay fair compensation to infected women. The ad hoc tribunal proposal put forward by the Minister for Health, Deputy Noonan, has virtually met with a stone wall from the voluntary groups representing those infected. As a result of pressure from those groups, an announcement was made by Fianna Fáil that it would publish a Bill to put the tribunal on a statutory basis. There was an indication from our colleagues in Opposition that they would support such a Bill and a motion was put before the Seanad last week on the tribunal. The Minister has entered into what I hope are genuine negotiations and discussions with the groups involved. I hope those discussions will be fruitful and will have a satisfactory result for the women infected and their representatives. However I warn that these discussions must be brought to a conclusion by the first week in December.

I hope that time limit will be adhered to because it would not be beneficial if negotiations were to again break down and the Minister and his Department went off on one tangent while the women's groups, with support from the Opposition, went off on another. I am sure the discussions would be supported by everybody as they would be a beneficial development. If they fail, the Bill introduced will provide for the findings of the tribunal being placed on a statutory footing and we will push that to a vote in this and the other House.

The experience of women with hepatitis C raises the wider question of women's access to health services. That is an important consideration in the formulation of policy. I would welcome research detailing women's experience of the health services which would be a useful input to the type of discussion that will and has arisen following the publication of this document. We do not know how many women have a regular general practitioner, if they make appointments with their doctors or how long women, often with children, have to wait in surgeries even when they have appointments. We also do not know if women find they can talk freely to a general practitioner about family planning, menopausal difficulties, sterilisation and other issues. The Minister gives a commitment in this document to make available a comprehensive family planning service before the end of 1995. There is little more than six weeks left before the end of the year and I do not have evidence of the availability of such a comprehensive family planning service — not just to the major towns and cities but also available through general practitioners in health centres throughout rural areas — where there is a major need and a demand for such a service for women. Research in this area carried out on behalf of the Department would be beneficial as it would highlight the weaknesses and strengths in different areas and one could be balanced against the other. The benefit of positive results in certain areas could be applied to those with negative results in regard to women who do not have as comprehensive a health service as they would like. Often, women seeking a comprehensive family planning service must travel a long distance from their area to gain access to it.

Another aspect not addressed, or one I could not find, in the report is the issue of the location of health centres. Given that part of the constituencies represented by the Minister of State and I are in rural areas, he will be aware that such a service is not available in many of them. In other areas they may be located in places to which women find it difficult to gain access. In some towns and villages the health centre is often a health hazard. For many years such centres may have been neglected perhaps because the health boards have not invested in upgrading local health centres as they consider other areas of health care deserve a higher priority. If we are to provide as comprehensive a health service as the Minister of State and I would like, the health boards must spend small amounts of money necessary in many instances to upgrade health centres. Health boards provide limited services in certain areas and that issue must also be addressed.

Women's access to hospitals is another important matter that must be discussed in the context of this document. The move towards the location of major hospitals in key areas makes a good deal of economic sense to the Exchequer, but the cost of making trips to such hospitals which may be located a long distance from women in low socio-economic groups must also be considered. I am aware from my time in Government that when a proposal is put forward that will incur a good deal of money it must be balanced against the best decision in terms of the Exchequer. That issue is like others we were sensitive in dealing with while in Government. A social as well as a cost factor in terms of the Exchequer must apply to such decisions.

Services can be made available in certain areas. For example, in my constituency it was the trend for many years for general practitioners to set up practices in areas and remain in them until their retirement. They provided an excellent basic service to the local people. Suddenly, a young, bright go-ahead general practitioner arrived, took account of the fact that he was living 50 miles from Galway city, decided it was unfair for this patients who have the same health problems as those who live in a city to be so far removed from an ambulance service and did something about it. He got the community involved and took a lead role in organising a fund-raising campaign with the assistance of the Order of Malta, a voluntary group, to provide an ambulance in his area. Such initiative was unheard of in that area previously and that general practitioner is from the same county as the Minister of State. The general practitioner took another initiative. He noticed that small operations were carried out in day care facilities in the local hospital and he questioned why he should send his patients to that facility in the University College Hospital in Galway which would clog up the system when he could perform them in his surgery. He put forward a proposal in that regard to his local health board and he now performs such day care surgery in his practice. Health boards should consider that issue and it should not fall to one individual with bright ideas to use his initiative to address those problems. Health boards and the Department of Health could learn from such practitioners. If more responsibility were given to general practitioners, many procedures carried out in accident and emergency departments of hospitals in the period from December to February could be reduced. Such minor emergencies could be dealt with in a day care facility in a well equipped health centre attached to a general practitioner's practice. That would save a good deal of money. I gave that example to highlight the initiative taken by a general practitioner for whom things have worked out very well.

Maternity services are crucial to the health and well-being of women. The task force which has been established is welcome. I hope it considers matters such as the length of time women are kept waiting for parental care and the presence, without consent, of medical students at the time of birth and during examinations. Some women find their presence offensive. This issue is not only confined to but particularly relates to maternity services. Female patients find that their consultants who make their rounds with six or ten medical students in tow is an invasion of their privacy and their consent is never asked before such an entourage arrives. That area should be considered by the task force.

Many women express concern about the lack of opportunity to ask questions about their pregnancy during hospital visits and when in hospital. We must remember that we in the House are articulate and would always ask questions irrespective of whom we would be dealing with, but many women do not ask questions about their health and sometimes feel intimidated. The task force should consider this matter.

The issue of breast-feeding raised in the document is important and must be treated sensitively. On the one hand, women may not be given enough encouragement to breast-feed their babies, but on the other, people may be over zealous in pushing that method. When my first child was born 21 years ago ten babies were born on the same day and eight of the ten mothers bottlefed their babies. When my second child was born 16 years ago 12 babies were born on the same day and ten of the 12 breastfed their babies. That was a major change in five years, probably as a result of a change in hospital policy. It was not that anybody was over zealous but an effort was made in the hospital to give information to expectant mothers when they called for their examinations prior to their confinement. Breast-feeding is recommended and provides a defence mechanism to a child against infection. It is an issue that should be dealt with sensitively.

The latest FÁS report on its Dublin services indicates that the number of women at work in the capital city rose by 50 per cent over the past 20 years while the number of men remained static. That interesting statistic points to the importance of healthcare in the workplace for women especially in relation to chemical hazards. The Department of Health can play a positive and supportive role in regard to this. However, the Department with responsibility for labour affairs has to take the lead. That Department is responsible for FÁS and NISO and it should take advice from the Minister's Department and implement it. The State services, where many women are employed whether in Departments or semi-State companies, should show the way and the Departments responsible for labour affairs must be vigilant.

In the debate on the abortion information Bill all Members, including the Minister, expressed concern at the lack of counselling for women in crisis pregnancies. It is important that proper counselling is available to women at every stage during this crisis in their lives and it should be State supported. Caring and compassionate counselling must be widely available and it was agreed at the time of the abortion debate that resources would be provided. The Minister was in agreement that education counselling services must be available to general practitioners who are the first professionals to be consulted by a women in a crisis pregnancy. I hope the Minister will tell us what progress has been made in regard to counselling because there was a definite commitment to it.

The main reason women are more in control in the area of health is the better flow of information. Cancer is a word seldom spoken, other than in hushed tones. It was viewed as such a threat to health that people closed their minds to it and refused to try to come to terms with it. That has changed. Today we have a greater awareness of the disease, how to prevent certain forms of it and how to cope with it. It would be wrong to overstate the progress that has been made and I do not want to falsify the picture in relation to breast cancer, one of the major unsolved problems and threats in medicine today. It is the second most common cause of death in women between 25 and 35 years of age and the most common cause of women's death in the middle years.

I mention those grim facts because it is important not to lose sight of the threat this disease poses. We should not stop supporting research into it or sharing information which can prevent it. The fact that breast cancer still presents a profund theat to women does not mean there has not been progress. There has been a great increase in the level of awareness of the disease and a radical improvement in detection methods. Better options are available to women who have had surgery to excise such cancer. A network of services — but not enough — and human supports are available to help women following surgery. The last group is worthy of special mention because women who have been through the ordeal and who are devoting a good part of their time to helping other women to get through the trauma need support. No treatment, whether surgical or chemical, compares with that simple human support.

This worthwhile document raises many issues. It has allowed people to debate many issues. This is not confined to women but to many organisations and groups. I look forward to the Minister receiving many submissions on the document and I will be interested to hear what the health boards have to say. I hope my contribution will be helpful. I will support any initiative to put in place a better health policy for women in each of the health board regions.

Ms O'Donnell

I welcome the opportunity on behalf of the Progressive Democrats to participate in a debate on women's health. As Deputy Geoghegan-Quinn said, it is a rare opportunity for us to address, in a positive fashion, women's health and well being as distinct from items of legislation which tend to deal with particular crises, such as the abortion information legislation and family planning legislation which was introduced over a long period.

For many years a policy on women's health lacked the participation and subjective experience of women because women were not involved where the policy was being formulated. As Deputy Geoghegan-Quinn said, there are very few women involved in the higher echelons of policy making. In the main, it is left to lobby groups and the umbrella group, the National Women's Council, to feed in the experience of women as a social partner to the formulation of policy. This has marked a great improvement in reflecting women's experience in the formulation of health policy. Unless women Members participate in debates such as this, and in our committee system, and unless women are appointed to the higher levels of public policy making outside the House there will continue to be a democratic deficit in relation to policy issues on women's health.

I welcome this discussion document which contains many good ideas. However, many of the ideas come from the 1994 health strategy, Shaping a Healthier Future, most of which are recommendations outlined by the Second Commission on the Status of Women in 1993. There is a danger of becoming bogged down in a paralysis of analysis on the various issues. There is no substitute for one definite initiative when it comes to issues on women's health. We could end up dealing with aspirational reports for a long time. I accept that women's health has been making steady progress. This relates to the greater economic independence of women and more control. It is accepted at public policy level that women have a right to control their own fertility which for many years was not accepted by the State.

A matter I wish to raise about the document reflects my own experience. The document is firmly entrenched in conventional medicine. At no stage in the report is there an acknowledgment that many thousands of women in Ireland have abandoned conventional medicine and have opted for alternative medicine. There is a medical prejudice against non-conventional medicine but this is not reflected in reality because many women have decided to move away from the drug-based prescription for every ill and have opted for methods such as homeopathy, healing, herbalism, reflexology and aromatherapy. It is extraordinary that in all the policy documents we debate in the House, and in all the responses from Government and State agencies, there is not even a mild acknowledgement of that sphere of alternative medicine which is so popular, particularly among women. I question whether there is a prejudice among the powers that be in medicine against alternative methods.

Mrs. Geoghegan-Quinn

We will bring in some oils to the Minister next week.

Ms O'Donnell

A silent revolution is taking place. The choice is being made by women on how to keep well. This debate would be devoid of reality if we did not acknowledge that hepatitis C has had a disastrous effect on women's health. That so many women were infected by this virus because of negligence by the State is appalling. I know discussions are ongoing, with a December deadline, but these women should be given whatever they want. My party will support placing the tribunal on a statutory basis if satisfactory negotiations are not completed between the representative groups and the Government.

The Government's response has been inadequate in terms of the availability of counselling on a nationwide basis. It is tragic that the main negotiators in this whole affair are the victims. These courageous women, victims of State negligence, are required to go through protracted and detailed legal negotiations with the Government to get what they want and to assure themselves that their long-term health needs will be guaranteed. Although there has been goodwill on the part of the Minister and the Government, they should be in a position to be satisfied with whatever deal is negotiated. In other countries people would be in jail as a result of this episode. Here, as usual, there has been a flight from accountability and voluntary resignations with golden handshakes. The report by Dr. Hederman-O'Brien must be debated by a committee of this House because its implications are serious.

Women bear the major brunt of the effects of unemployment and poverty in addition to having the responsibilities of child care, care of the elderly and the disabled members of our society. Consequently, women are more likely to become ill and in general to be more dependent on health services. For these reasons, even if health policies in principle do not appear to discriminate against women, it is vitally important that when health policy is being considered, its effects on women are taken into account and their specific needs considered. This gender based approach, therefore, to the formulation of health policy is justified in the case of women because women's health issues are different from those of men. This House must concentrate specifically, at policy and discussion document level, on issues which particularly affect men's health such as the uniquely high rate of suicide among young men.

Health services account for approximately 20 per cent of all Government spending. The existing health services, with varying degrees of success, attempt to meet a wide span of needs. The Commission on the Status of Women made a wide range of recommendations recognising that the delivery of a responsive and comprehensive health service would make a significant difference to the quality of women's lives. Those recommendations were made almost three years ago and we are still discussing them.

Depression is a major cause of illness among women. Approximately 38 per cent of all admissions of women to psychiatric hospitals are related to depression. That figure is from the Annual Report on Health Statistics, 1993, published today. Overwork and putting their dependant's needs before their own have contributed to low esteem of women and subsequent depression.

In the past, too much emphasis was placed on drugs as a treatment for depression in women. Many women now use alternative medicine such as reflexology and aromatherapy to treat the symptoms of depression. Those forms of alternative medicine are not available in the public health service because there is not any recognition that they exist. If the State recognised them they would be much cheaper than conventional medicine.

Women are the main users of the health system either for themselves or their families. By virtue of pregnancy and childbirth women are particularly vulnerable to ill health. While women may live longer than men, the quality as well as the length of their lives must be examined. Figures show that at the age of 40, women in Ireland have the lowest level of life expectancy of all women in the EU. This document focuses on reducing premature mortality in women by reducing smoking, extending breast and cervical screening and ensuring proper nutrition.

In doing this there is a danger we might be drawn into creating a parallel health care service for women. We already have a good GP service network and if the primary health care system was enhanced by virtue of a good GP network, it would be more responsive to women's needs. Women like to have their health needs addressed at local level at the first possible and most convenient point of contact. There is great scope for an economic enhancement of medical services by extending GP services around the country. The Minister seems to be in agreement with this principle as at the recent European medical conference in Dublin Castle, he said that specialist services should not be duplicated in any health board region.

Governments all over the world spend huge amounts of money on their health services. We must ensure that more money is allocated to primary care and to streamlining expensive high technology medical services. Excessive duplication should be eliminated. A greater enhancement of primary care is the best way forward, particularly in relation to women because many do not have transport and their best health needs can be met at local level by their GP. Access to laboratory and physiotherapy services would cost less than funding high technology hospital services, to which we all aspire, but when we are talking about an area of limited resources and a relatively small population, we do not have the opportunity of providing high technology services around the country.

Primary care services should be better developed in relation to health education. The discussion document outlines the dangers posed to women's health by smoking, heart disease, lung and cervical cancer. It is fair to say that the increased life expectancy and the improvement in women's health through the years has not come from medical improvements but by changes in lifestyle and in the environment. Given that they come in contact with approximately 90 per cent of their patient population over a three year period and that women of childbearing years have the highest attendance at surgeries, general practitioners are in an ideal position to implement the health educational aspects of this document. Women should be entitled to avail of a full medical check-up by their GP every two years. This would involve a breast examination — despite the fact that breast cancer is the main killer among women most of them do not carry out this examination — a smear test and advice on diet, nutrition, the dangers of smoking, family planning, HRT and the menopause. This would not involve a huge cost to the State and would greatly improve the quality of life and health of all women. We could substantially improve primary health care by using the existing GP network and the detailed knowledge GPs have of the family history, social background, etc. of their patients.

Cancer accounts for approximately 20 per cent of deaths among women. Cancers of the lung, large bowel and stomach account for the largest number of deaths among both sexes while cancer of the breast accounts for the largest number of deaths among women. Ireland ranks fourth highest in the EU in terms of the number of deaths from breast cancer. I welcome the breast screening initiative recently announced by the Minister which will eventually ensure a national breast screening programme for women over 50. Mammography screening has not yet proven to be totally effective for women under 50. The most effective method of screening for younger women is regular breast examination. However, some women are not fully aware of the importance of these examinations and unfortunately many of them do not carry them out on a regular basis. We could make some impact in this respect by improving GP services and ensuring that women have bi-annual check ups.

In 1993 cervical cancer accounted for 74 deaths. While screening for cervical cancer is simple, quick and relatively inexpensive, not all women at risk of the disease respond to requests to attend for screening. It has been found that women from the higher socio-economic groups present for screening while women from the poorer socio-economic groups may fail to do so. As it is mainly in the latter group that deaths from cervical cancer occur one can see that there is a direct relationship between socio-economic conditions and mortality.

A report on cervical screening was recently lodged with the Minister for Health. When will we see this report? Should we not be reading it in conjunction with this discussion document? Women and their doctors would like to know what the Minister and the Department will do in relation to screening for cervical cancer. The document says that smear testing could be provided without charge to women covered by the GMS and women in the 30 to 50 age group who are covered by medical cards could be invited to avail of a smear test at recommended intervals. However, these are only aspirations and there have been no detailed promises on the action to be taken in regard to this aspect of women's health. Women who are covered by the GMS can only have a smear test as a diagnostic measure and they are not allowed to have one for screening purposes. It is outrageous that poor women with medical cards are only allowed to have a smear test as a diagnostic measure. I hope the Minister will allow such women to avail of smear tests for screening purposes.

The document deals with abortion and the need for counselling. The abortion rate among women is rising and, given the clandestine manner in which Irish women avail of abortion abroad, it is inevitable that they will have inadequate aftercare. The Minister said that funding had been allocated for counselling women with crisis pregnancies and research has been commissioned on the reasons women with crisis pregnancies seek terminations abroad. He will not have to spend much money in trying to find out the reasons women with crisis pregnancies seek terminations abroad; it is because they cannot have their pregnancies terminated here. We could deal with the issue of counselling but unfortunately it is not being dealt with at present. The provision of such counselling was promised during the debate on the controversial abortion legislation. It was extremely difficult to get that minimalist legislation, which only allowed women to receive information to facilitate their travel abroad, through the House.

Every year approximately 5,000 Irish women travel to Britain for abortions. During the past 23 years 63,000 Irish women have had abortions in the United Kingdom. Research has shown that the majority of these did not consult with any medical professional here. A study of 53 Irish women in Britain in 1991 shows that four were sent by a pregnancy counselling service and five by their GP while the rest had obtained the telephone numbers themselves. We know very little about the conditions under which these 5,000 women travel to Britain each year. While many of them have independent means I believe the vast majority of them are young poor women who travel alone. In many cases their pregnancies will be more advanced as it will have taken them a few weeks to collect the money. They leave like thieves in the night. The State cares very little for the physical or emotional condition of these young women, not to mention the difficulties experienced by them when travelling alone. Research has shown that many women who receive counselling, which is absolutely essential, opt not to terminate their pregnancies, which is in the public interest. Given our national self-delusion and hypocrisy, we will not solve this problem during my time in the Dáil.

Teenage pregnancies are a related matter. While the marital birth rate has fallen sharply there has been a tenfold increase in the birth rate outside marriage. Births to single mothers are heavily concentrated among the younger age group. Approximately 40 per cent of all first time births are to single mothers while approximately 19 per cent are to teenage girls under 20. Early parenthood can have physical and social consequences, including a greater likelihood of living in poverty. The high incidence of pregnancy among young people highlights how vulnerable and ill equipped they are to deal with the issues of sexual responsibility and contraception. There has been little or no success in the promotion of pregnancy prevention in the education system.

The findings of a recent survey of teenage mothers conducted at the Coombe Women's Hospital showed that many of them took no precautions and had no understanding of their own ovulation cycle. The best way to address this matter is to be honest and introduce a comprehensive sex education programme in second level schools. The number of births is proof that teenagers are not being given the information they need. There is a need to highlight for young women the disadvantages associated with early unplanned pregnancies and for young men the responsibilities associated with parenthood as well as the requirement to share the responsibility to use some form of contraception. That is the only way forward if the number od teenage pregnancies and abortions is to be reduced.

While women are well represented in the category of general practitioner this is not the case when it comes to senior medical posts. There are only three female consultant gynaecologists out of a total of 83. The imbalance as between women and men in senior positions needs to be systematically and thoroughly corrected to provide equal career opportunities for women and to ensure that female patients have the option of being treated by a female consultant, if they so wish.

The Department of Health, health boards and professional bodies need to adopt equal opportunities policies. There is scope to pursue a more flexible approach to job-sharing in the health services. Some work practices militate against the advancement of women and constitute indirect discrimination. For example, junior hospital doctors have to work long hours. This work pattern can cause severe problems for doctors with children. What specific action will be taken to address these issues?

The unlawful activities of a doctor which were brought into sharp focus recently have shaken women throughout the country. The nature of the abuse was such that it could only be understood by women. They are anxious that procedures are put in place, be it at Department of Justice or Medical Council level, to ensure that allegations of abuse are dealt with as a matter of urgency.

Concern has also been expressed about the way in which the board of a voluntary hospital dealt with the complaint from a patient who alleged she had been abused. It dealt with it in the way it would have dealt with a personnel or disciplinary matter. It has now been accepted this was inappropriate. An external review of procedures at the hospital in question is being carried out.

There is an anomaly in that a doctor in a health board hospital may be suspended under the relevant legislation pending an investigation whereas the voluntary hospitals are left to their own devices. The Minister has ordered an inquiry into the matter.

This debate is timely in that serious issues have arisen during the past year. I look forward to hearing the contributions of female Members and of those Members who are also members of the medical profession. It is important that we obtain their views.

Mr. Nealon

I wish to share my time with my colleague, Deputy Ring. We have all heard successive Ministers for Health outline aspirational plans to shape a healthier future. A gender based approach has been adopted in this discussion document — Developing a Policy for Women's Health. This is great stuff, but I would like to see results. The Minister should immediately launch a national breast cancer screening programme targeted at all women in the high risk age group of 50 to 64. The Irish Countrywomen's Association recently organised a magnificent campaign to encourage women in this target group to attend for screening.

This document states that the number of deaths from breast cancer among women over 50 years of age could be reduced by about 30 per cent by a well organised breast cancer screening campaign. The Government is committed to the phased expansion of a screening programme for breast cancer in women between the ages of 50 and 64 thoughout the country. This phased expansion will take place subject to the limitations of ensuring appropriate expertise in all aspects of breast cancer screening.

That is not an adequate response given that the number of deaths could be reduced by 30 per cent. There is no need for further research or the introduction of further pilot programmes. It is a question of making the necessary resources available for a national screening programme. While the Minister may point to the cost of providing mammography facilities women must be encouraged to attend for screening as a matter of routine once they reach a certain age. Such a policy would produce results.

I was fascinated to hear recently that there are significant benefits to be gained in having two X-rays taken as distinct from one. This may lessen the need to recall patients for further examination. It is also significant that the number of deaths from cervical cancer in women of all ages could be reduced by up to 60 per cent by a similar screening programme.

I am glad this document contains a commitment to promote equal opportunities programmes in organisations funded by the Department of Health and to secure the appointment of a greater proportion of women to health bodies.

I also note the discussion document's remarks about aid in the developing world. Last week I had the great satisfaction of seeing what can be done with such aid in South African townships. With little money enormous advantage can be derived from the efforts of the Irish aid programme abroad.

Finally, I return to my original point. There is no need for further research or pilot schemes, only for action on national screening for breast cancer. The Minister can take such action, all that is required is the will. The services are available and I trust the Minister will implement them.

Debate adjourned.

Dáil Éireann debate - Thursday, 9 Nov 1995