Seanad Éireann debate -
Thursday, 15 Feb 1945

Vol. 29 No. 14

Tuberculosis (Establishment of Sanatoria) Bill, 1945—Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time".

Mr. P.J. O'Reilly

It is very difficult to pick up the threads of a speech which has been truncated. Perhaps, it would be well for me to refer to one or two points which I made last night. The principal of these points was that, instead of concentrating on two or three big sanatoria, it would be better to have a larger number of smaller sanatoria — perhaps one for each county, or area, under the control of a county medical officer. If our efforts to eradicate this disease are successful — and we hope they will be —then the need for the larger sanatoria will not be pronounced. In fact, the two things are inversely related— the size of the sanatorium necessary and the educational campaign.

I should like to call the attention of the Parliamentary Secretary to an incident that happened nearly 30 years ago near the village of Fethard, in County Tipperary. A site was purchased for a sanatorium then. It has remained in the possession of the county authority since. Nothing has been done about it. Nearly 30 years ago, a nurse and medical officer were appointed for the sanatorium, which has not yet been built. The people of Tipperary with whom I am acquainted feel that some steps should be taken, and taken soon, to implement that scheme of nearly 30 years ago. Now, we find that a big regional scheme is contemplated. That will change the position considerably. Tipperary, measured inland, is 106 miles in the longest way, and if you associate Tipperary, Waterford, Kerry, and Cork you will create a problem as regards the sending of patients to the sanatorium to be situate in Cork. I think that the county medical officer should have some sort of institution under his control. He would, in that way, be able to centre the attention of the people of the immediate neighbourhood on this disease, and on the importance of its eradication.

I quite agree with previous speakers that the educational aspect of this question — the aspect with which I am particularly concerned — is, perhaps, the most important aspect. There is one point in relation to that matter to which I should like to call special attention. The county medical officer has informed me that the age at which young people normally enter the vocational schools — 14 years — and the time they remain there — from 14 to 16 or 17 years — is the most serious period as regards tubercular disease. It is curious that the Act under which schools are inspected — the Inspection of Schools (Medical Services) Act, 1919 — applies only to elementary schools. Students attending vocational schools may not be medically inspected under that Act. I draw the attention of the Parliamentary Secretary to the need for revision of that Act, so that young people attending vocational schools will, in future, be subject to medical inspection by the county medical officer. A good example of the importance of an educational campaign was furnished many years ago. I refer to the campaign organised by Lady Aberdeen. Many Senators will recall that considerable results followed from that campaign. Windows that had not been opened since the repeal of the window tax a couple of hundred of years ago were opened for the first time, and the importance of fresh air as a curative factor in the treatment of this disease was realised by a number of people. The campaign resulted, so far as I am aware, in a very considerable reduction in the incidence of the disease.

Considerable attention has been devoted to the position of the county medical officer of health. I suggest that, in addition to a county medical officer, there should be a county veterinary officer with somewhat similar powers. I agree with Senator O'Donovan that diseased milk is a very big factor in the spread of his disease. I know a district about 25 miles from here where a large number of people have suffered from tubercular disease of the bones. Many painful cases came under my notice in that connection. I am informed — the Parliamentary Secretary will correct me if I am wrong— that that is a form of the disease related to bad milk. It is unnecessary to emphasise the advantages which would accrue from the appointment of a county veterinary officer, not alone from the standpoint of the prevention of tubercular disease, but from the standpoint of the farmer anxious to rear healthy live-stock.

Inspection of dairies is allowed; in fact it is obligatory in a case where milk is being supplied to the towns. But those of us who are familiar with the country will remember the awful conditions under which the housing and milking of cows goes on. Many of us then are not surprised that this disease takes a grip in places which are never inspected. I wonder why a veterinary surgeon should not be allowed to inspect those places, even in cases where milk is not supplied to the towns. It is rather significant that we have this Bill dealing with the establishment of sanatoria, the Diseases of Animals Bill and the Mental Hospitals Bill, all coming together. I am informed that there is a very close relationship between mental and tubercular diseases, and so it would appear that the three Bills will help in this fight.

The educational campaign, in my opinion, is very important, and I agree with some speakers of last night who suggested that we do not fully utilise the services of the ordinary medical gentlemen throughout the country. One of the things that astonished me is that there does not appear to be any organised co-operation between the county medical officers and the various other medical officers throughout the country. If a small sum of money were set aside and the medical officers in the different parishes agreed to give a certain number of lectures to the young people attending the primary and vocational schools, and also a certain number of evening lectures, I imagine it would be a very important part of the educational campaign. Of course, the need for co-operation with the Minister for Education is obvious, but from my experience, when two or three different Departments are concerned, each Department sits tight, and wants to know for how much money the others are going to assume responsibility. That seems to be the great difficulty when we are trying to get co-operation between the Departments.

In the matter of co-operation, I should like to give one little example. Possibly the Parliamentary Secretary is already familiar with it. In Tipperary, we have in the vocational schools a number of those shelters to which I made reference last night, and I suggest that, in addition to their intrinsic value, they have the much more important value which comes from a realisation of the need for segregation. If an individual who is either developing the disease or has not fully recovered from it lives with the rest of the family, it is almost certain that everybody in that house will be wiped out sooner or later. Therefore, in my opinion, there is great advantage in arranging for the provision of those shelters. As the Local Security Force and the Local Defence Force appear to be about to be disbanded, it struck me that the members of those forces could do very valuable work for the country if they continued to give their services in the fight against this disease. I would also suggest that if many young people attending rural technical schools would agree to give their services free in the making of a sufficient number of those shelters, a considerable amount of good work would be done in the fight against this disease. Everybody has heard the Americanism about taking down the sidewalks, and I think we have all heard of those big training colleges, some of which turned out to be more or less white elephants. I suggest that if this educational propaganda is carried out extensively and thoroughly, which can only be done if a sufficient sum of money is set aside for the purpose, then the need for those big buildings which are to cost a considerable amount of money will not be nearly so great. I should like to see buildings of a type that could be expanded or contracted according to our needs. I would almost go as far as to say that I should like to see buildings of that type on wheels so that they could be moved from one part of the country to another.

I am afraid my remarks have been just a little bit disjointed. If I had been able to continue my observations last night I might have done better, but I think I have said enough to suggest to the Parliamentary Secretary some things which may require attention. I should like to say to him too that, if I appear to disagree with his big scheme, I am merely seeking to get his views. I realise that his information is far greater than I could ever hope to have, and I am putting up those suggestions about the county sanatoria so that he may see his way to explain the advantages of the big buildings. As I explained last night, I have been a member of a tuberculosis care committee for the past ten years. I think I have attended practically every meeting, and I can assure the House generally and the Parliamentary Secretary in particular that I am very keenly interested in this matter. A very dear relative of my own died of this disease, and so I have always taken a very great personal interest in the subject. My remarks, therefore, are intended to be of a constructive nature.

Mrs. Concannon

In the admirable speech with which the Parliamentary Secretary introduced this Bill in the other House, he intimated that he would welcome a full discussion of the whole problem of tuberculosis. The whole-hearted way in which Deputies and Senators — because the invitation was extended to us also — responded to that invitation must have pleased him very much, not only because of whatever additional light the many-angled discussion may have brought to him but still more as a proof that members of all Parties are conscious of the magnitude and the urgency of the problem which he is tackling, and are ready to give him every ounce of help they can give in bringing his fight against tuberculosis to a successful conclusion. I do not remember any proposals which were received with such cordial unanimity as those embodied in the present Bill. For the proposals themselves, the Parliamentary Secretary does not claim more than this: that they are — I think he called it — an urgent pre-requisite of any rational attack on the menace of tuberculosis. The aim is the provision of adequate institutional treatment and the eradication of the tuberculosis bacilli in our surroundings by the isolation of the persons affected. We are all conscious, and the speeches we have listened to have emphasised the fact, that even though these new sanatoria may be up-to-date and satisfying in every way, when they are in full working order, a great deal will have to be done before the problem is solved.

A great deal must be done in the fields of sociology and above all, in education. It is going to be a hard fight and our Parliamentary Secretary will need everybody behind him, but in a special manner he will need the women of the country. It is largely the women of the country who can help him to bring this fight to a successful conclusion. We are heartened by the knowledge that other countries have brought it to a successful conclusion. Somebody mentioned the case of Sweden. Not so long ago I was talking to a nurse who was training in Holland and she told me that Holland was ravaged by tuberculosis, but that before the war they had brought it under complete control. What Holland can do we can do, because in the matter of climate I am sure that we are more favourably circumstanced. They say that the economic condition of the Dutch is better than ours, but that is probably because they work harder, and I think their women are better trained in those domestic arts which are at the root of all true and sane living.

The women, I cannot emphasise it too often, by training themselves, by running the home properly, and giving their families the best food, can make a vast improvement in our living conditions. It is not that the food is not there, or that it is dear, because dear food is not always the best food. For generations the people lived on a diet of potatoes and milk. Of course, they were good potatoes. Some of the potatoes to-day do not seem to have the proper nutriment, but in the olden times people did live on potatoes, milk, oatmeal and vegetables. Oatmeal porridge and oatmeal bread produced a splendid hardy type of man and woman, capable of doing great manual work and giving a good account of themselves everywhere.

Side by side with what we are trying to do in this Bill, we must begin a great campaign for sound education and especially the education of the women. If the Parliamentary Secretary has not the women behind him to keep the homes of the people in a healthy condition and provide the food which is in their reach, then the building of sanatoria will be of no effect. In the other House, one of the Deputies spoke of the purpose of this Bill as the first round—talk of boxing was then in the air. Unfortunately the fight against tuberculosis cannot be fought according to the Queensberry rules— you cannot finish the round with the ringing of a bell. Several speakers reminded us that if you give institutional treatment to the bread-winner of a family, immediately the problem arises of providing for those who were utterly dependent on his earnings to keep alive.

That problem has already been mentioned by the Parliamentary Secretary and I am sure it has given him a headache. Already the rates are very high and there is a heavy burden of taxation to be borne by the citizens. In this connection, I mean to make a suggestion which might provide a partial solution of the problem, but it is a suggestion which is, I think, at all events worthy of the Parliamentary Secretary's attention. I say it is only partial because it only affects 600,000 people who are members of the National Health Insurance Society. Not so long ago, the Parliamentary Secretary, with that care which is a conspicuous hall mark of his work, piloted through an Act which made it possible for the Committee of Management of the National Health Insurance Society to provide additional grants rather than to pile up reserves from the savings and surpluses as disclosed by the quinquennial examination of their finances.

Although I am a member of the committee of management of the society, and believe that it is bad taste to give ourselves bouquets, I think it is one of the best managed and economically run societies that ever existed. It is quite certain that there will be very considerable surpluses and savings in the future. I would suggest to the Parliamentary Secretary that the most clamant need that could be met by those surpluses and savings is such an increase in the statutory sickness and disablement benefit as would bring them within a shorter distance of the needs of the sick people whose earnings they are supposed, in a meagre manner, to replace.

I think it is quite possible that at the next quinquennial valuation there will be such a surplus available, and perhaps the Parliamentary Secretary would look into this matter with a view to trying to see how the statutory sickness and disablement benefits can be made worth while in view of the steep rise in the cost of living and the change in social conditions. These statutory benefits are illusory at the present moment, and I have always felt that the first thing we could do to improve the National Health Insurance Society is to try to apply the savings and surpluses to give sickness and disablement benefits that would be of some use.

With the other questions debated, from the sociological side, the incidence and the effects of malnutrition and bad housing, as far as possible the people are trying, the Government are trying and the local authorities are trying to deal, but there is a great deal that people could do for themselves. One of the things they could do is to educate themselves. At least it should be possible and within the reach of most people to have a sound education on health and malnutrition. Senator Baxter commented on the fact that while the Minister for Agriculture arranged lectures on the proper feeding of animals nobody bothered much about the proper feeding of human beings.

I suggest that the vocational educational committees should have lectures on such subjects in plain and simple language, demonstrating what can be done, for instance, by the use of the stock pot which should be in every Irish home. We are now using turf for cooking and heating and the stock pot, which is the equivalent of the old pot oven, is particularly suitable where there is a turf fire. Into that pot can go the vegetables which the man of the house should grow in the garden or allotment. There should be an encouragement also to people who have cows. Of course, it may sound fantastic, but if we can share machinery with a neighbour I do not see why some families cannot share a cow. That would not bring us back to the days of the Táin Bó Cuailgne as somebody might suggest; it is an idea which could be considered. With good potatoes and vegetables in comfortable homes, the health of the people and the whole economic prospect of the State would be improved, and in this fight against tuberculosis these are some of the objects to be attained. I commend them to the Parliamentary Secretary most cordially on my own behalf and on behalf of the women of Ireland. I wish him God speed.

Prof. Fearon

Unfortunately I had not the pleasure of hearing the debate last evening, and I do not want to raise any point that has been already raised, or to say anything irrelevant, but it appears to me there is one point that might be brought up at this stage. The great Bill is, of course, a very comprehensive attack on a very great problem. It concerns nutrition as well as education. It appears to me that it might be possible to make this scheme to provide new sanatoria a kind of focus for the convergence of what might be called goodwill when dealing with this problem. The word "sanatoria" here means hospitals for the treatment of persons suffering from tuberculosis. One has recollections of hospitals as places where people were sent for treatment. I should like to see the word "hospital" changed to "centre" and to see the centre linked up with medical research, agricultural research and all other knowledge gradually acquired.

This scheme is so large, and it can do such an enormous amount for the subject, that it seems to me that this is a great opportunity to spread its ramifications. For that reason I should like treatment to include rehabilitation, the preservation of records, and even diagnosis. I should also like to see many other things associated with it. Unfortunately I speak under the disability of not having been present yesterday, so I hope the Parliamentary Secretary will excuse me if I am forcing an open door. Tuberculosis is a big problem, a challenge, but I feel that in this Bill we are taking a very great step forward, and that we are capable of meeting it.

Mr. Duffy

The course which the discussion has taken here and in the Dáil may mislead people into thinking that the field is much wider than it is. The excuse or the justification for the character of the discussion in the Dáil was, probably, to be found in the fact that a very comprehensive resolution was discussed there in connection with the debate. I take it that here we are discussing the Bill only. In that connection I draw attention to the fact that the Bill is strictly limited in its scope. It authorises the establishment of sanatoria, and I gathered from the Parliamentary Secretary that it is intended to provide three new institutions out of the Hospitals Trust Fund, and that these institutions are then to be handed over to local authorities to administer. There is general agreement with the proposal and there is pleasure derived from the fact that the Parliamentary Secretary is taking a big step in providing these three institutions. Some doubt arises in my mind concerning the location of the hospitals. I assume that I am entitled, when money is provided to erect three institutions, to say what I think as to where they should be erected, and, if possible, where they would be best situate. County Dublin generally is a suitable centre, but I have a grave doubt about the site suggested at Ballyfermot. I suggest that Rathfarnham would be a much more suitable place in the vicinity of Dublin. I do not profess to have any expert knowledge, but I gather that there is a feeling in other countries that these institutions should be erected at high altitudes. I came across a statement dealing with this subject in an American publication recently, which pointed out that altitude has a decided influence at least on phthisis. The quotation runs:

"The rarity of the disease at high altitudes in Switzerland has been demonstrated and a like protective influence is enjoyed by certain elevated districts in Mexico, notwithstanding the insanitary conditions of the towns within these districts."

If the site suggested for Dublin is capable of being rejected on the grounds that it is low-lying and inconvenient, I think the idea of erecting one of these institutions in Galway is doubly wrong. That is not a central point for the area intended to be served, including three Ulster counties. Again, almost any site in Galway is low-lying. I have a strong feeling that that is not a desirable venue for an institution of this kind, and that from the point of view of convenience, Sligo would be a far more preferable centre. I prefer not to discuss the suggested institution for Cork. I have a feeling that the Cork site is not an ideal one.

Dr. Ward

If the Senator does not mind himself he will have a worse feeling when the Corkmen get after him.

Mr. Duffy

I was afraid of that and I do not want to discuss it at great length, but I might point out that when the Cork County Council were providing a sanatorium they went to a place about 40 miles out from Cork. I should imagine, if these institutions are to have permanence and if their erection is to involve the expenditure of a lot of money, that attention should be given, as no doubt it is being given, to the question of location.

There is another aspect of the provision of sanatoria which appeals to me very strongly, that is, the desirability of having attached to each institution a sufficient area of land to be utilised for farming purposes. That has been the aim in regard to mental hospitals. There is, I think, in all cases an effort to provide a large farm attached to the institution and the same aim seems to me to be desirable in regard to sanatoria. The Parliamentary Secretary is probably conversant with the character of the institution provided at Papworth in Cambridgeshire. In that instance a very large farm at a high altitude was selected, a farm which had a large building already standing on it. It is interesting to recall that the building was the home of the celebrated Ernest Terence Hooley. The building formed the centre around which the institution was erected. I do not know exactly the extent of the estate but it certainly was a large one, something, I think, in the neighbourhood of 700 acres. It was used for the purpose of enabling men who were in a position to go out working, to follow a normal active occupation. Something similar was attempted at Peamount but the land available there was not a very large area and the scheme did not get very far.

The conditions, of course, were totally different from those obtaining in Britain from every angle, because in the case of Papworth the aim was to build up a colony and a large number of houses were erected for persons who had passed from the patient stage. Men brought their families to live there in very comfortable houses. Men who were patients actually got married and started their married life in the colony. I do not think it desirable that we should go that far, but I think that attached to all sanatoria there should be a certain area of land which patients could cultivate. Buildings should also be provided in which they could engage in such other occupations as they desired. In the case of Papworth there was even a very big printing works. They competed for contracts all over the country against ordinary commercial printers. They had also woodworking shops, leather-making factories and glove-making, and at one stage I remember they took over central premises in London as showrooms, so that they actually carried on a commercial venture in connection with the treatment of patients in the sanatorium.

I do not want to go into the matter at great length, because I do not think it quite relevant to the Bill, but it is worth while noting that patients employed in these enterprises, both in Peamount and Papworth, received full wages, the ordinary rate of wages for the job, related to the number of hours the men worked. The difference between the cost of the patients' maintenance and the amount earned was met from some special fund, but as these men in the case of Papworth reached a condition where they were able to work an ordinary day, they earned an ordinary day's pay and ceased to be a charge on public funds. I am mentioning these matters because I think they are of value in regard to treatment. I have no doubt that the Parliamentary Secretary, who has himself professional qualifications in this matter, will appreciate the value of them.

I think it was Senator Mrs. Concannon who pointed out that what is provided in the Bill is only a step in the war against the ravages of tuberculosis. That, I think, is generally acknowledged. The Parliamentary Secretary himself acknowledged it in the course of the debate elsewhere. I would point out that while isolation is important, we should not stop merely when we take an affected person from his home and put him into an institution. We ought to look behind that case to see what further action can be taken, and further action must be taken if we are to stamp out tuberculosis or even to keep it under control. The Irish Red Cross Society estimates that there are 40,000 sufferers in the country to-day. The death-rate has been pretty well stabilised for 25 years. Prior to that, figures were very high. In 1904 deaths from the disease numbered 8,798. In 1910 there were 7,000, and then up to 1939 there was a gradual decrease until they came down to the 4,000 figure. I think the figure for 1938 was the lowest, 3,260. Roughly, the death-rate represents ten deaths per 1,000. Out of every 1,000 deaths in this country, ten are attributable to tuberculosis of one form or another. That figure may appear alarming but it bears no relation at all to the statistics when you come to examine the sections in which the greatest number of deaths occur.

The real liability to phthisis begins between the ages of 15 and 25 and the deaths in this country in 1943 from tuberculosis within these age limits numbered 642 out of every 1,000. Out of every 1,000 people between the ages of 15 and 25 who died in 1943, 640 died from tuberculosis. The figure is still high for the class between the age limits 25 and 30 — 540 out of every 1,000. Then there is a sharp decline in the ages between 35 and 45, the figure being 356 out of every 1,000. You may take it, therefore, that the serious inroads made by tuberculosis on our people occurs mainly between the ages of 15 and 25. All told, the death-rate between the ages 15 and 35 from tuberculosis is roughly 60 per cent. of the total number of deaths. Some question has been raised elsewhere as to the accuracy of certain figures concerning deaths from tuberculosis.

I want to point out that in this country we have a remarkably high record of uncertified deaths. We have heard here figures with regard to certified deaths during the last ten years in this country, but we have nothing to show the cause of these deaths, or to what disease they were attributed. I think that, for the year 1943, it was shown that in Dublin the rate of deaths due to the disease was something like 16 per cent., but I imagine that it would be somewhat higher in the rural areas. Fifteen or more years ago, it was commented on by the report of an insurance committee that there was a serious defect in our statistics of mortality, due to the large percentage of deaths from unascertainable causes. I think that some argument might be developed as to whether tuberculosis is induced by, or is the product of poverty. Possibly, the Parliamentary Secretary could contend that it is not. It has been established that tuberculosis is not a hereditary disease. I understand that that has been established, and I understand also that it has been established that it is not due to climatic conditions. I believe that that has been proved. I have here a statement by a German scientist, which says:

"The mean level of the temperature has no significance for the frequency or rarity of phthisis in any locality."

Sir John Keane

Or the humidity?

Mr. Duffy

I have nothing to show that, but it has been accepted for at least 40 or 50 years that the disease is not hereditary, and, therefore, we are faced with the problem of dealing with the germ of this disease successfully in the way that members of the medical profession deal with other diseases. For instance, a few years ago there was an epidemic in one portion of this country, with which, I am sure, Senator O'Dea would be familiar, and as a result of the efforts of members of the medical profession that disease has been eradicated. Now, I feel sure that it is possible to do the same thing in regard to tuberculosis. I want to quote here, in this connection, a statement from a pamphlet published by the Irish Red Cross Society. The title of the pamphlet is: "Tuberculosis and How to Prevent It." The following is the quotation:

"The most important factors in the development of the disease, after infection, are, without any doubt, malnutrition, over-exertion and bad housing, in that order. Malnutrition is undoubtedly the most important of these three. If you eat enough, and if you eat the right foods, the danger of developing serious tuberculosis is immensely diminished, even if you become affected."

Dr. Ward

"After infection." Would the Senator develop that point of "after infection", because it is a very important point?

Mr. Duffy

Yes. I emphasised that. The most important point was after infection.

Dr. Ward

Yes, we are all in agreement there.

Mr. Duffy

The pamphlet issued by the Red Cross Society, as I have indicated, said that the most important factors in the development of the disease, after infection, were malnutrition, over-exertion, and bad housing, in that order, and that malnutrition, undoubtedly, is the most important of these three.

I want to emphasise that because of the fact that you are now dealing in these institutions with people who are already affected by the disease. You are taking them away from their homes in order to prevent the spread of the disease in their families, but by doing so you are leaving the family in a condition through which they are more likely to become victims of the disease than through the original cause. Let us assume that a man is earning £4 a week. He is living up to that standard and lives in the kind of a house that a man earning £4 a week can afford to live in. He generally buys the quantity and the kind of food that a man earning £4 a week can afford to pay for.

Now, that man is found to be suffering from tuberculosis, and is induced to go to a sanatorium. In fact, I think that the Red Cross Society and the medical profession, generally, practically insist on his going into such an institution early, so that treatment can be given to the disease at the beginning, and before the disease gets a hold on him; but it must be remembered that by taking that man away from a job in which he was earning £4 a week. and putting him on unemployment assistance at 15/- a week, you are reducing his family, during the period of his treatment for the disease — which might take three months, six months, or more—to a standard of living on a basis of 15/- a week. The real trouble is that such a man, notoriously, puts off and keeps adjourning the time until he has to go into the sanatorium. Of course, in that sanatorium you have a wonderful building, every equipment that might be necessary, and highly skilled people to deal with the patient when he gets there, but once that patient surrenders himself to the institution, he knows that his family are going to be worse off by his going into the sanatorium, because he has abandoned his job for that period.

It will be argued, of course, that people can get national health insurance benefits, in certain circumstances, or that they can go to the home assistance officers and get free fuel, and so on, but I want to point out that the ordinary workingman in this country —the tradesman, the small farmer, or the farm labourer — for whom this remedy is prescribed, would rather die than go to the relieving officer to get home assistance or food vouchers, and I think that that is something for which we should commend them. If we do, however, we should face the consequences, and realise that something must be done to provide for the family of a man whose means of livelihood have been affected by having to go into an institution for treatment of this disease. We have to give that family the means by which to maintain the standard of life to which they were accustomed before the bread-winner was taken from them.

We read, for instance, in the last bulletin of the Irish Red Cross Society that "food and rest will be the chief and, probably, the only medicines used in the treatment of this illness". The bulletin says:

"The aims of sanatorium treatment are to prevent the spread of the infection and to build up the natural resistance of the patient's body with rest, fresh air and good food."

Surely the people outside, if they are not to become victims, also need rest, fresh air and good food. If we neglect to provide those things, we shall be only adding to the magnitude of the disease — creating hew cases and defeating the whole purpose and design of this Bill.

Since we are discussing this question of infection, there is one other aspect of the matter to which I should like to refer. Other speakers have, I think, referred to it. I have in mind the question of bovine infection. So long ago as 1907, a British Royal Commission on Tuberculosis, in an interim report, which I think was published towards the end of that year, gave publicity to this conclusion:

"There seems to be no valid reason for doubting the opinion, never seriously doubted before 1901, that human and bovine bacilli belong to the same family. On this view, the answer to the question, ‘Can the bovine bacillus affect man?', is obviously in the affirmative. The same answer must also be given to those who hold the theory that human and bovine tubercle bacilli are different in kind, since the bovine kind are repeatedly to be found as the causal agents of many fatal cases of human tuberculosis."

In Dublin City, very effective steps have been taken over a period of years to eliminate the risk of infection from contaminated milk. The Parliamentary Secretary got power some months ago to set up a commission for the purpose of investigating further the steps that are still desirable or necessary to deal with that problem. That is all related to Dublin. I do not know of any steps being taken to deal with the danger of contaminated milk in rural Ireland or in the small towns. A very large proportion of the patients in sanatoria come from rural Ireland and from the small towns.

I do not know whether or not there is any relationship between the existence of the disease in those centres and the absence of milk inspection, but I think that it is a matter which ought to be seriously considered. While we are availing of this Bill, and of the latitude with which you, A Chathaoirligh, allow us to discuss many points that are important, I realise that those points do not arise properly on the Bill, which is confined to the giving of authority to the Parliamentary Secretary to provide institutions for the treatment of the disease. However, it is worth while to make up our own minds on what should be our attitude towards the whole problem of tuberculosis, so that the Parliamentary Secretary may know that he will have a certain volume of support for any action he may consider it necessary to take to eradicate the disease.

Donnchadha O hEaluighthe

Ní coimeadfai mé sibh ach cúpla noimeat. There are just a few points to which I wish to refer. Yesterday evening, Senator Baxter laboured the point of lack of sufficient nourishment for children who are not strong. It is true that, if people are properly nourished, they are better able to resist the inroads of any disease than undernourished persons. But, in the City of Dublin, never was such provision made, in my opinion, as now for the less well-off sections of the community. We have school meals, free milk, and many other such services which, certainly, did not operate before. If children are not nourished, I am very much afraid that a great deal of the blame — I do not say all of it — rests on the parents who, instead of nourishing their children, prefer to spend the money in publichouses and picture-houses. Other factors than nourishment must be considered. The Dublin Corporation are endeavouring to grapple with this tuberculosis question in the city. If any member of the Seanad goes through the city in the evening, he will see queues of children lined up outside the picture-houses. When we were going to school, we did not go to places in the evening where we would be inhaling foul air and the smoke of other people's pipes and cigarettes. We spent our time in the pure air of the hurling field and at the handball courts. How the children of this city can escape tuberculosis or any other disease passes my understanding. They are in school during the day. They come home in the evening and line up outside the picture-houses.

Last Tuesday, a deputation came to a committee of the corporation from the five school attendance areas in connection with this question. They laboured the danger to the health of children who lined up in front of picture houses, getting their clothes wet, and then went inside. I told them that there was greater danger, in my opinion, inside than there was outside. I happen to be a non-smoker, and how people can live in the polluted air of those picture houses I do not understand. I am emphasising that point because, in my opinion, fresh air is necessary to the healthy upbringing of children as well as school meals. I speak subject to the correction—probably sarcastic correction — of the Parliamentary Secretary.

Dr. Ward

No. I shall not say a word against you.

Donnchadha O hEaluighthe

We often hear that "prevention is better than cure", and the sooner we start a campaign in the City of Dublin — of course I am speaking chiefly of Dublin —to get those children out of the foul air they are inhaling the better for the children.

Reference has also been made to the schools. In Dublin, the educational authorities are certainly doing their best in providing splendid well-ventilated schools in the city. Any member of this House can go out and see the schools recently built in Cabra, the St. Agnes School in Crumlin, and the splendid new convent schools in Sundrive Road. They will find that very fine modern schools are being built around Dublin, where the children will certainly not suffer any disadvantages whatever.

We have had references to housing. Unfortunately, the housing position in Dublin has been very bad. We have had to grapple with a legacy left us by an alien Government. We had old houses which had survived their span. They were falling and crumbling, and the Dublin Municipal Council had to cope with that situation. I think anybody who knows the facts will admit that they have done very well in difficult circumstances, in the past ten years anyway. People who are suffering from tuberculosis are specially dealt with by the allotment section of the Dublin Housing Department. As was mentioned here last night, there is the danger of infection lurking behind when people who suffered from tuberculosis leave an old house, but the Dublin Municipal Council takes very good care thoroughly to disinfect every premises vacated by people who were supposed to be tainted with tuberculosis. I am now going to embark on a question in regard to which the Parliamentary Secretary may give me a rap over the knuckles.

Mr. Sweetman

Who is better able to take it?

Dr. Ward

It will not take a feather out of him.

Donnchadh O hÉaluighthe

The Parliamentary Secretary said here last evening that tuberculosis was not inherited. Like the Leas-Chathaoirleach I happened to be reared in the fine fresh air of the South of Ireland, and unquestionably the idea prevailed there that tuberculosis is inherited. I am making this statement for the purpose of hearing a clear pronouncement from the Parliamentary Secretary as to whether it is right or wrong. In fact, the prejudice is so great that sensible parents discourage their children from marrying into families which are supposed to suffer from tuberculosis. I am making that statement now for the purpose of getting a clear pronouncement from the professional men who are here, including the Parliamentary Secretary. It is only fair to those people who are supposed to be infected with the disease that a clear statement should be made on the matter here and now.

Senator Duffy a few minutes ago — I am sorry he is not here now — made reference to the desirability of sanatoria being built on high ground. I could not exactly follow Senator Duffy because he is very sparing of his lungs. I raised that matter here before, and asked him to speak louder, and I do not like having to repeat the same thing over again. He is far away from us over there, and because of the care he is taking of his lungs we cannot hear him here.

Mr. Sweetman

The Senator had better cross over to this side of the House.

Donnchadh O hÉaluighthe

He made some criticism of the sanatoria sites in Cork and Dublin. I do not know whether he was referring to the site which the Dublin Corporation has purchased out in Ballydowd for the purpose of building a sanatorium.

Dr. Ward

In Ballyfermot.

Donnchadh O hÉaluighthe

Ballydowd I call it.

Dr. Ward

It was to Ballyfermot the Senator referred.

Donnchadh O hÉaluighthe

Ballyfermot is the site of the tuberculosis hospital, but Ballydowd is the site for the tuberculosis sanatorium. I think he also made some reference to the site in Cork, and I am sure Senator Crosbie will deal effectively with that.

Mr. Crosbie

I will not.

Dr. Ward

The Senator will have to deal with Cork too.

Donnchadh O hÉaluighthe

As far as the site purchased by the Dublin Corporation is concerned, it is certainly on the highest point that the Dublin Corporation could secure within a reasonable distance from the City of Dublin. It is on the way to Lucan, right beside where the old electricity station was. It is the highest point between Chapelizod and Lucan. In approaching it, you climb up a gradient, and then there is a fall into Lucan. I just want to make it clear that, so far as the site purchased in Ballydowd is concerned, it is a very suitable elevated site within easy reach of the citizens who may be anxious to visit their friends. Having mentioned those few points, I will not detain the House any longer, and I will welcome the Parliamentary Secretary's criticism.

Mr. Campbell

I am afraid that the fact that Senator Duffy and Senator Healy caught your eye before you caught mine deprived me of a few arguments which I meant to put forward on this Bill. At the outset, however, I should like to congratulate the Parliamentary Secretary on the introduction of this very necessary measure. The plans indicated in the Bill for dealing with the problem of tuberculosis will be welcomed, I think, by all sections of the community. It is a measure which is long overdue. We have lagged far behind other countries in legislation in this respect, and I think the introduction of this measure has indicated to all of us a change from the attitude of comparative complacency towards this problem. I do not wish to criticise the Parliamentary Secretary or his Government in that respect, nor do I wish to criticise the previous administration. We have all been guilty of an attitude of laissez faire towards this very grave problem. If there had been well organised and well informed public opinion, we should not be considering now the situation envisaged by the Parliamentary Secretary — the death rate from tuberculosis would have been reduced by half. Be that as it may, we are at least glad that steps have now been taken to deal with this very grave problem. As the Parliamentary Secretary knows, we are behind other countries in this respect, but I feel that, given the support of the people as a whole, rapid progress will be made towards arresting to a great extent, if not ultimately completely eradicating, this disease.

Senator Hayes in his able speech last night referred to the fact that ease of mind is a most important factor in dealing with this problem of tuberculosis. He referred, of course, to the bread-winner of a family who is affected by this disease. While in a good many cases the person affected regards the discovery of the fact that he is suffering from the disease as almost amounting to a death sentence, he considers that death sentence very lightly compared with the knowledge that his family will probably be left in a position of penury because of his inability to continue to support them.

Nobody has referred very much to that point, but I think the Parliamentary Secretary stated last night he hoped, in the final analysis, to make provision for these people. The Parliamentary Secretary said that provision for the reasonable maintenance of the dependents of a bread-winner who contracted this disease must find a place in the completed plan. I do not know whether the Parliamentary Secretary is envisaging the situation in which he will complete his plan before he makes provision for the dependents of those afflicted by the disease. That is reversing the whole position. I imagine that even now he should consider the position of adequate maintenance for the dependents of those affected by the disease before his plans come to complete fruition.

It has been my experience, as a trade union official for 25 years, that there are some terrible examples of the results of a wage-earner contracting this disease. Senator Duffy has already referred to the matter. Malnutrition may contribute to it in some degree, but how much more appalling to a sufferer is the spectacle of his family becoming affected by the disease as a result of malnutrition? The prospect for a man affected with the disease is appalling. I have seen men shaking with terror at the contemplation of what was to become of their families during this period.

There may be some explanation in that for the fact that the tuberculosis death-rate increased in 1942 and 1943, a period in which the cost of living soared so much that the weekly wage was inadequate even to purchase the necessaries of life. I am not exaggerating in that respect — I know what can be bought for £5 a week, and many Dublin workers have much less than that sum. It is easy to imagine the plight of families in that respect, and anyone who knows our working class is aware that when the head of a family is attacked by the disease he is moved to a hospital and the family income diminishes almost to nil. Senator Duffy indicated 15/- per week. Fifteen shillings per week is almost inadequate to meet the rent of a house, either a corporation house or a utility house.

We all know how the poor of the city regard their sick brethren. Even other families will deprive themselves of the necessaries of life to bring comforts and little luxuries to those who are sick. I commend greatly the statement of the Parliamentary Secretary that provision will be made for the dependents of a bread-winner, but I think he is putting the cart before the horse. Ease of mind, as Senator Hayes said, is a great factor in the treatment of the disease, and if a man affected with it knows that his dependents will not want while he is away it will be a great help to his recovery. From my own knowledge I know that the hardships arising from it are very great. I am sure the Parliamentary Secretary, in examining the matter, will agree with me that it is necessary to preserve the standard of life of these people by giving them adequate maintenance grants during the treatment of the disease.

Reference was made, too, to the necessity for education in this matter and particularly the education of the young. Well, it is very difficult to put over education and propaganda in many of the schools. It is suggested there should be elementary education in hygiene and sanitation. As we have all heard here, many of our schools are in a very bad condition — I am not saying it is applicable to Dublin — and there is neither adequate sanitation nor hygienic measures adopted in them. It is very difficult to convince young people of the importance of these matters when they look at the school itself.

Senator Healy raised another point which I think is a tremendous problem. I refer to the crowding of picture-houses between 3 and 6 o'clock on Sunday afternoon, winter and summer. There are queues from 1.30 outside picture-houses on brilliant sunlit Sundays, waiting to get indoors between 3 and 6 o'clock. Very often when they come out on a summer's evening at 6 o'clock, I have seen them putting their hands to their eyes, blinded by the glare of the sun. These crowded picture-houses on Sundays are a terrible menace. I have been visiting the country in connection with wages tribunals for two or three years, and I must say that I am amazed at the number of children who go to the picture-houses at night and stay there until 10.30.

I think it was a colleague, Senator Honan, who referred to this matter, but I want to say the most appalling example I have witnessed was in Ennis. There the young people were behaving like lions, or some other wild beasts, and the turmoil was shocking when they tried to scramble out of the picture-houses. When the National Anthem was played at the end of the performance, the scenes which occurred were no example coming from a constituency represented by the Taoiseach. The young people tore out of the cinema and into the streets like a lot of wild men. Apart from that, the moral as well as physical deterioration resulting from the crowding of picture-houses in Dublin and the provinces is very serious. I think power should be taken to exclude children from picture-houses on Sunday afternoons, particularly in the summer months.

References have been made to housing areas like Drimnagh, Crumlin, Kimmage, Cabra. Ordinary people going about their business cannot get a bus on Sundays. Immediately dinner is over there are queues half a mile long around the bus stops, and the people whom the corporation brought out to these fresh air areas are all gathered there madly intent on getting back into the city. This should be prohibited on Sunday afternoons, particularly in the summer. Not only is the moral deterioration very serious, but so is the physical deterioration, which will be probably more acceptable to some people as an argument.

These are the two points I wish to develop. They were dealt with at considerable length by Senator Duffy, and also by Senator Healy, and I think that the Parliamentary Secretary may be assured of the support of all sections of the people in any steps he takes towards eradicating this disease from the community. The question inevitably will arise: Who is going to pay for this?

Well, of course, my answer is that the State will pay for it. The State very rightly at the outset of this emergency took steps to safeguard our national well-being. We all approved of that one hundred per cent. Some £9,000,000 have been spent maintaining the defence forces, very rightly spent, but we all hope, please God, that it will not be necessary to keep that large force still in existence. While there may be criticism of diverting that money towards such a useful social purpose as the Parliamentary Secretary contemplates, I think the Government ought to face up to it. The people have been able to pay that taxation, and money is being freely spent by people who are making it rapidly. I do not think the Government ought to be put out by any clamour on the part of taxpayers. We are, in the main, well able to pay this taxation, and the money ought to be diverted towards the very laudable plans the Parliamentary Secretary has embraced in the Bill. I congratulate the Parliamentary Secretary on taking this first step, one in the right direction, towards removing this great menace to the country.

Mr. Foran

There has been a general eulogy of the Parliamentary Secretary and the Government for their efforts in this Bill. I must say that I cannot join in general admiration of the Bill. Boiled down, what does it mean? It means that the State makes no contribution whatever to the wiping out of this awful scourge. We are dipping into the funds of the Hospitals Trust and we are making up the balance from local councils. We are going to get three sanatoria. In essence, that is the whole strength of the Bill as I see it. Tuberculosis is becoming a great menace, and certain voluntary organisations through their efforts and agitation have forced the Government to recognise that state of affairs, and to take some action to deal with it. It was felt at one time that it was going to be left to voluntary effort to deal with this menace. Fortunately the Government were wise in their generation and took due notice of the clamour that an effort should be made to deal with this plague. I must say that their methods of dealing with it do not go nearly far enough, and certainly are not going to achieve all that some people believe they will. This is a very big question. I am one of those who believe that it is the first duty of the State to ensure as far as possible that the health of the people is protected. I think, in doing that, the money from the Central Fund ought to be made available rather than from Hospitals Trust funds. When inroads are made on the fund created by the Hospitals Sweeps there will be very little money left for the voluntary hospitals, and that will create another problem. I do not know where they are going to find the money. The Parliamentary Secretary has in mind putting a tax on the ratepayers in Dublin. That may or may not be a good thing, but I think his first effort ought to be to provide funds from the Central Fund and that there ought to be a greater effort to concentrate the work of all the organisations that are in operation to-day. Bring that to bear on this problem. It may be that the Parliamentary Secretary has in mind that a sustenance fund will be provided from the National Exchequer.

It has already been emphasised that uneasiness of mind of a tubercular person who is a bread-winner, influences and militates against ultimate cure or early treatment. The State has got out of some responsibility very lightly in this matter. Will the Parliamentary Secretary say that funds will be available for the maintenance of families out of money that ought to have been spent in providing sanatoria? Will he be generous at that end? He is certainly not generous in the beginning. Will the funds which ought to have been made available in the first instance be made available for the sustenance of the families of sufferers? He ought to be able to say that. He has already hinted that provision will be made but that is hardly good enough. Reading through Senator Sir John Keane's remarks on this matter I heartily agree that we are not tackling this health problem in a proper way. There ought to be more co-ordination. After all, tuberculosis is certainly a menace and a plague but there are other illnesses that affect the bread-winners of families. What effort has been made to make provision for the treatment of these? I submit that we are dealing with this health matter in a piecemeal way, and certainly not in the most effective way, which is to deal with in general the health of the population. One Senator referred to the number of children attending cinemas. That was spoken of as if it were an awful calamity. Can anyone visualise the position during the last few weeks when there was frost in Dublin? Let him come with me into the tenement houses that Senator Healy is so proud of.

Mr. Healy

So proud of, did you say?

Mr. Foran

I thought you said that.

Mr. Healy

You fancied it. I am not responsible for what you fancy.

Mr. Foran

If the Senator says he did not say that I accept it. Come with me into some of these tenements and see the efforts of the woman of the house to try to make a fire for the children. I wonder would Senators find fault with children for not remaining in these houses, and going to cinemas where there are fairly warm and comfortable seats?

Mr. Healy

In your school days there were no cinemas.

Mr. Foran

I am too old. We had a magic lantern now and again, but we have to recognise modern thought, and these people will be modern whether you and I want them to be or not. I have a great deal of sympathy with the children who have to live in awful squalor in these tenements. If they can get any relaxation and comfort in cinemas I do not think it is a great crime for them to go there. Certainly the fare provided may be improved but that is outside this Bill. I believe the kernel of this Bill is contained in Part II Section 5. We are dipping into the Hospitals Trust Fund for at least two-thirds of the money and we are making the local authorities responsible for the remainder. The State provides nothing, according to the Bill, and they are getting all the credit. I do not think it is merited. I do not think it is deserved. Certainly I cannot agree with the general chorus of eulogy of the Government for introducing this Bill which, in my opinion, is only a very short step towards dealing with the awful menace which faces the country.

Mr. Sweetman

I want to try to get a little further information from the Parliamentary Secretary. It may have been that I did not fully grasp what he was saying last night, but it appeared to me that he gave the impression that the problem had only become more acute in the years since 1938. I think the Parliamentary Secretary will agree with me that the fact is that for the previous 20 years the death rate in every country from this disease had been declining, but had been declining in this country at a far slower rate than in other countries. I should be grateful if the Parliamentary Secretary could give the House any information he has available as to the manner in which the tuberculosis death rate has moved in other countries in the last six years, bearing in mind that during these six years it has started to move up in Ireland after declining for a previous period of 20 years. The real genesis of the difficulty that has been created for us has been created not in the last six years but I suggest is due to the fact that in the previous 20 years we did not make the same rate of progress as was made elsewhere. I should be glad to know what the comparison is in recent times, so far as a comparison is available having regard to war conditions.

I should like the Parliamentary Secretary also to explain if he can what his Department considers to be the reason for the very much higher incidence of the disease in one part of the State as against other parts, why, for example, the situation in Wexford appears to be so bad as against the situation in Cavan and why, so far as my own county is concerned — a matter which, of course, is of particular interest to me—we have such a dreadful rate for pulmonary tuberculosis in girls between the ages of 15 and 34 whereas the figures for males in our county bear a reasonable comparison with the rest of the country. On the female side, taking the figures for County Kildare for these particular years which are so very important, particularly for the woman in the home, our record is shocking. There must be some reason other than the reason I gave before in another place, namely, the incidence of urbanisation. It must arise, I feel, from continuous infection, diet or something else. While the disease is certainly not hereditary, I think the Parliamentary Secretary would possibly agree that heredity may make one person more liable to infection than another. These are general remarks.

On the particular scheme he has in view, I understood him to say that so far as the eastern counties are concerned, excluding the city and county of Dublin, Peamount, Newcastle and Our Lady of Lourdes Hospital of Dun Laoghaire, are to be the sanatoria for these counties. Does he intend to allocate two or three particular counties to Newcastle, two or three others to Peamount and the remainder to Dun Laoghaire, or does he intend to form one unit in three different places because the answer to that would affect very much local feeling on the subject?

I should like to mention also one small point which really would more properly arise on the Committee Stage. When the Parliamentary Secretary is deciding the most suitable site for a sanatorium, we all agree that he must choose, having regard to the danger of the disease, what is the best spot for his particular scheme. If he erects a sanatorium in a particular field, he may injure very considerably the property of the man adjoining, and in the Bill, as I read it, there is no scheme to provide for compensation for consequential damage of that sort. I may be wrong but I should be very glad to be corrected. So far as I can see, it is only when there is some actual interest in land that is acquired that a claim for compensation will be entertained. I do not want to be taken in any way as trying to limit the power of the Parliamentary Secretary in acquiring a desirable site but I do think that if the taking of that site results in consequential loss to any property adjoining, not necessarily belonging to the same owner, provision should be made in the Bill for compensation for such consequential loss.

Mr. Meighan

In regard to the selection of sites, I think it would be desirable that the decision should be left entirely to those with professional qualifications to decide what is the best location. It would be very detrimental to the whole scheme if there was anything such as "pulling", as there may be. We can quite realise that people interested in a large town or city might be anxious to have a particular site selected. I feel that it would be in the interests of the community in general that an assurance should be given that no such consideration would enter into the selection of a site and that the matter would be left entirely to the Minister's professional advisers. I quite agree with Senator Sweetman that if the erection of a sanatorium on certain property affects detrimentally the value of adjoining property, some provision should be made for reasonable compensation for the owner of that property.

I should like to add my voice to the case put by Senator Hayes and other speakers with regard to the mental anguish caused to patients removed from their families, when these families are not in a position to earn a living for themselves. I can fancy nothing more detrimental to the speedy recovery of a patient than the knowledge that he, the bread-winner of his family, has had to be removed, and that his family is not able to carry on. That point has been stressed by so many speakers that I merely wish to add my voice to the case that they have already made for some effort to alleviate the distress caused by the removal of such patients. With regard to the maintenance of those institutions, I understood from the opening statement of the Parliamentary Secretary that the local authorities would be supposed to contribute one-third of the cost of those institutions, and that two-thirds would come from the Hospitals Trust Fund, and further, that the local authority would be responsible for the staffing and upkeep of the sanatoria. I feel that it is up to the Government to see that, if possible, there should be no local charge in connection with the maintenance of these institutions. The cost of the upkeep should come out of the Central Fund.

Dr. Ward

The local authority is recouped to the extent of 50 per cent. of the cost of maintenance of existing institutions, and the same arrangement will apply to new sanatoria.

Mr. Meighan

There is just one other matter with which I desire to deal, the question of children in rural areas. Something has already been said on the subject of the rest necessary for such children. I know areas in Mayo and Roscommon where children in rural districts have to go three or four miles to school.

Business suspended at 6 p.m., and resumed at 7 p.m.

Mr. Meighan

Some children in rural schools have to walk a distance of three or four miles, and most of the schools in the country — I think the majority of them — open at what is called "New Time." Now, according to the opinion of medical doctors whom I have met, it is an injustice to children to pull them out of bed at such an early hour in the morning. It must be remembered that these children now have to get out of bed an hour or an hour and a half earlier than they had to get out of bed a few years ago, and that must have an effect on their health. Apart from that, owing to the lack of lighting facilities in the country at the present time, an extra hardship is imposed. Paraffin oil, for instance, is very scarce, and I know that, so far as many of the rural districts to which I refer are concerned, they have no light at all and find it very difficult even to get candles. I think it would be a good thing if the Minister for Education could arrange for the children to attend school at least an hour later; certainly during the winter months from, say, November to March.

Another thing to which I should like to refer is the question of the provision of milk for children. After all, milk is the most valuable food that could be given to children, but I understand that in a great many of these rural schools the children do not get any milk, or very little. In many of the districts to which I am now referring it is quite usual for the people concerned to have only a cow or two. Now, for a great part of the year, the cows are dry, and the result is that the family concerned have not even enough milk with which to colour their tea. The youngsters have to hurry off to school without a proper meal, with the result that, in bad weather, they reach school in a heated condition, and many of these schools are draughty.

Now, I am not blaming the Department of Education or the Minister who is responsible for education for those conditions. I feel sure that the Minister for Education is doing his best to have those conditions remedied, and I realise that that will take some time. I also know that there is a number of very fine schools in this country, but, on the other hand, I know that there is a great number of schools that are anything but desirable. I know of many schools that have only a concrete floor and a corrugated-iron roof, and one can realise what that might mean to the health of the youngsters in winter months.

My idea in mentioning these points is that I feel that it is a serious matter, and if we are told that, in order to combat this disease, proper food and housing should be provided, then I think it must be more necessary to provide proper food and housing in the case of youngsters going to school. I think it would be within the scope of the Parliamentary Secretary to see that at least a reasonable quantity of milk will be got for children who are not able to procure it otherwise. Children should have a cup of hot milk after travelling two or three miles to school, often they reach it in an overheated condition and are exposed to a draughty unheated atmosphere perhaps for six hours without a meal. That must be detrimental to their health. On the whole it should not be very hard to get a supply of milk, because in rural areas, especially in creamery districts, there are quantities of milk. I do not see why there should be any scarcity of milk in the country or towns, especially under normal traffic conditions where if there was a scarcity in one place it can be relieved by bringing in supplies from other areas. There is no reason why children should suffer from want of milk.

On the cinema question, I am inclined to agree with Senator Healy to a great extent, and I have sympathy also with the point of view put forward by Senator Foran of the Labour Party when he said they were driven from tenement houses in summer time to form queues outside cinemas. I regret to say that this habit has taken root all over the country. Our people were not used to that, but in these days I suppose we cannot put the clock back. In a great many matters we are not improving on the ways of our fathers. Senator Mrs. Concannon gave us some very interesting suggestions about food and I entirely agree with her, but there, again, local authorities have made provision for free plots and I am afraid these plots are not availed of to the fullest extent. But, there is no use in blaming the Government or the authorities for that. I am afraid that until the people in general become more awake to their own interests and there is a more widespread co-operation we shall not make all the progress we desire. A great many points have been raised in this debate and explained more ably than I can do it. All I want to do is to state the views of the people I represent in welcoming the Bill and to express the hope that it will be a fruitful and effective measure.

Mr. McEllin

I am rather inclined to agree with the Senator who has just spoken in regard to the supply of milk to schools. Milk is the only known complete food for the maintenance of bodily health. During the past ten years the Government have gone a very long way, and I am sure they have returns of the results of their efforts, but there is no doubt that the policy which has been pursued could be extended with effect. What made me rise to speak was principally this: Tuberculosis is a very serious matter, and the medical profession does not seem to be fully able to reach any definite conclusion as to its origin or its development in a satisfactory sense of the word. They do not know whether it comes from milk or from animals, or develops automatically as a result of climate or other conditions under which the people live.

We have had it from George Bernard Shaw that there are more healthy children in the hills of Connemara than in the most modern clinics in the world, which are in Germany. There is no doubt about it that three-fourths of the health of youngsters depends on the amount of freedom of movement, exercise and fresh air they enjoy in their early years. My personal view is that the Minister and his Department should not be in any way niggardly in tackling this whole question. Money should be spent freely on it, and the officials, all of them, at some time or other, should make use of the brains, money and study of other countries in the past, pooling their ideas when they come home, and setting up a more comprehensive and up-to-date scheme here. I am sure the House will agree that money spent in that way will be intelligently spent. We can afford to ignore the narrow-minded people who will question it and make ignorant criticism. The Parliamentary Secretary can rest assured that he will have the support of all sections in every effort he makes to get rid of this dread disease.

But there is another problem as well as tuberculosis. You have every bit as serious a disease, yet little is said about it. That is cancer. I do not know whether they are related to each other or not, but one hears of an appalling number of cases, particularly amongst young people. Why it should develop amongst those young people I do not know. I feel that that serious problem should be brought within the ambit of the Parliamentary Secretary, who is making energetic efforts to grapple with tuberculosis. I again emphasise that we should be in no way niggardly in permitting the Local Government Department to use their full discretionary powers to obtain information and assistance from other countries and to tackle the whole question from a broad point of view.

Liam Ó Buachalla

The most satisfactory aspect of the introduction of this Bill has been, I think, the opening speech by the Parliamentary Secretary. In that speech, I believe he convinced us all that he is entering upon this fight with the greatest of enthusiasm and confidence. We are satisfied, also, as a result of his remarks, that he is filled with determination to eradicate this disease with all speed, in so far as that can be done by him and his Department and by the Government. The Parliamentary Secretary has every reason to feel satisfied with the reception of the Bill here. He has, I think, reason to be satisfied that the House has endeavoured to assist him so far as lay in its power. Many of the recommendations which have been put before him here are hardly directly connected with the Bill. Nevertheless, I think that the Parliamentary Secretary will not fail to take note of these recommendations. They should prove of the utmost value to him in the days ahead, when he is working out his further schemes for the eradication of this dread disease.

So much has been said that little remains to be said. However, I want to make one suggestion. I am reluctant or loath to make it because I have already made it more than once in this House. My conviction is that a great deal of the trouble with regard to tuberculosis arises from the neglect of schoolchildren by their parents — not so much, perhaps, in the home as outside the home. Often, when going through the country at a time when travelling was easier than it is now, I was struck by the number of children I saw huddled around the school fires on a wet day. The rain was dripping from their clothes and they remained at the fire for nearly half an hour to dry out. The fire was, generally, allowed to die down then and the children remained in school for four or five hours in a considerably reduced temperature, without — as has been stressed more than once, by other speakers — anything in the nature of a hot meal. It would go a long way towards checking the spread of this disease if the Department of Local Government would consider, as soon as practicable, the provision of rubber capes and the issuing of those capes to every school-going child. It is not so much the lack of clothing that is the trouble. I hardly think that the lack of boots or shoes is a very serious matter in the case of youngsters. What is serious is that children who get wet on their way to school have to dry themselves very rapidly and then remain in school for the remainder of the day, or else sit in their wet clothes throughout the school day. If children could be got to school dry, it would solve the problem. The schools are generally comfortable and dry, though I agree that the sooner a number of them are razed to the ground and replaced, the better. Anyway, taking it by and large, very little complaint is to be made about the schools. Let me stress again that if the children can be got to school dry, we shall have made a big advance towards checking this disease.

There are only a couple of other points to which I should like to refer. I do so more in the hope of getting information from the Parliamentary Secretary as to the true position than anything else. Senator Foran and Senator Sir John Keane seemed to be somewhat exercised at the Department seeking to provide moneys for these new sanatoria out of the Hospitals Trust Fund. They seemed to have the idea that that fund was created to assist certain types of hospitals. I gathered that they think the Department has no right or power to make those moneys available for dealing with tuberculosis. I am not aware of any provision limiting the power of the Minister for Local Government to advance those moneys for any hospital purpose he considers fit. I hope the Parliamentary Secretary will give us some information on that matter. I think that Senators other than Senator Foran are under a misaprehension with regard to the object of that fund and the powers of the Minister for Local Government in respect of its spending.

Another point that seems to worry a number of Senators is the proposal that local authorities should make a 50 per cent. contribution towards the maintenance of the new sanatoria. I cannot for the life of me see anything unreasonable in that proposal. The State has to contribute 50 per cent. and, everything considered, it is only reasonable that the local authorities should make good the other 50 per cent. I heard no argument as to why local authorities should not make good that 50 per cent. With these few remarks, I want to join with the other Senators who have spoken in welcoming the Bill, and I want to say again how satisfied I am with the opening speech of the Parliamentary Secretary. That speech, in itself, has given me considerable hope, and I wish the Parliamentary Secretary well in the policy he has announced. We all trust that it will come to a speedy and satisfactory conclusion.

Dr. Ward

I should like at first to thank the House for the spirit in which it has received the Bill, and for the general tone of the discussion. As the last speaker has said, many suggestions have been made that undoubtedly will be useful in the consideration of the various difficult aspects of the problem that we are now undertaking from a somewhat new angle. All these suggestions will be carefully considered and where they are deemed to be helpful after full examination they will certainly be incorporated in our attack upon the disease. Mention has been made in the earlier stages of the debate about consulting with bodies outside the State and consulting outside bodies within the State. Well there is no doubt that other countries may have made more progress in medical research and scientific investigation and may have had more finances at their disposal.

At the same time while one need not challenge that assertion it is true to say that medical science in Ireland is well abreast of medical science throughout the civilised world. That is no idle boast. We have little to learn concerning this disease from medical science in neighbouring countries or in far away countries for that matter. At any rate it is the merest truth to say that our medical advisers are fully abreast of scientific development throughout the entire medical world and any advance that may be made available to other communities differently circumstanced will, if it proves of real advantage, with little delay be made available to our people here. We have in fact, as many Senators I am sure are aware, been in the closest consultation with outside bodies concerning this problem of tuberculosis, particularly with the Royal Academy of Medicine, and the Hospitals Commission has made a special investigation.

Perhaps, indeed, I may leave out the word "perhaps" and say in fact, we have been in the closest consultation with the anti-tuberculosis section of the Irish Red Cross Society and its expert advisers. The scheme I have to-day outlined to the House is based very largely on the long-term policy that was put before us some time ago by the Irish Red Cross Society. We have no complex about a matter such as this. We realise that while we know a fair share about scientific medical subjects we can usefully learn something from other people outside. My medical advisers are always in closest contact with the outside medical world and most of them are themselves men of high academic distinction and wide experience so that we do not approach a problem like this in any ill-considered fashion. The problem has been a concern for us for a considerable time and every aspect of it has been fully examined. Consequently the proposals before the House are proposals that have not been hastily conceived. Coming to the actual debate Senator Hayes who was the first speaker complains, not indeed in a very unhelpful spirit, of the central control. Well, everybody agrees that in the present circumstances if we are to achieve the purpose of this Bill we can only achieve it through central control. On that point I would like to draw attention to the fact that the period of central control is confined to three years in the Bill so that we have to make the best use of our time in a very critical and difficult period and that time is not very long.

Senator Hayes also stated very wisely that if we can convince the people that the disease is curable, then we would be making real headway. Well, that is just one of the many prejudices that we have got to fight regarding tuberculosis — the popularly accepted idea that tuberculosis is incurable. As I have said many times, and I think a fact such as this cannot be stated too often — tuberculosis is in fact much more curable than many diseases that are held to be highly curable. So curable is tuberculosis that 90 per cent. of the people who contract the disease get over it without any treatment at all, and in fact get better of the disease without realising that they have been ill. That is a scientific fact, and any medical member of the House will confirm it. But if medical science does not get the chance to come to bear upon the disease in the early stages its rapidly gets out of hand.

In almost nine cases out of ten of those that have come under our tuberculosis schemes the disease is so far advanced that medical science is not getting a chance. That is the fact, and I suppose we will have to keep on repeating it until we get the people to believe it. There are other aspects that are closely related to that consideration that I will deal with later on when I come to reply to other speakers, as they have been raised by somebody else. Senator Hayes also talks very wisely of the importance of easing the patient's mind. Well, again, we are all in full agreement with that. I might perhaps dispose of that aspect of the matter, which was emphasised almost by every speaker — that we cannot hope to make new headway until provision is made for the reasonable maintenance of the dependents of the bread-winner. There is no difference of opinion on that.

If a labouring man, or a man in any sphere of life, is to give up his occupation at a sufficiently early stage, when he is fit to work and yet when he should not be working, if he can be induced to give up his work in order that we may cure him, provision must be made for his dependents while we take him into an institution for treatment. Again, if we find it necessary to isolate a bread-winner because he is a danger to his family and a danger to the community at large, I think that the community owes something for the protection they thereby get by the removal of that man to an institution. We have to approach it from that angle. This Bill does not deal with that question, but it is a very important subject. There has been no limitation on the debate, and the Cathaoirleach, I think, acted very wisely in giving it the widest possible scope, because the better we understand these problems, apart from the particular Bill before us, the more successful we shall be in our attack upon them.

When it comes to the question of how all these various aspects of this huge problem can be financed we get into difficult water. The general tendency is to turn one's eyes to the central government and say: "Oh, let the Government pay for it.""The Government ought to provide the institutions," somebody told us. "The Hospitals Trust Fund should not be called upon for the purpose of providing beds, the institutions should be maintained by the Government and the dependents of the bread-winner should be maintained as well." It would be better if we took a realistic attitude about a matter such as this. The Government cannot undertake these things. There is no good or sufficient reason, so far as I can judge at any rate, why the Government should accept financial responsibility for these various aspects of the problem. So far as the Hospitals Trust Fund is concerned, somebody— I think it was Senator Liam O Buachalla—pointed out that the Hospitals Trust Fund has not been specially earmarked by law for any particular group of hospitals. I may have to develop that thesis somewhat further later on in reply to Senator Sir John Keane. By a deliberate act of the Oireachtas more than 12 years ago, it was determined that the Hospitals Trust Fund should be administered in a certain manner. Formerly, in 1931, the Fund was divided into two sections. One-third was earmarked for local authority institutions and two-thirds for voluntary hospitals under the 1931 Act. The 1933 Act repealed the Act of 1931 and provided that the moneys would be centralised in one fund and that the Minister for Local Government would be given full and unrestricted discretion in the allocation of that fund for the provision of institutions for the medical care and treatment of various categories of patients—absolute discretion as between the local authority institutions and the voluntary hospitals. Consequently, it is foolish to raise 12 years after the event, or indeed at any stage, for that matter, the issue that we are doing anything wrong in allocating from the Hospitals Trust Fund the necessary money to provide these hospitals for the special treatment of tuberculosis.

Senator Sir John Keane wants to know what will become of the deficits of the voluntary hospitals and if we are to continue to encroach on the capital fund which is now invested and producing an income out of which the hospitals' annual deficits are paid. I have dealt with that matter in the House before. I have dealt with it on more than one occasion. I dealt with it very fully when meeting a deputation from the Associated Hospitals' Committee and briefly I shall deal with it again. Let us first get some round figures in our minds. The total income made available for hospital purposes from sweepstake sources was £16,500,000.

As I have said already, under the 1931 Act, one-third of the fund was earmarked for local authorities institutions and two-thirds for voluntary hospitals. That method of sub-division, as I have already indicated, was abolished under the 1933 Act. Let us assume just for the sake of discussion that the 1933 Act was never passed and that the same sub-division remained all through, that we earmarked one-third for the local authority hospitals. One-third of £16,507,000 is roughly £5,502,000. In fact the local authority hospitals have already had disbursed £3,115,000, so that the local authority institutions could encroach to the extent of a further £2,386,000 on the Hospitals Trust Fund before they would have absorbed one-third of the proceeds from the Hospital Sweepstakes. While I say that, I do not want to convey the impression that any such sub-division is recognised, but I do want to point out that, notwithstanding the fact that the Oireachtas abolished that particular method of allocation, we have a long way to go before the local authorities would have absorbed one-third of the total proceeds.

As to the problem of the payment of deficits, it seems to me to be eminently simple. The difficulty is that people will not face up to the obvious solution of it. What is the position? The position is that our local authorities throughout the State are under a statutory obligation to provide necessary hospital facilities and treatment for the poor. Outside the area of the immediate operation of the voluntary hospitals, the local authorities face up to their statutory obligations and they pay for the maintenance of the institutions and the hospitals' services that they provide. Not only that, but when a case is sent from the provinces—as very often a case has to be sent from the provinces that requires specialised treatment which cannot be adequately and properly given in our local institutions—to the voluntary hospitals, the local authority has to pay £2 12s. 6d. per week for the maintenance of that patient in the voluntary hospital in Dublin. I do not say that there is anything wrong in that but I do say that there is something wrong in the proposition put to me that we should continue to increase the cost to the local authorities in the provinces for the maintenance of patients in the voluntary hospitals, while the local authorities in Dublin pay nothing for the maintenance and treatment of their poor. I do not think that there is anything reasonable in that proposition. The position that has got to be established here is that whatever benefits accrue to the community out of the Hospitals Trust Fund, should extend to the whole of our poor and not to a limited section of them.

I have asked the voluntary hospitals to take this matter up with the local authorities here in Dublin. Perhaps some figures may be useful: they may perhaps be useful to Senator Sir John Keane, so I will just quote them. Bearing in mind that the case has been pressed that £2 12s. 6d. is not sufficient to maintain a patient from a local authority down the country in a Dublin hospital, I have had an examination made as to what would be the effect on the hospital deficits if a minimum of £2 12s. 6d. was being paid in respect of every patient who is being treated in the Dublin hospitals. Between the special hospitals and the general hospitals I find that, if £2 12s. 6d. was paid in respect of every patient who was paying less than £3 3s. a week in the year 1943, an additional sum of £162,488 would be brought in to the voluntary hospitals, and the deficits would be reduced by that amount. It does mean, if that policy is adopted, that the ratepayers of Dublin City would have to pay for a service that is being maintained for them at the present time out of the proceeds of the Hospitals Trust Fund, but I do not think that there is anything unreasonable in that line of policy, and that is the line of policy which I hope to see adopted.

Mr. Baxter

Would the Parliamentary Secretary say at this point what effect that would have on their expenditure? Would it go any way to meet their expenditure in the year?

Dr. Ward

The annual deficits for the year 1943, again in round figures, amounted to £189,000.

Mr. Baxter

So it would practically cover their outgoings?

Dr. Ward

Almost. I do not suggest that we should eat up the whole of the Hospitals Trust Fund. What I should like to see is this, assuming that it takes £3 3s. a week to maintain a patient in one of our voluntary hospitals: that we could reach a condition of things under which the service would be offered to the local authorities, whether they were provincial or whether they were central, at say, £2 2s. a week, and that we would set aside sufficient money of the Hospitals Trust Fund to bring in a subvention——

Sir John Keane

May I ask the Parliamentary Secretary a question? Suppose the hospitals say: "Until you provide this money, we are not going to treat your patients," what effect would that have? Suppose they say: "We adopt the suggestion of the Minister, and we will not take the sick people in Dublin without three guineas a week," would that be acceptable to the Parliamentary Secretary?

Dr. Ward

Well, I will deal with that.

Mrs. Concannon

Would the payment of the doctors have to be taken into consideration?

Dr. Ward

Do not let us get confused. There is no proposal and, as far as I am concerned, there will be no proposal at any time, that we interfere with the voluntary hospitals system. My suggestion is that the representatives of the voluntary hospitals will go to the local authorities and say: "Under present circumstances, six or seven or eight million pounds cannot continue to be locked up for the purpose of paying deficits. Deficits accrue because of the fact that we are maintaining your patients free. We cannot continue to do it; we must come to some arrangement about it." It is quite possible, as Senator Sir John Keane suggests, that until the voluntary hospitals take a stiff stand in this matter the local authorities will not come forward and say: "We will give you £100,000 a year or £120,000 a year from Dublin City and Dublin County." The voluntary hospitals may have to take a stand in this matter; they may have to say: "We cannot continue to give you the service, because we cannot continue to have this money locked up that is necessary for capital expenditure." I have told the representatives of the voluntary hospitals, I have told anybody and everybody who discussed the matter with me, and I now tell the House again, that anything I can do in assisting the voluntary hospitals to get a reasonable adjustment of the financial position with the local authorities I am quite ready and willing to do. They have the legal responsibility, and they must shoulder it. As I have already said, what we ought to aim at is that they will be given that highly-specialised service that they are so privileged to have at their own door, that the voluntary institutions already provide, with the highest medical skill in Europe right beside them, and that we will ask them to pay as much for that as we ask of the people down the country who have sent up their cases which require special treatment.

Mr. Baxter

In other words, you would put them on the rates?

Dr. Ward

The rates will contribute a reasonable amount. So far as the rates are concerned, Dublin Senators would naturally be anxious to know whether this would be an insupportable burden. It would not. A shilling in the £ in Dublin City would bring in approximately £100,000. A shilling in the £ in Dublin County would bring in about £20,000, so Dublin City and County, by 1/- in the £, could reduce the deficit right away by a sum of approximately £120,000. Senators from provincial areas know that 1/- in the £ does not go far in the maintenance of their public institutions. However, I quite realise that the matter is not raised in any contentious spirit; we are all anxious to reach a solution of this problem, but the present position cannot be allowed to continue.

Senator Sir John Keane also raised a question, which was subsequently raised by other Senators as to how the new institutions will be maintained. They will be maintained on just the same financial basis as our existing tuberculosis institutions are maintained. The local authority appoint the staff and maintain the institutions, and they are reimbursed to the extent of 50 per cent. from the Exchequer. That will apply to the new institutions as it does to the institutions which are already in operation.

Senator Sir John Keane also raised another very interesting question, which will have a very important bearing on an aspect of the problem as soon as institutional accommodation is available. He posed the question: what is to be done with the people who will not accept isolation? Now, that is a really serious problem, and one to which we will have to give very serious consideration. It does not arise on the Bill, but it is well that people's minds should be directed towards that problem. If I should ever come before the House and say: "We cannot deal with this problem effectively until we isolate the people who are spreading this infection," I am sure we will hear a good deal about the liberty of the subject.

Well, at that stage we will have to make up our minds whether the rights of the community will have to take precedence over the rights of the individual. My personal feeling on the matter—I do not mind confessing it— is that I see no logical reason why a person who is suffering from any infectious disease should be allowed to constitute himself a danger either to his family or to his neighbour. That is my personal reaction. However, on another occasion we will have an opportunity of talking about that. While I say that, I hope that compulsory measures may not be necessary, but a lot might be said in favour of having the power to do certain things. It is easier to talk to people when they know that you have the power, than when they are armed with the knowledge that you have not got it.

Senator O'Donovan—I am sorry that he is not here at the moment—raised some interesting points, all of which were sound enough, within certain limits. He would like to see early diagnosis. We all would like to have early diagnosis of the disease, but the trouble is that we cannot get hold of the cases in their early stages. I do not believe that we will be able to reach the stage of early diagnosis of the disease, in the full sense, at any rate, until we have the necessary radiographic equipment to provide full facilities for mass-radiography for the general public. The old-fashioned diagnostic methods are not sufficient to detect the disease in its early stages, no matter what we may be told about former methods. By the time that, according to the old-fashioned methods, such as palpitation, percussion, auscultation, and so on, you find that the patient is suffering from the disease, it is too late to grapple with it. It is only by means of radiography that we can get the best results, and I do hope that we will see the time in this country when radiographic facilities will be available to all our people, and particularly to children from the age of 10 years upwards, so as to enable us to get hold of the disease in time. I believe that if we can do that, the solution is comparatively simple.

Senator O'Donovan, and some other Senators, whose names I cannot remember, raised the question of bovine tuberculosis. Now, it is always well, in connection with such matters, that we should endeavour not to lose our bearings. Undoubtedly, it is a scientific fact that tuberculosis, of bovine origin, may be contracted by humans, but it is equally true that pulmonary tuberculosis, of bovine origin, is very rarely met with in humans.

Mr. Baxter

That is very important.

Dr. Ward

It is well to know that. Even the layman can see, a certain proportion of the disease, such as that connected with glands in the neck, etc., is of bovine origin, but while that is scientifically true, it is equally true that a very small proportion of our dairy herds is, in fact, secreting infected milk. I occasionally see discussions, as reported in the public Press, about the proportion of tuberculosis in cattle—I think it is said to be 8 per cent. I do not know whether that figure is accurate or whether it is exaggerated, but I do want to say that 70 per cent. of humans will give a positive reaction to a tuberculin test, and yet we do not look upon ourselves as being by any means a people who are particularly subject to the disease of tuberculosis. Quite the contrary. The scientific fact is that a very large proportion of humans will give a positive reaction, and that a positive reaction in the case of cattle is much smaller proportionately than in the case of humans. However, I may be wrong there.

Mr. Baxter

No. I think it is the most important statement that has been made in this House for a long time.

Dr. Ward

At any rate, what I want particularly to stress is that there is nothing alarming about the tuberculosis position in this country at all. When I say that, I mean—and it has been pointed out here before—that since 1904 the death rate in this country from tuberculosis has fallen by 50 per cent., and during the period since 1904 we have not made anything like this kind of specially concentrated attack upon the disease.

Mr. Sweetman

What date did the Parliamentary Secretary give?

Dr. Ward

Since 1904. While I am on that point, Senators may be interested to know that, in 1944, there has been a very substantial fall in the death-rate from pulmonary tuberculosis in this country, and so, apparently, we are on the march again.

Mr. Baxter

Does the Parliamentary Secretary mean, since 1943?

Dr. Ward

Yes, particularly since 1943. There was a slight fall from 1942 to 1943, and another fall in 1944. The figures show a very substantial fall as between 1942 and 1944. However, what I want particularly to say is that we are not scared about tuberculosis in this country, and that we do not want to create any scare. I do not think that the disease is more widespread in this country than in many other countries, but the real point to be stressed is that tuberculosis is a preventable disease. We are losing, say, 3,000 persons every year as a result of deaths from that disease, and let us say that there are 40,000 people in this country who are in ill health as a result of tuberculosis.

Our job is to try to prevent the disease, get hold of it in its early stages, and endeavour to grapple with it. I believe that that can be done in connection with this particular disease. People talk about deaths from cancer, but you cannot make the same attack upon cancer, with every hope of success, that you can make upon tuberculosis. Cancer is not in the same category at all. Tuberculosis is a disease that is preventable, and if we tackle it with courage, and in the knowledge that if we spend enough money upon it it can be dealt with in in a proper way, then I believe that we can solve the problem. That is the beginning and the end of the whole matter.

Now before leaving the question of bovine tuberculosis, I should like it to be understood that even the small percentage of our milch cows that give a positive tuberculin reaction do not all produce tubercular milk. But here is the danger, and this is the type of problem I hope the Milk Tribunal will say how it should best be solved—if there is a pooling of milk supplies, and if the milk from one tubercular cow is mixed with the milk from a number of healthy cows, you may convey infection to a much wider section of the community. That is a problem of a different nature, and I hope I do not weary the House when I try to draw attention to these rather fine distinctions, but as I have said, and perhaps I could not say it too often, only a small percentage of milch cows that would give a positive reaction would secrete milk dangerous for human consumption because of the presence of tuberculosis bacilli.

One final word before I leave bovine tuberculosis, and I wish I could get the assistance of all enlightened people on this until we can find some more satisfactory solution—people talk about bovine tuberculosis, the human contracting it, and the terrible economic and social consequence of the disease, but if they would apply a simple remedy ready to their own hand, they can protect themselves, if they just boil the milk. Similarly, although it is not appropriate to this Bill, like many other subjects, a lot of the enteritis with the huge death-rate which we get among children, particularly in the City of Dublin, could similarly be guarded against by boiling the milk, and yet we cannot get people to take that simple remedy to protect themselves and their children.

Elected representatives, whether members of this House or of the Dáil, have considerable influence in guiding public opinion, and they would be doing a great national service if they talked to the people in plain language and showed them how they could save themselves—do a tremendous lot for themselves—without looking to the Government or to the local authority or to anybody else. If there is one thing more than another that would protect the children particularly from many diseases, it is the pasteurisation of milk. If they are not sure as to the purity of the milk they should boil it, until we reach the time when we can guarantee a pure, wholesome and safe milk supply. We are far from that a present.

Senator Baxter talked about the nutritional aspect of tuberculosis. Other Senators followed. It is well that we should understand, as clearly as we can, this aspect of tuberculosis. Will you get it into your heads, and take out from this debate, if you take out nothing else, and will you tell everyone who discusses it with you, that nobody will get tuberculosis who is not infected with Tubercle Bacilli? That is the fundamental thing: that it is an infections disease, and being infectious, if you are invaded by a sufficiently large army of these germs, down you go, whether you live in a mansion or a slum.

I am not foolish enough to suggest that a well-nourished man in good surroundings has not a better chance of fighting tuberculosis or any other disease than a man who is half starved and who has, perhaps, to sleep in a room with three or four or five other people; but, at the same time, what I want to warn you against is another danger which I see ahead of us. We have heard a lot about "the stigma of tuberculosis", and we know the terrible handicap it has been to everybody who tries to fight it, but there is, in my judgment, the danger of a new stigma.

If the people get a firm conviction into their heads that tuberculosis is evidence of malnutrition, of hunger, then you are going to create a new complex. You will have people afraid to admit to having tuberculosis or to come forward for treatment because they will say: "Sure, it will be said I am half-starved and that if I got proper food I would not have it." I emphasise that because of its importance and, for goodness sake, do not labour this question. Get malnutrition in its scientific setting, as Senator Fearon put it during the debate. You can refer to his contribution to-day on dietetics. Malnutrition is a scientific problem. As I said before, people may get plenty of food, an abundance of food, but from the scientific point of view they may not be properly nourished, because the food they get may not have the necessary essential nutritional elements. The laity cannot understand that, and if you labour malnutrition too much they will interpret it, in their own simple way, that they are not half fed.

So far as the nutritional aspect is concerned, we are in close consultation with the Medical Research Council with a view to determining, if they can be determined, suitable nutritional standards, a very difficult thing, because nutritional standards that would properly apply in one country could not be automatically applied in another. We must get a basis of nutritional standards on which to operate before we can make any effort to determine the nutritional state of our people. If we can get standards established, we propose to carry out a nutritional survey to see how well or how ill our people are nourished, and what we might be able to do to supply, in the future, some of the elements which scientific investigation may show to be wanting.

Senator Baxter, too, poses the question: how do the children become ill? I have dealt with that. There is an aspect of this that one does not want to emphasise too strongly because it is not too much to our credit. The fact is that our habits of life have a lot to do with the spread of tuberculosis, and some people truthfully say that tuberculosis plays havoc among certain classes of the community. But it means that the habits of life of these particular classes are not of as high a standard as the habits of life of other classes.

The fact is this—that if in a household, particularly where there is overcrowding, a case of open tuberculosis enters, and if there is coughing, sneezing and spitting in the open, and that the germs or the bacilli of tuberculosis are being scattered broadcast about that house, it is no wonder that the spectacle is witnessed of even whole families being wiped out. Of course, they are. It is inevitable, if the dose of the infecting germs is overwhelming. Some people say that tuberculosis runs in families. Well, you could with equal truth say: "So does diphtheria, if no steps are taken to isolate the person who first contracts it." It brings us back to the point from which we started. Until we have institutional accommodation to house the people who are openly infective, we cannot make headway. When we get accommodation, we can go out searching for cases and we may find it necessary to take strong measures if the accommodation is there, to ensure that the disease will not continue to be spread.

Senator Baxter mentioned after-care. Other Senators followed on the same line. We are all at one in that regard. As regards after-care and rehabilitation, if we can get the patient early enough, we hope to send him back a sound and healthy man. What most lay Senators have in mind is, however, the danger of the family when the patient is sent home. I hope that we shall not be releasing people from our institutions who are a danger to anybody. Perhaps that is too much to hope for but that is what I am aiming at. Even in the case of patients who are cured, there will be a considerable period during which the physical capacity of the individuals will not be equal to the full effort and it is at that stage that the voluntary organisations can do most good. In that way, as well as in the line of education and propaganda, I am hoping for a great deal from the Irish Red Cross. The State and the local authorities only can lead in the matter of treatment but, as regards the ancillary services, tremendous good can be done by voluntary organisations. A voluntary worker has a different standing with the community and with his neighbours from that of the individual who is paid to call around and give advice. I need not labour that point. It is sufficient to say that after-care must constitute an essential element of any full scheme that may be operated here.

Senator Honan was the first Senator who raised the question of heredity. He said that he saw whole families wiped out by this disease. Senator Healy saw families who successively occupied the same house wiped out, and he said that tuberculosis must, accordingly, be hereditary. Senator Honan, particularly, laboured the hereditary aspect of the matter. Again, this is one of the things we cannot get the layman to understand. We often hear how doctors differ but it is a scientific fact, which is not questioned by any section of medical thought, that nobody is born with tuberculosis. Given a certain environment and the necessary microbes, a person will develop the disease but everybody is born free of it. If a family previously free of the disease, who come into occupation of a house where a number of people have died of it, contract the disease, it is because the house has not been properly disinfected. The germs of tuberculosis are there in their millions and wipe out one family after another. That is the secret of the matter. Tuberculosis is not hereditary and it does not run in families, unless as other infectious diseases run in families.

Mr. Healy

That is a welcome statement.

Dr. Ward

Senator P. J. O'Reilly is not fully convinced that the policy of treatment in regional sanatoria is sound. He would prefer to see a sanatorium in every county, with all the necessary services. The answer to that has to be based more upon scientific factors than on other considerations. The fact is that, so far as the surgical treatment of tuberculosis is concerned, medical science has advanced by leaps and bounds in recent years. It is not within our competence to provide in county institutions the specialist service that can now be provided. We hope to provide that specialised service in those regional institutions. It does not necessarily follow that we shall no longer require our local institutions. We shall, but for a different purpose. I propose to bring into our regional institutions all the cases requiring active treatment or treatment of a specialised nature. There are very few cases of tuberculosis so far advanced that they are not now open to treatment.

I shall not labour that point beyond stating that cases formerly regarded as utterly hopeless are now open to treatment—particularly treatment of a surgical nature. I propose to provide that type of service in our regional institutions. The local sanatoria will find their place in the ultimate scheme in this way: it is agreed that 70 per cent. of the community contract what is called primary tuberculosis—a very minor infection—which they are usually able to fight down themselves. They regard it as only a cold and they acquire a certain amount of immunity when they have successfully negotiated that stage of the disease. But a percentage of those who contract primary tuberculosis require rest, care and a special diet. That is all they require. It is to the treatment of that type— the early cases who require only rest, care and proper diet—our local institutions will be devoted in the future. The cases that require more active, more highly scientific and more specialised treatment will be brought to our regional institutions. Senator O'Reilly will, probably, be satisfied with that explanation.

Mr. P.J. O'Reilly

I am satisfied.

Mr. Sweetman

Are those who constitute the percentage requiring only rest and diet, germ disseminators?

Dr. Ward

No. All open infective cases will come to the regional institutions. A considerable proportion of the primary cases are really in the pre-tuberculosis stage: the institutions will be more "preventoria" than "sanatoria".

Senator Mrs. Concannon contributed some refreshing ideas and useful suggestions to the debate. I have not had an opportunity of examining the figures, and I speak subject to investigation, but I do not think that anything is to be hoped for from the possibility of surplus accumulations in the National Health Insurance Funds. The fact is that we have not sufficient money to continue our hospital and dental benefits over the entire year. It would be very desirable to have those benefits continued over the entire year instead of carrying them on for six months and then interrupting them. If funds were available, I should like to see a position under which those benefits would be made available for the whole of the year. While saying that, I am not turning a deaf ear to Senator Mrs. Concannon's suggestion. It is worth considering, but I am afraid that, without an overhaul of the financial structure of national health insurance, with increased contributions so as to obtain increased benefits, not much is to be hoped for in the direction of an accumulation of funds.

Senator Fearon did not like the word "hospital" so much. He would prefer to have it called a tuberculosis centre. It is being called a hospital in our drafting, because in the Tuberculosis Acts, to which, of course, this Act must be related, these institutions are described as hospitals for the treatment of tuberculosis. It is more a matter of drafting than anything else. Senator Duffy talked about sites. I can only say that the sites deemed the most suitable in the opinion of my technical advisers will be acquired, and the layman's viewpoint in the light of present day scientific knowledge is not always just as sound as it might have been considered even ten years ago. The Senator also mentioned occupational therapy in mental hospitals and considered it would be desirable to have a similar development in connection with our sanatoria. Again, the layman slips a little bit there. The types of ailment are altogether different, and the lines of treatment are altogether different. In tuberculosis the most important factor nowadays is rest, not work. The question of the development of a settlement for patients who had recovered is a different matter from employing them at farm work. I can only express my personal viewpoint with perhaps a fairly close knowledge of the psychology of our people. It is my conviction, right or wrong, that our people will never take to the settlement idea. I may be proven to be wrong, but my firm conviction is that the trouble always will be to get our people to stay long enough for treatment. Perhaps it is a virtue, but there is a sentimental attachment to the home in Ireland no matter what the home may be like. They want to be in the home, and our problem has been even in cases that were promising, to get them to stay in the institutions until they were well enough to go out. Time may prove I am wrong, but I believe our people will not take to the idea of a tuberculosis settlement which the public would regard as a place for the untouchable. I do not think it will ever be accepted by the people. If it should turn out that I am wrong I would be very glad to find that I had miscalculated.

Senator Duffy also made the point that our statistics were not really reliable because of the fact that 16 per cent. of the deaths were uncertified. Well, again with the very best intentions in the world the layman sometimes slips. Any census figures will show that the vast bulk of the uncertified deaths are in respect of old people. When people think that the old man is going to die and is not going to get better anyway, they do not always bother about bringing in the doctor and the death is registered with the cause uncertified. It is really seldom, when a young person is in danger of death, that the doctor is not called in. That is a little fallacy in accepting this 16 per cent. as vitiating our statistics. Tuberculosis as everyone knows is a disease of the young, of the adolescent type. Senator O'Duffy said, amongst other things, that people would die rather than accept home assistance. There may be some small nucleus of truth in that idea. But if there is, it is another of those stigmata that we should set out to fight and defeat. What is wrong with home assistance? What is home assistance? Is it not financial assistance or assistance in kind provided out of local taxation? There is nothing wrong in it. If it is not wrong for the rates to contribute towards the provision of institutions, there is nothing wrong in the rates making provision for the maintenance of dependents, and intelligent understanding of those facts by Senators, and public men in general, should help us in getting rid of this stigma. It is time we got away from this position. There should be no stigma attached to the provision of assistance from local taxation that does not equally attach to assistance from central taxation.

Mr. Baxter

They would take anything you give them to-day. The whole trouble is that they are not getting enough.

Dr. Ward

So long as it is local taxation they cannot blame the Government for that; they can blame their good neighbours for it. Senator Sweetman is concerned as to the areas that will not be served by regional sanatoria. The only point I want to make in answer to him is that while a general geographical allocation is contemplated, there would be no rigid geographical arrangement. It is going to be difficult to provide these beds. I do not know whether it will be possible, but I am going to have a very hard try. If we can provide the beds, and if there should be cases in an area adjacent to Dublin to be served, or if there should be beds vacant in Dublin and beds required in a place like Wicklow, then geographical boundaries will not operate. If they are vacant in any area these beds will be occupied.

Mr. Sweetman

Will the smaller institutions be given the same scientific conditions as the larger ones?

Dr. Ward

Yes, in all probability. If we cannot have special treatment we will have it arranged that only a special type of patient will be treated there. I think I have covered nearly all points that were raised. If I have not covered them, if Senators remind me, I will deal with anything I have omitted. I emphasise that this is only one element in the scheme of health. It is an essential element. It is a fundamental element. Until we provide beds and until we can isolate the infectious and remove the source of infection we cannot make headway. We hope to provide, and it seems possible that we will operate a scheme to get rid of the disease or, at least, reduce it to such dimensions that we will be looked upon with eyes of envy by our civilised neighbours.

Question put and agreed to.

Committee Stage ordered for Wednesday, 21st February.