In submitting this Bill to the House I avail myself of the occasion to give Senators some information on the general position throughout the country regarding tuberculosis.
For some time, largely by reason of the changing attitude of the medical profession to tuberculosis, and to a lesser extent due to epidemiological changes in the disease, it has been clear to me that a change in our methods of tuberculosis control, involving radical alteration in the local authority services, was necessary. For example, reports received from county medical officers of health in response to my inquiry, showed that a great. proportion of the cases referred to the tuberculosis service of the local authority were in an advanced stage of the disease when they sought assistance. Such experience is common elsewhere and has brought about a natural reaction on the part of the medical profession, and it is now universally agreed that the first essential in any campaign against the disease is a successful search for, and detection of cases in an early and curable stage.
It is unnecessary to point out that to secure early detection we shall require co-ordination of effort between not only the various branches of the profession, tuberculosis experts, general practitioners, public health officers and surgeons, but also the general public, all of whom would need to co-operate in a national endeavour to deal with the disease in a manner that would be calculated to achieve success.
The development of this aspect of the tuberculosis services maintained by local authorities is at present being actively pursued. As can be understood, great difficulties confront us, difficulties occasioned by the times in which we live, by the necessity to preserve the rights of the individual and yet safeguard the community, difficulties both expected and unexpected. But of all these difficulties the greatest is the lack of bed accommodation in sanatoria not only for the cases of which we are already aware, but for those which exist below the surface, and which without sign or indication, even to the unfortunate victim, progress towards a fatal stage and infect many others before detection.
It is futile to develop a full case-finding service until accommodation is available for the cases found. It is idle to hope that finding cases will be of much advantage unless the accommodation in our institutions is of a nature sufficiently attractive to the cases found to ensure that they will cheerfully avail of it, and it is clear that provision for the reasonable maintenance of the dependants of a breadwinner who contracts the disease must find a place in our completed plans. It is probably unnecessary for me to elaborate arguments in favour of the provision of increased sanatorium accommodation. Apart from the expected demands resulting from case-finding campaigns, Senators are aware that for some time past there has been an acute shortage of beds for tuberculous persons. In each county there are lengthy waiting lists, and prolonged delays have occurred between the date of diagnosis of the disease and the date of admission of the patient to a sanatorium.
The number of deaths from tuberculosis in the year 1904 was 8,798, whereas for the year 1938 the figure was 3,216, the lowest ever recorded in the country. For over 30 years it had shown a continuous and pleasing fall. Since 1938, however, there has been a rather sharp upward trend in mortality, and in the year 1942 the number had increased to 4,347. In 1943 a decrease to 4,306 took place. During that year, 24,580 persons received treatment under tuberculosis schemes administered by local authorities, and of that number approximately 8,000 received institutional treatment.
Reports received from medical superintendent officers of health and county medical officers of health indicate that many factors may have contributed to the rise in the death-rate. Housing conditions, malnutrition, return from outside the State of workers broken down in health, physical strain of training in the Defence Forces, increase in dancing facilities, movement from rural to urban areas, have all been cited as causes. It is possible that all or any of these factors may have had some influence, but it is not possible to dogmatise as to the actual cause or causes. I have fully examined the position and I am satisfied that some new factor affecting all sections of the community has exercised an influence. There is evidence to suggest that during the emergency we have been suffering from calcium deficiency and that a deficiency in blood calcium may have rendered us particularly vulnerable. This aspect of the problem is under investigation, as are also other aspects, such as housing conditions and malnutrition.
Considerable public interest has been taken in the spread of the disease in recent years. The Tuberculosis Subcommittee appointed by the Royal Irish Academy of Medicine made a special report in 1942. The Hospitals Commission has dealt exhaustively with the question and has recommended the establishment of regional sanatoria in Dublin, Cork, and in the West. The commission considered that the provision of out-door pavilions in the grounds of existing hospitals would not provide a solution and urged the earliest possible realisation of the projected sanatoria.
The Anti-tuberculosis Section of the Irish Red Cross Society has rendered valuable assistance, and in December, 1943, it presented to me a report on the outlines of a long-term tuberculosis policy. They adopted two principles:—
(1) That the standard set up by the National Tuberculosis Association of the United States of America of two beds per death should be adopted in Ireland.
(2) That the patients should not be classified as early, moderate, and advanced with a view to treatment in separate self-contained institutions, but that all types of pulmonary tuberculosis should be treated in the same institution with separate accommodation for sputum positive and sputum negative cases.
The society also favoured the establishment of regional sanatoria and advised that five such sanatoria should be provided.
The elements of a satisfactory tuberculosis scheme are:— effective and modern methods of diagnosis which will enable the disease to be detected in the early stages, not only in the case of persons who contract it but also in unsuspected persons who may be sources of infection; segregation of pulmonary sputum positive cases with a view to the limitation of the spread of the disease; provision of the most efficient and up-to-date sanatorium treatment; medical observation, advice, nutritional and other assistance as required, for persons most liable to contract the disease by reason of their exposure to infection; organisation of assistance measures so that those who require institutional treatment will not be prevented by economic causes from taking advantage of treatment; and, lastly, a campaign of education in the true facts of the disease so that the prejudices which prevent our services operating successfully will be overcome.
It is apparent to me that of all these factors the last is of supreme importance. All these essential features will be contained in the services of the local authorities following their reorganisation. But they all are pivoted on or are entirely dependent on the sanatorium — without the sanatorium it is almost useless to find cases. Welfare work is only fully successful when organised in relation to the sanatorium. Education and propaganda fall down unless there is a record of good results and cures — tangible evidence of the value of treatment-to show to people.
The isolation of known open cases is, undoubtedly, the objective of greatest urgency. The prevalence of tuberculosis infection can only be reduced by this means. Isolation is the measure which, applied to the smaller number of persons, gives the maximum of protection to the community. From the knowledge of the disease available not only from sources outside the State but from the experience of our own medical observers we know that if is in the household associates, and those living in close proximity, that the search for the new or unknown cases should begin. Such a search will reveal—of a certainty—many persons hitherto unsuspected who had fallen victims to the disease. The desirable degree of isolation is not possible unless there are institutions in which persons can be accommodated. It is impossible to segregate satisfactorily in their own homes persons who are in an infectious stage. Failure to isolate such persons or to provide them with the means of removal from their families and from the general community is responsible for the spread of the disease.
It has always been found that during wars the number of deaths due to tuberculosis increases. As I explained earlier, it is not always possible to determine the cause of this increase, but this feature has a relationship to the sanatoria project, because a rise in the death rate always is accompanied by an increase in the number infected.
The principal weapon in the fight against tuberculosis is the approved tuberculosis scheme operated by each local authority. The medical superintendent officer of health and county medical officer of health of each county as the case may be is the authority co-ordinating the various elements of the scheme in each area. Under his direction there are assistant medical officers of health with special experience of tuberculosis work, or whole time tuberculosis officers. I propose in the course of my re-organisation to equip, re-group, and by means of intensive training bring the local authority services up to the highest standard.
The tuberculosis dispensary is an important element in the scheme, and the successful reorganisation of this service will, I believe, reflect itself in the results of our efforts. Such centres exist and are necessary for the operation of the tuberculosis specialist services in each area. It is my intention to develop and equip them, to the greatest possible extent, so that they will be in future the principal diagnostic centres. They will be equipped so that each centre will provide facilities for the fullest and most comprehensive investigation of the disease. It is unnecessary to go into details of the development in mass-radiography, tuberculin testing, post-graduate education of personnel, recruitment of staff, equipment and all the multifarious activities contained in the project on which I have engaged, but as soon as supply conditions permit I propose to lose no time in providing the essential equipment that cannot at the moment be made available, and in the meantime the things that can be done to improve the service will be done.
The number of beds required has been carefully considered. It has been decided that we need at least 4,300. There are available at present approximately 2,200, so that 2,100 additional beds will be needed.
Under present conditions it would be impossible to provide these additional beds without radically changing established procedure. It has, therefore, been decided to set up a special organisation within my Department to provide and equip sanatoria on a regional basis. While the Bill proposes to confer the necessary power on the Minister for Local Government and Public Health the powers of local bodies in this respect are not being interfered with, and their responsibility for the provision of measures to combat tuberculosis are not being in any way lessened. It is intended that the administration of schemes for the treatment of tuberculosis shall continue to be the responsibility of the local authorities. In fact, the main object of this Bill is to provide these bodies with the institutions which are required to enable them, in partnership with the State, to intensify their efforts in the eradication of the disease.
In this connection the provision of accommodation for the advanced case has presented many difficulties. The disease is generally very infectious at this stage and consequently institutional care is imperative. Where treatment is afforded in small local institutions it is difficult if the institution is utilised solely for advanced cases to prevent the institution becoming associated with such cases only, eventually meaning that early cases, or cases which consider themselves early, refuse to enter. On the other hand it is not always possible to provide in such local sanatoria satisfactory segregated accommodation for persons in different stages of the disease. In the new institutions, which it is proposed to establish, separate units can be provided within each institution for cases in all stages of the disease.
I propose to establish three new regional institutions: (1) An institution containing 1,000 beds to serve the needs of Dublin City and County; (2) an institution containing 680 beds to be located in Cork to serve the Counties of Cork, Limerick, Waterford, Clare, Kerry and Tipperary (N.R.) and (S.R.) together with county boroughs of Cork, Limerick and Waterford; (3) an institution containing 400 beds to be located in Galway and to serve Counties of Galway, Mayo, Roscommon, Sligo, Donegal and Leitrim.
The eastern region consisting of Counties Carlow, Cavan, Kildare. Kilkenny, Laoighis, Longford, Louth, Meath, Monaghan, Offaly, Westmeath, Wexford and Wicklow will be served by the institutions at Peamount and Newcastle and Our Lady of Lourdes Hospital, Dun Laoghaire.
Under present conditions the provision of regional sanatoria of the size contemplated presents many difficulties. The successful completion of such a large building project requires a complete team of advisers, professional and technical, whose work can be co-ordinated under one organisation. The work must be directed and co-ordinated from the earliest stage of planning to the actual completion and equipping of the buildings. The successful provision of modern hospital buildings requiring highly technical equipment depends not only upon the architects but also upon the various branches of engineering, such as civil, structural and mechanical. Architects and engineers must work in close harmony as a team and, moreover, they must have available to them throughout the whole course of the work, but particularly in the early planning stages, administrative and medical advisers for consultation in connection with the patients' accommodation, staffing, services, and equipment. The local authorities would not themselves have that complete team at their disposal. Moreover, their proposals would require examination at the various stages of planning as the work progressed, while difficulties would likely arise during the construction period calling for decisions on the spot as to alterations in the plans, or the substitution of materials for others not readily available.
It is clear, therefore, that with the best will in the world the local authorities would be badly handicapped, and even with the closest possible liaison with my Department they would be unable to obtain the same co-ordination and speed that would be achieved by a single organisation working together in the same building under one direction. It is proposed, therefore, that the establishment of the sanatoria shall be carried out under the direction of the chief engineering adviser of the Department and his staff, who will have the Department's administrative and medical advisers available for consultation.
In this manner the work will achieve that necessary co-ordination and direction which is essential. The institutions will be of a simple character but will, at the same time, provide all the essentials for the modern treatment and comfort of the patients. Owing to the difficulty of obtaining materials there will be many departures from standard practice. The building will be designed to have all the normal amenities but some of these amenities may have to be provided later as the necessary materials become available.
The cost of establishing the sanatoria is provisionally estimated at £1,500,000 and will be provided from the Hospitals Trust Fund. The sanatoria will be transferred to, and will vest in, the local authority when they have been established. The local authorities concerned may be called upon to repay to the Hospitals Trust Board such amount as is considered reasonable, but the amount shall not exceed one-third of the total cost.
Section 5 of the Bill empowers the Minister to direct the Hospitals Trust Board to make payments out of the Hospitals Trust Fund for the purpose of defraying the expenses of the establishment and equipment of a sanatorium, and Section 6 authorises the transfer to a county or county borough council or councils of a sanatorium when established and equipped. The local authority or authorities to which the sanatorium is transferred will be responsible for the upkeep and management of the sanatorium.
Part III of the Bill sets out the procedure to be followed where land is to be acquired compulsorily. The various steps to be taken, firstly, by preliminary order and, secondly, by vesting order are defined in Sections 9 and 10. The remaining sections are concerned with procedure in relation to registration, compensation and deducing of title.
In bringing this Bill to the Seanad I am confident it will have the approbation of the House. By this step we are making an advance at a time when the results to be obtained will be greater than might be achieved at any other time.
I wish the Seanad to regard the provision of additional bed accommodation not only as the most urgent immediate requirement upon which our further progress will depend—but also as a part of the general plan I have outlined, and which I hope to bring to maturity.
Given the full co-operation of all good citizens, and the financial resources necessary, I believe the 1942 death rate could be reduced by 50 per cent. within ten years. Such a possible achievement is worth working for, and if we can convince all concerned that it is worth paying for, one of the obstacles between us and real progress will have disappeared.
