Seanad Éireann debate -
Thursday, 22 Feb 1945

Vol. 29 No. 16

Tuberculosis (Establishment of Sanatoria) Bill, 1945—Report and Fifth Stages.

Sir John Keane

I move:—

In page 3, line 25, to add at the end of Section 5 the following words:—"Provided always that a sufficient capital sum shall be left in the fund to provide income adequate to defray the deficits of voluntary hospitals on the basis of the year 1944".

I told the House yesterday the reason for putting down this amendment. I hope the Parliamentary Secretary will not make this a sort of question of personal antagonism, because I think I am being quite fair in asking him to give us further enlightenment on this matter of the hospitals' deficits. On the Second Reading, the Parliamentary Secretary said—I take no exception to what he said—that the hospitals should take steps through the corporation to put those poor patients on a paying basis. I pointed out the difficulties in bringing that into practice. I hope the Parliamentary Secretary, having slept on it, will admit that I am entitled to a reply.

A poor patient comes along to the outpatients' department of a hospital. The doctor says: "This patient should be an intern patient," and in due course, under the hospitals' charter, under the hospitals' traditional practice of taking in our people, that patient is taken in without question. If the Parliamentary Secretary's proposal that the corporation should pay for those patients is to have effect, the hospital authorities must go to the corporation and say: "We have taken in A.B., and we want two or three guineas a week." The point I am trying to make is that the patients must come in the first instance through the dispensary system. What happens in the country is that a patient goes to the dispensary doctor; in due course a case is put up, the county board of health agrees to his going to the hospital, and a payment is made. Some system of that kind must apply in the city in order to make the thing workable. For that purpose, the dispensary system must be made effective. I may be told that there are dispensaries. But they are not effective; they are not large enough, and in practice the poor patients do not go to them; they go to the outpatients' department of the voluntary hospitals. I would ask the Parliamentary Secretary to deal with that point. He says that the hospitals must go to the corporation, and he says he will aid them in their approach, but I really feel that it is for his Department to put pressure on the corporation to take the first step by setting up a working dispensary system. That is the first step. I shall be glad to hear the Parliamentary Secretary's reply.

Parliamentary Secretary to the Minister for Local Government and Public Health (Dr. Ward)

I am glad to find that Senator Sir John Keane has adopted quite a reasonable attitude on this amendment. We are dealing with a Bill to provide sanatoria, and an important feature of our scheme will be the provision of dispensaries. I understood, when Senator Sir John Keane talked in a rather vague way about dispensaries last evening, that he had in mind dispensaries under our tuberculosis schemes. Now, I understand that he is concerned about our dispensary system under the Public Assistance Act, particularly in the City of Dublin. He has no radical objection to the principles involved in the policy I have outlined, but he is concerned as to how it can be made operative. I cannot outline to the House a scheme of operation that will, undoubtedly, work smoothly, but my case is that so long as we continue to pay the deficits of the voluntary hospitals and fail to put pressure upon them to reduce those deficits in the only way we can see they can be effectively reduced, so long will those conditions obtain and the deficits not be reduced.

For years I have been trying to impress on the voluntary hospitals the urgency of doing something practical in this matter of their rising deficits. A scheme cannot be worked out until the necessary contact is made between the parties, the voluntary hospitals and the local authorities which will have to contribute towards the maintenance of their patients, and I am not suggesting, and have not suggested at any stage, that the local authorities should pay the full cost of the service that is provided. I do not believe that it is conceivable that any local authority could pay the full cost. The services provided in the City of Dublin, particularly, are not purchaseable. We have nothing to compare with it in the provinces at all. It is a voluntary system in which all these eminent physicians and surgeons place their services freely at the disposal of the community.

All I am suggesting is that the local authority make a contribution, not towards the treatment of their patients, but towards the maintenance of their patients in these institutions. I do not think there is anything wrong in that principle. It can be worked out as soon as the representatives of the voluntary hospitals and the local authorities come together and set themselves towards finding a solution to the problem. Senator Sir John Keane feels satisfied that it is my function to insist at the outset that the local authorities should take action in this matter. I rather think that the initiative ought to be taken—I agree with him to that extent —by the voluntary hospitals. After all, it is scarcely in accordance with our experience of life to hope that the local authority so long as they can get service completely free will come forward and say: "We want to pay three guineas" or "We want to be afforded the privilege of paying two guineas towards that amount." I do not think they will do that until the authorities of the hospital make it clear that they cannot continue to provide the service without some contribution from the local authorities.

I do not think that any detailed debate in the House will help towards a solution. Everybody is anxious to find a solution. The voluntary hospitals themselves are anxious to find a solution and I do not want to suggest that Sir John Keane is constituting himself a busy-body, but I do think that if we had less public discussion on this matter until the difficult aspects are more fully examined by the people who are now beginning to examine them for the first time, we would have a better prospect of making headway.

I have reason to believe, and I think some Senators have reason to believe, that there is a better understanding of the position now, and that an effort will be made to find a reasonable adjustment. Consequently, it might be wiser if we did not pursue this matter too far on this particular Bill. Again, of course, I do not know that I can contribute anything very helpful as to how the agreement might, in fact, operate. I concede, immediately, if it is necessary that I should concede it, that the public assistance system in the City of Dublin is far from satisfactory. But we cannot overhaul that system within a year or two. It is one of the problems I have set myself, and whether I will be there long enough to solve it or not is another question. If not, somebody else will take it on where I left off. Anybody who knows anything about the operation of the system is not satisfied that it is working satisfactorily, but other machinery could be set up for the easy admission of patients of all classes for whom the local authority should take a share of the financial responsibility.

Machinery other than the dispensary system might be employed. It may be possible that, through the bed bureau, a system of admission to hospitals could be worked out. I quite agree with anybody who contends that to operate a satisfactory admission system entirely through the dispensary service in the City of Dublin would scarcely be feasible. I take it that the Senator has put down this motion for the purpose of extracting, let us say, a statement. I thought I had said nearly everything I could say on the last occasion, and I certainly did not intend any discourtesy to the House. I did not think such a charge could be levelled against me.

Mr. Baxter

You are much better than usual.

Dr. Ward

I thought I went to great pains in concluding the Second Reading debate to deal with every point raised.

Mr. M. Hayes

That is so.

Dr. Ward

Members of every Party came to me afterwards—a very unusual experience——

Mr. Baxter

For you.

Dr. Ward

——and they certainly seemed to be not only delighted but enthusiastic. We all belonged to the same Party that night.

Mr. M. Hayes

I think the Minister for Industry and Commerce was a dissentient that night.

Dr. Ward

He might be, but we were all standing together that night, and there was one leadership in this particular war in which we have now engaged on the problem of tuberculosis. As I say, I do not think we need discuss the actual motion. Perhaps it has served its purpose and Senator Sir John Keane would not press it.

Sir John Keane

Have I the right to reply, Sir, to an amendment on the Report Stage? I am going to be very brief. Do the Standing Orders give me the right, as the mover of an amendment, to reply?

An Cathaoirleach

Yes, Senator, if no other Senator desires to speak, you may conclude on the amendment.

Sir John Keane

I do not want to embarrass the Parliamentary Secretary in negotiations going on at present. I am sorry that I should have given the impression of discourtesy— I did feel a bit irritated by his refusal to answer. I am sure the Parliamentary Secretary appreciates that an efficient dispensary system would very much reduce the expenses of the hospitals. Obviously, one of the big expenses of the hospitals is the outpatients' department, and if the main strain is taken by the dispensary system it will save the deficits. I do see difficulties in sponsoring a meeting between the hospitals and the corporation. Would the Parliamentary Secretary consider sponsoring such a meeting and even presiding at it? Unless the convening comes from the Department, it will not be very easy to arrange such a meeting. That is all I have to say, Sir, and I should like the leave of the House to withdraw the amendment.

Amendment, by leave, withdrawn.

Question—"That the Bill be now received for final consideration"—put and agreed to.

Question proposed: "That the Bill do now pass."

Mr. McGee

I have a few remarks to make on this stage of the Bill. I do not want to detain the House very long except to say that I thought I recognised in the discussions yesterday a sort of anxiety in regard to the Bill at which, I am glad to see, the Parliamentary Secretary has hinted and quietly resisted. At all events, there was an impression left on my mind that there was a sort of anxiety to rush the matter through— at least, it seemed to be suggested by some Senators—without, perhaps, very full and complete consultation with the local bodies concerned. I think we are all wise enough to realise that if the Bill is to be the success which we all desire it to be, that can only be achieved after the fullest and most careful consideration so that practically everybody connected with a public body will bring his goodwill to bear upon it. Speaking on behalf of the smallest county in this country— smallest in area, at any rate, but containing a population of 64,000 people, and with two towns of a population approximately of 16,000 and 18,000 respectively—we find an increase in the number of tuberculosis patients that have to be attended to, and I must admit that in the past, in County Louth, we have not reached the measure of success which we would like to have reached.

In that connection, I venture to suggest that we have had the best medical service at our disposal that could be had in the land. During my experience, we have had four or five county medical officers of health who were as good as could be found anywhere and who did their best to deal with this matter, but, for one reason or other, their efforts or their schemes were not availed of. For some reason or other, the people in this country are not hospital-minded and have never jumped to the orders of the county medical officer of health in the way we would desire. Therefore, I hold that if a general urge is going to be made on the Ministry to rush up the rates for this purpose, a prejudice will be created in the minds of these people against the scheme. I have seen suggestions of 1/- in the £, or something like that. Now, obviously, this cannot be expected to take place at once, and if an increase in the rates means the imposition of greater hardships on our people, that will only make the people, and particularly the poor, more susceptible to the disease. The various public bodies, I am perfectly certain, will try to balance the matter faithfully and well, with the little means at their disposal. They have done so in the past, and I am not without hope that they will continue to do so in the future.

I realise that the Parliamentary Secretary has a difficult path to tread; it is beyond his resources or those of any Minister or Ministry, or of any body of people, to eliminate this problem at once, but we all wish to give him our support. In this connection, I am of opinion that an ideal sanatorium would be one situated amongst the trees, and in a part of the country where there would be a nicely adjusted temperature, where they would produce their own milk, butter and, so far as possible, their own food. I would also suggest that, wherever possible, such sanatoria should be staffed by the members of a religious community. To my mind, the best service we could hope to receive would be from such people who have built up and carried on hospitalisation for so many years, and I might give, say, St. Vincent's Hospital or the Mater Hospital as an example here in the city. I may say that in my own county some years ago I sold two demesnes, one to the Dominican Convent and one to another religious community in Drogheda. These institutions are equipped to send out people all over the world, to serve the needs of black men, red men or yellow men, and I am perfectly certain that it should be possible to get girls here to devote their lives to the treatment of tuberculosis at home. I am sure the Parliamentary Secretary realises that, and I only mention it by way of trying to assist him in arriving at the decisions he will have to make in order to make the scheme for the treatment of tuberculosis here sufficiently stable and attractive to the poor. It is a very big problem, and its solution will not be reached in an hour or a year. Realising our responsibilities in this matter, I think that the fullest and calmest consideration should be brought to bear upon it between the Department concerned and those who have to foot the bill. That is all I wish to say on the matter.

Professor Johnston

Before the Bill finally passes, I want to say a few words, particularly as I was interested in what the last speaker said. This Bill is a very useful step forward towards trying to remedy the incidence of tuberculosis in this country, but a complete policy for the permanent eradication of tuberculosis from our midst must be more than merely remedial. Such a policy must seek to remove the fundamental causes of the disease, and the first and most necessary step in that direction is to isolate the patients suffering from that disease so that they will not be a source of infection to other people.

For that reason, I welcome the proposals contained here, but, in addition, I should like to emphasise the importance, apart from this matter of isolation, of better housing, better nutrition and better clothing for our people if they are to maintain a state of health that would be likely to enable them to put up a successful resistance against the incidence of this disease. In that connection, I think that, of the two, better nutrition is perhaps more important than better housing, and a policy of better nutrition is not only complementary to the remedying of tuberculosis, but also complimentary to the remedying of other diseases, so far as our national policy is concerned. I think that a certain cookery book mentioned, as part of the recipe for cooking jugged hare, that you must first catch your hare, and then cook it. Along the same line, before we can have an adequate policy to deal with this disease, we must increase the national income of our people so that they can have proper nutrition, housing and so on, and I think we should expand the national income for that reason, and especially that part of our national income which is derived from agricultural production. That, directly or indirectly, is a necessary step in the improvement of the standard of living of our people as a whole.

I may say that, in another capacity, I have been very much impressed by the room that there is for expansion in our national income as a result of the development of our own national resources. I think that it could be doubled, or even trebled, within the next 20 years or so, and I believe that if we could do that, we would be able to create an environment favourable to our agricultural development and very much against the present conditions which are so unfavourable to the health of our community.

Mr. Douglas

I did not speak on the Second Stage and I would like to say that I entirely agree with the remarks that have been made with regard to the particularly helpful way the Parliamentary Secretary dealt with the Bill. Not only in the way that he dealt with this Bill but in the information which he saw fit to give the House on matters pertaining to the subject, but which are not strictly connected with the Bill. I think the Parliamentary Secretary was exceedingly wise in doing so because apart altogether from his courtesy he brought out quite a number of points which are not fully understood. If I might make a suggestion it is that I have a strong feeling that if propaganda notices which appear from time to time were to start with the simple statement that tuberculosis is curable it would be a wise step.

If you once get the people to believe that it is curable then everybody will think twice about staying away from the doctor. On the other hand, you have the opinion, which is far too prevalent, that: "I have a family; I have dependents; I will be able to stick out this for a bit and they will be better off. If they once think I have tuberculosis nobody will want me and I will never be able to get employment." I have found that attitude and it is a fairly common view. I know comparatively little about advertising. I have always been puzzled by it, but I do know that a great deal of money was made by simply stating: "Tyler's boots are the best" and things like that without any attempt to prove it. I have a strong suspicion that if it was impressed on the country that tuberculosis is curable that would be the starting point and would be much better than present publicity. I am not so much criticising present advertisements as saying that the other course would be better.

The Parliamentary Secretary made it very clear that while this Bill was essential he felt they must almost immediately consider the problem of the bread-winner—I would go a little further than the bread-winner—who is taken from work and see that some provision for his dependents is made, because it is not in the public interest or in the interest of the person concerned or his family that the present state of affairs should continue. The Parliamentary Secretary pointed out, I think wisely, that if the State takes a man away from his work it is not only for his benefit but for the benefit of other people who are thereby removed from the danger of infection. It is, therefore, reasonable that the community should be considered as sharing in that benefit. I take it that the Parliamentary Secretary has under consideration at an early date some method by which allowances may be made to dependents. I do not know how far he has gone into the matter, but he is probably not in a position to make any statement now. I am not asking him to do so, but I would like to see much better consideration given to the possibility of employment for persons who suffer from tuberculosis. Senator Duffy made some reference to Papworth and said that there should be a farm adjoining or connected with each new sanatorium.

I think the Senator said that any other kind of employment such as takes place at Papworth would not do here. I do not agree. I was interested in watching the very praiseworthy effort that was made at Peamount. The Parliamentary Secretary need not be worried. I am not going to try to reopen that question, but I was given figures and looked into the matter pretty carefully. I am satisfied that £500 a year would have kept these industries going. The total number given employment by that means was relatively small, but to have given adequate payments to the dependents would have cost considerably more than £500 a year.

I should like to see some small committee, with probably representatives of the Department of Health, one or two men with industrial experience, and one or two of the doctors who have been advocating the finding of employment for people suffering from tuberculosis appointed and, without committing the Government to anything, considering whether it would not be possible to provide a scheme of employment in some cases partially and in other cases wholly. Senator Duffy said that conditions were different in England, and he gave that as a general reason why a scheme like that at Papworth would not be suitable. Of course, conditions are different, but our people are not so different. The vast majority of them would rather earn the money that was being paid to their dependents and feel that they were earning rather than getting a State grant. I am not foolish enough to think it would be immediately practicable to provide employment for all who come into the sanatoria, but I am suggesting that there would be a great deal to be said for some settlement or industrial concern more or less on those lines. I would like to see three or four of them in this country and work paid at normal trade union rates. If they worked only half the time they would get half the rate. I would like to see articles required in the country produced there. I would like to see it run on ordinary business lines. It could only be run on ordinary business lines if the difference was made up by a grant or by some other means to cover any loss from partial employment and from having to pay trade union wages to people not able to do whole-time work.

Closely allied to that is what is called occupational therapy. Dr. Duffy gave a lecture, and dealt with the problem, and other doctors are interested in it. Dr. Duffy told me himself that some form of work of the nature of occupational therapy would be very helpful indeed. I do not want anything I am saying now to take away from my approval of the Bill, and certainly not from the approval that I have given to the statement of the Parliamentary Secretary that he was going to try to make it easy and more beneficial from the point of view of a man who has dependents to be taken into a sanatorium in the early stages, instead of waiting until it is too late. I do suggest you would add to the satisfaction of many of these people, and that it would probably cost less money to the State as a whole if some kind of work could be found. We have had an experiment which had many drawbacks, but which I am satisfied was not a failure at Peamount, and we have the experience at Papworth. There is a settlement in Switzerland, and others on the Continent, including the Scandinavian countries. There is one, I think, in Sweden, and with the experience to be gained from these, plus taking into account our conditions here, it might be possible to do something. I can easily understand the actual reluctance of the Department of Health to take on this matter as part of their functions, but I think the Parliamentary Secretary might very well consider whether it would not be wise to get one or two enthusiastic doctors like Dr. Duffy on the medical side, and a few intelligent men with business experience, with some officers from the Department, so that they would keep in touch with Government policy to see if they could not make some proposal.

They might say that it could not be done, but I think that they would make some proposals, and that those proposals might reduce the cost, not of this Bill, but of later expenditure which the Parliamentary Secretary says is an essential part of the whole scheme.

Mr. S.T. Ruane

I should like, before the Bill becomes law, to make a few observations on it, not in a critical spirit, but with a desire to be helpful. My remarks are shared by practically all those in my native county who are associated with the work of public bodies, and especially by those endeavouring to arrest the spread of tuberculosis. This Bill will lead to the adoption of many methods for preventing the spread of this disease. In those activities, I hold that the medical inspection of schools should play a very important part. Unfortunately, colds contracted by school-going children develop in many cases into acute tuberculosis. If it were possible to have those colds attended to in their early stages, much would be done to prevent the spread of this disease. The medical inspection of schools should make a substantial contribution towards the success of this work. As the work is carried on in my native county, and in practically every other county, only the fringe of the question is being touched, because the officers concerned have multifarious duties of other kinds to perform. The medical inspection of schools comes in for little of their attention, because they have not the time to give to it.

In Britain, school children are examined twice a year by a competent medical officer. While I should not expect to reach that standard, arrangements should at least be made by which there would be an annual medical inspection of school children. In my own country, there are between 360 and 370 schools, and the school-going population is 27,000. Though school medical inspection has been operating for the past ten years, only the fringe of the matter has been touched. I am of opinion that very little has come of the inspection because of the limited time which can be devoted to it. Instead of an annual inspection, the doctor can attend only once in five years. With a view to more frequent inspection, a scheme was devised in my county some years ago, with the co-operation of the county medical officer of health, by which dispensary medical officers would be linked up with the inspection. The idea was that, in the initial stages, the county medical officer of health would visit the schools, and that subsequent visits would be made at least once a year by the dispensary medical officers. These officers are in touch with the health of their districts. Oftentimes, they are present at the births of the children who attend the schools. They see them when they are being vaccinated and at other times when they are visiting their parents' homes.

Unfortunately, the scheme was turned down by the Department on the ground that the carrying out of school medical inspection required special training and experience and that the proposed scheme would not secure the co-ordination which was necessary for the provision of treatment and the keeping of proper records. The keeping of records would remain with the county medical officer of health and the scheme provided for that. We all understood that, in the early stages, there might be a certain amount of discrepancy between the opinions of the dispensary officers regarding nutrition and so forth but, after a while, coordination would be reached as a result of their consultations with the county medical officer of health. We all fervently hope that this Act will be a success. It will have the co-operation of every body in the country, especially those who understand the ravages which the disease is making. Therefore I trust that a trial will be given to the scheme drafted in Mayo for linking up the dispensary medical officers with the county medical officer of health. I believe that valuable information would be gleaned in that way and that that information would make the efforts for checking this disease successful. It is the opinion of those in touch with those matters that good results would follow from adoption of the scheme.

Mr. Patrick O'Reilly

I said nothing on the Second Reading of this measure, because I took it that it would be an agreed measure and that, therefore, a number of Senators would be anxious to speak on it. I should like to make a few points on the Bill at this stage. It is generally agreed that the Parliamentary Secretary has taken the first step in combating tuberculosis. For that reason, he has been congratulated. While this is the first step, we are all agreed that the next step should be the provision of maintenance for the dependents of people stricken with the disease. I should like that any scheme to provide such maintenance be administered by a machine controlled by the tuberculosis officer in each county. If it were administered by the home assistance officer we would be putting the badge of home help on it and it would not have the favourable reaction we should like it to have. In some respects, it might retard applications from people for the assistance to be given. That would be a very bad thing, because it might prevent the reporting of cases early enough to ensure proper recovery. I should regard it as very important that the scheme be administered by somebody other than the home assistance officer.

As regards the cost, I take it that it will mean some extra burden on the local authority. Because the Parliamentary Secretary is responsible for local government, I should like to point out that, while local authorities are anxious to co-operate so far as possible in the scheme, a number of them are reaching saturation point so far as the compilation of their estimates is concerned. In making up their estimates this year, a number of county councils had to strike a rate of around 18/- in the £.

The extraordinary fact is that these counties are very often the poorer counties. I am aware that in County Mayo the rate is 18/2 in the £, while in County Leitrim it is 18/0½ this year. I am told—I may be quite wrong in making the statement—that it is 24/- in Kerry. If that is so, having regard to the extra burdens that are being placed year after year by the State on the shoulders of local authorities, I am inclined to take the view that some measure to re-distribute the burden more equitably would have to be devised. Take the Arterial Drainage Act which was passed by this House a week ago. In my opinion, that will place an extra burden next year on the shoulders of local authorities. I agree that the system of raising money on a valuation basis is equitable within a county, except perhaps in the case where a widow might have a big farm and might not be able to make proper use of it. It would be very hard for me or any member of the House to suggest an alternative scheme that would raise the same amount of money without creating greater hardship. For that reason I say that the valuation system of paying rates is equitable within the different counties, but I am prepared to say it is not equitable as between the different counties. A county with a very low poor law valuation has generally more commitments in the way of public health services and a hundred and one other things for which local authorities must take responsibility, than counties with larger valuations. Such county may have to bear a greater burden in home assistance and to send more patients to sanatoria. That is a very serious position having regard to the comparatively low taxable capacity of these counties. I am sure the Parliamentary Secretary has already examined this question.

In my opinion some measure will have to be adopted to arrange a more equitable distribution of the burdens between the different counties. In the administration of this scheme, I think that as far as possible an effort should be made to enlist the co-operation of the dispensary doctors so as to ensure early diagnosis of the disease. The county tuberculosis officer may not be able to get the same results as could be obtained by proper co-operation with dispensary doctors. The dispensary doctor is called in to treat every type of case and it is he who would be normally consulted in a case of tuberculosis. It is through him that the machine should begin to work if we are to secure early diagnosis and treatment to ensure a satisfactory recovery.

Much has been said or could be said on the location of sanatoria. I myself might be inclined to take the view that all sanatoria should be situated on the east coast, having regard to the fact that the climate is more suitable, but then there would be the possibility that people might not wish to travel long distances and in the long run it might be better to have them located in areas which the patients would not regard as being too far away from their homes. I agree that if you try to remove all the patients from the West of Ireland to the east coast you might find unwillingness on the part of people affected to go there. For that reason the matter is one for the Parliamentary Secretary and I am sure that he will have regard to all aspects of the case in deciding where the sanatoria are to be located. I do not think there is anything further I can add except to say that we hope that this first step forward will be followed by other steps and that the Department and the Parliamentary Secretary will meet with success in combating tuberculosis.

Mr. Baxter

I have only one brief point to make. It arises partly out of the statement made by Senator Douglas to the Parliamentary Secretary that he should consider propaganda in favour of the idea that this disease is curable. I should like to add my suggestion that he would consider propaganda to the effect that the disease is preventable. I think that is the right place to start and I am reinforced in that opinion by a very important and interesting statement made by the Parliamentary Secretary in his reply to the Second Reading of the Bill. Listening to Senator O'Donovan talking in this House as a veterinary surgeon, sometimes one feels slightly frightened about the dangers to our health by contracting disease through live stock, not that I think the Senator is as much an alarmist on that point as he was perhaps some years ago.

Mr. S. O'Donovan

I was never an alarmist.

Mr. Baxter

The Senator is getting more mature and his judgment is better balanced. The Parliamentary Secretary, however, was very definite in his statement with regard to the incidence of tuberculosis of bovine origin. It was very comforting and I was rather surprised that the Press of the country did not make more use of the statement. In fact it was necessary to do so to combat a great deal of the propaganda that has been going on inside and outside the country on this very vital point. The impression we drew from what the Parliamentary Secretary said is that the origin of tuberculosis, as far as milk is concerned, is very limited in its scope. I suggest to the Parliamentary Secretary that if he went out and told the people that thousands of cases of tuberculosis could be prevented if people drank more milk, it would be the soundest doctrine he could propagate. I am convinced of that myself. I believe that people, and especially children in farm houses as well as in town houses, have nothing like a proper realisation of the value of milk as food. I am not speaking without knowledge of what conditions in Ireland are, or without having information or the ability to make comparisons as between conditions in one farm house and another. I am absolutely satisfied that the health of the people could be considerably improved if more attention were paid to the drinking of milk by young people. I put it to the Parliamentary Secretary this aspect of the question requires urgent consideration.

I am very glad to see that the go-ahead people in University College, Cork, have taken steps to make a social survey down there. I think if the Parliamentary Secretary would ask them to examine in their survey the situation especially in regard to the consumption of milk over the area, whether it be partly city or partly rural, the information we would obtain would be startling indeed. I hold very strong views on this question. I was greatly encouraged by the statement of the Parliamentary Secretary with regard to the purity of our milk supply on the whole, but I am satisfied that it is not as good as we could make it. I hope, on the other hand, that Senator O'Donovan and his colleagues in the profession will be given a chance to make it more pure than it is. I believe it could be brought to the point at which we could be all sure that we were drinking milk under conditions in which it would be 100 per cent. free from disease. In the meantime I am convinced that the soundest doctrine that the Parliamentary Secretary could preach and the best propaganda he could spread throughout the country, in order to combat the dangers of tuberculosis, would be that all the people, especially in rural Ireland, should drink more milk.

Mr. Foran

I was greatly relieved by the attitude taken up by the Parliamentary Secretary to-day on this question of the voluntary hospitals. I am very pleased to hear that he is in favour of negotiation between the hospitals and the local authorities. I think that is all to the good. The Dublin Corporation spends something over £390,000 per annum on public health services. That is a very big sum for the City of Dublin—excluding County Dublin altogether. The sum for the current year is £343,000, under the heading of public health services. I do not know whether the people could bear another £100,000 and remain solvent. Included in the £343,000 there are grants to all the voluntary hospitals totalling something in the neighbourhood of £5,939, which is altogether too small, in my opinion, and leaves plenty of room for negotiation. I submit, Sir, that it is a matter for negotiation. I am sure the Dublin Corporation would be willing to increase those grants to the voluntary hospitals very substantially, rather than be coerced into contributing £100,000 per annum, or increasing the rates by 1/- in the £. I would point out to the Parliamentary Secretary that, to my own knowledge, there is very little co-operation between the voluntary hospitals. It would be extremely difficult for anyone to initiate a conference between the corporation and the voluntary hospitals, so I suggest that he or his Department might take the lead in getting them together to discuss this matter on a friendly basis. I was very struck by some of the suggestions made up to now, particularly in the case of the Senator who talked about bringing all the tuberculosis cases to the east coast. I think the great bulk of the tuberculosis cases are there already.

Mr. P. O'Reilly

I did not exactly say that they should be brought there. I said that was a matter for the Parliamentary Secretary, and that while it might be considered advisable from the climatic point of view, there might be other difficulties; for instance, you might not get the people to go there. I said that should be decided by the Parliamentary Secretary.

Mr. Foran

The point I want to make is that we laymen should not trespass on those matters. Up to now, the highest percentage of tuberculosis cases in Ireland is to be found on the east coast. I do not know what would happen if we were to bring more of them there.

In my opinion, there are two notable omissions from the Bill. There ought to be more information as to what provision is to be made for the maintenance of dependents. If satisfactory information on this point were made available, it would be possible to get after the disease in its early stages when the possibility of cure is much greater. It is well established that this disease is preventable and curable. Senator Douglas suggested that posters might be got out telling the people that the disease is curable. I want to relate a little experience which I had recently. I was presiding at a lecture on T.B. by Dr. Duffy, a man who is very closely in touch with this subject. One of the audience stood up and asked everybody present to look at him. He had been a victim of T.B., but fortunately he was in employment where he was well looked after, and during the period of two years while he was undergoing treatment the company by which he was employed paid his dependents 35/- a week. He was a perfectly healthy man as he stood up there to prove to the people present that T.B. is curable. The company which paid his dependents during all that period deserves the highest praise. If that were done more frequently we would have a far greater number of T.B. cures. The point I want to make is—that instead of merely telling the people that T.B. is curable, we should go around and prove to them, by photographs or personal appearances, that that is so. I am sure a great number of people who have been cured of the disease would, in their gratitude, be prepared to submit themselves to a personal demonstration that T.B. is curable.

As I say, one of the things missing from the Bill is provision for dependents. In the second place, we have not been told, as far as I know, how soon any of these sanatoria will be in operation. It occurs to me, that before the first bed is occupied, five years or so may have elapsed. Some provision ought to be made for extra bed accommodation in the meantime.

Senator Douglas, in speaking about Peamount, advocated the running of industries in those institutions on business lines. In connection with that aspect of the matter, we must not forget that at the present time we have something in the neighbourhood of 100,000 unemployed people. If we are going to set up industries on business lines in those institutions, and allow them to enter into competition with outside concerns, I do not think it will get us anywhere. I do not think we should lose sight of that aspect of the matter. In Peamount, there definitely was competition with outside workers. The institution had the advantage of subsidies and so on, and the outside people could not compete with them. That is perfectly true. I know it myself.

Mr. Douglas

I did not say it is not.

Mr. Foran

I want to say again that I am glad the Parliamentary Secretary is going to approach this matter of the voluntary hospitals in the way he has outlined here to-day. I certainly wish him every success in regard to those sanatoria.

Mrs. Concannon

In reading the outstandingly able and ardent speech with which the Parliamentary Secretary concluded the Second Reading in this debate, there arose in my mind a deep regret that the lessons contained in that speech were not made available for the general public. That feeling, evidently, has been shared by other speakers. Certainly, two or three sentences could be taken from that speech. Boiled down, it would be a most effective method of propaganda for starting off the attack which we are going to make on tuberculosis. The lessons of that speech ought to be made available to more people than those who have an opportunity of reading the Parliamentary Debates.

There are two or three statements in particular which have already received comment. The first was reiterated by Senator Douglas that tuberculosis is curable. That should be broadcast widely, and it should also be made known that it is preventable. Those should be our slogans, and we should also lay emphasis on the fact that tuberculosis is not hereditary. People have a great dread of it, and, accordingly, approach it in a fatalistic frame of mind, because so many are convinced that it is hereditary. I know a splendid young girl who was engaged to be married, but the engagement was broken off because some of her people had died of consumption. There is no trace of consumption in her, yet her life is ruined. That should be brought home to the people, so that everyone will be convinced that it is not hereditary.

Speaking of the cure of tuberculosis as the object of this Bill, there are two or three factors that have already been stressed in this debate. The cure of tuberculosis is not merely a physical cure. There is a spiritual and psychological aspect that has to be taken into consideration. I, myself, have had a rather melancholy acquaintance with sanatoria. As we know them, they are very lonely places. The patients need all the help they can get to fight against depression. For that purpose, the influence of religion is very helpful and, therefore, I was glad when Senator McGee spoke incidentally of the desirability of associating some specially trained religious orders with the conduct of sanatoria.

Another thing that the people I knew complained of was that the days seem so long. It is most important, not from a mere economic point of view because that would not be an objection, that the time of the patients should be occupied. There is no reason why they should not be trained to use their hands. We all remember that during the internment period in the camps a lot of our young men acquired great skill with their hands. They flooded the country with brooches, rings and ornaments and these were made by people who never did anything like it before in their life.

When these young men come back to their homes, there may be cheap electricity, and it may be possible to repeat in rural Ireland what was one of the strengths of rural France, namely, the carrying on of occupations by cheap and abundant electricity. The training for that is very good, all sorts of arts and crafts might be developed, but apart from that, the training would fill the long and melancholy days. When you are working, work is life, particularly when you are working with your hands. I join with Senator Douglas in pleading with the Minister to attach importance to this aspect of the cure, and to keep it in view. Once more, I wish, on behalf of the women of Ireland, God speed to the Parliamentary Secretary in the great task he has taken in hands.

Mr. Barniville

I am afraid this House is very definitely affected with tuberculosis. I am not going to deliver a lecture on the care or treatment of it, because I think that is not the point at issue. The Parliamentary Secretary, speaking as a medical man, has put us on the spot. When he puts up the proposition of sanatoria throughout the country for the proper care of tuberculosis, we must naturally agree 100 per cent. We cannot raise our voices against it, and we all welcome it, but one of my problems is the question of the financing of this wonderful institution. The Parliamentary Secretary mentioned the number of 4,300 beds. Now, I have not got a census of the bed population of Ireland for ordinary diseases, but I would point out that there are other diseases besides tuberculosis.

I am complimenting the Parliamentary Secretary on any efforts he can make in combating this curse of tuberculosis, but there are diseases like cancer, and there are broken legs to be mended. There are patients who require urgent treatment in hospitals throughout the country. These other diseases we shall always have with us. My point is that it is not a question of treatment, rehabilitation and rest of patients at the moment. This is a Tuberculosis Bill to establish sanatoria for the treatment of tuberculosis patients. I have a feeling that the Parliamentary Secretary has got the bit in his teeth with regard to this £8,000,000 he has in hands, and he is going to spend that sum on bricks, mortar, concrete and cement, rather than on staff, equipment, fuel, warmth and care of the patients for two or three years after their treatment in that sanatorium.

I am afraid he is going to take too much out of that £8,000,000 for that particular disease. I shall be unpopular if I am quoted in the Press for that, because I should be 100 per cent. in support. Nevertheless, I say that there are other things to be considered. If the Parliamentary Secretary is going to build sanatoria with 4,300 beds, with a 500-bed hospital costing roughly £250,000, it is going to take a considerable amount out of the funds we have, and I think we ought to consider carefully the facts of bricks and mortar deficits. My hospital, I am informed by an accountant, is the cheapest hospital in Ireland, and our deficit is the lowest, considering the number of patients.

Dr. Ward

Might I interrupt the Senator to give some information? It is not proposed under the Bill to provide 4,000 additional beds. The total aimed at is 4,000. We have about 2,000 of them already, and it is proposed to provide an additional 2,100. I might also say that it is not proposed to build these institutions in the same elaborate constructional manner in which voluntary hospitals have been built and will be constructed in the future. We are aiming at a simple type of construction. On pre-war figures, the average cost of a bed in a voluntary hospital would be about £1,500. Post-war, the equivalent will be £2,100 or £2,200.

Mr. Douglas

More than that.

Dr. Ward

I agree that it is very conservative, but I am giving a rough idea of what is ahead of us. I do not know whether I can do it, but I am aiming at a cost of about £700 a bed for the type of structure we propose to provide for sanatoria treatment.

Mr. Barniville

I am sorry, but I was just referring to previous speeches. However, the point I am on is this. I should like to make a plea to the Parliamentary Secretary, who has control of something over £8,000,000, to reserve as much as he possibly can of that for housekeeping money, even in the institutions that he has at present. It is a queer thing to say, but we have an excellent hospital—I am referring to the Mater Hospital—and we have plans to build a new 500-bed hospital in the neighbourhood during the next few years. I say that, from the point of view of the public, from the point of view of the patient and of medical treatment, it is much more important to have that patient properly fed, clothed, and kept warm in his bed, than to put him in a hospital with chromium, glass screens, and all the rest of it. In other words, I make a plea to the Parliamentary Secretary to reserve as much as he can of the money for the proper feeding and warmth of the patient, even if it is only in a hut.

Another point that I want to mention is that, speaking as a medical man, I do not like this term "voluntary hospitals" that has existed since the sweepstakes started. Now, what is meant by a voluntary hospital? The patient is voluntary; the religious people who staff the hospitals are voluntary, and the medical staffs who work in these hospitals are voluntary— they work for nothing. I know most of my colleagues in Dublin, and I am certain that not one of them knows whether a patient is paying a shilling a week, £1 12s. 6d. a week, £2 2s. a week, or whether they are paying any thing at all. That term "voluntary" is completely misunderstood, and I should like to say that these sweeps —I shall not say, these accursed sweeps—have ruined us in the sight of the public. I know that I have not made one penny as a result of these sweeps, and I am quite sure that neither has any other medical man nor any charitable committee made a penny out of them; and I think it is a pity that the public and the Oireachtas—and I am afraid that this is also true of the Parliamentary Secretary, although he is a medical man—should have lost sight of the fact that these institutions are voluntary.

Mr. O'Dea

I did not intend to speak on this measure, being a non-medical man, but having heard a number of other non-medical men speaking about it, I thought I might make a few remarks. Under Section 7 of the Bill, where the Minister transfers to one county authority his estate or interest in the land on which a sanatorium has been established, he may require the county authority to pay him, for repayment to the Hospitals Trust Fund, a certain contribution, up to one-third. I would ask the Parliamentary Secretary that, if there is to be a demand on the local authority, it should be for a nominal amount. I think that the application of the Trust Fund for this purpose is a very good idea. I have a very different view from Senator Barniville's view on that matter. He seems to want to have it reserved to the Dublin hospitals, but I think it would be better to have it reserved to hospitals, in general, and use it for general maintenance. As has been pointed out already, the cost will be very big. Take the case of the proposed hospital in Galway. I understand that Deputy Beegan was right when he stated, in the other House, that it costs about £200 a year to maintain each bed. In the case of a hospital, such as is proposed in Galway, with a 400-bed accommodation, the annual cost of maintenance will amount to something over £80,000 a year. Now, that hospital, I understand, will have to deal with four very large areas, and if four hospitals were concerned, dealing with each of these areas, the cost would be very much larger. For that reason, I think that the cost should be borne entirely out of the Sweepstakes Fund and that the local authority should have only a very nominal amount to pay towards the erection of the hospital.

Senator Ruane has referred to the question of medical examination of the children in the schools, and I agree with him in that view. We have, for instance, a very large county—the second largest in Ireland—and to deal with that huge area we have only one county medical officer of health and one assistant medical officer. If they were to examine every school in the county, as far as I can make out it would take them over two years to do so, and that, certainly, is not sufficient. In America, I understand, they have a very different system. The teachers in America, I am led to believe, are given a certain amount of medical training, and every day, at a clap of the hand from the leader of the class, the children in these American schools march out and are examined with regard to their eyes, throat, and so on. I should like to see something like that obtaining here, and I should like the teachers to have the power, if they see anything wrong or suspect anything wrong with the children, to call in the local dispensary doctor who, as Senator Ruane has said, knows the family history of the child and will be able to say what is the cause of the complaint. In that way I think we would be enabled to go about the remedying or the prevention of this disease early in life. There is no doubt that tuberculosis is a curable disease. At least, I hope it is, because I myself had it when I was young, and I am now cured—or I hope I am, at any rate.

Dr. Ward

The Senator looks pretty healthy, at any rate.

Mr. O'Dea

Well, I hope so, but I should not like to be brought around as a specimen. Now, there has been a good deal of talk about the prevention of this disease, and I think that that is very important. Somebody told us the other day: "Oh, we never heard about tuberculosis in the old days." No, but you heard about a neglected cold or what used to be called "a decline". I do not know whether a neglected cold might be the cause of this disease or not, but I do believe, because I have heard it from medical men, that people who have colds are more likely to be infected, and, therefore, if colds could be prevented or taken care of in time, it is probable that tuberculosis might be prevented to a large extent.

I often wonder why there is not more tuberculosis or rheumatism in this country, in view of the carelessness of our own people. We have a damp climate, and yet it would seem that very few of our people realise the necessity for keeping bedclothes or their ordinary clothes dry. Somebody told me the other day that in some parts of this country the bedclothes are aired only once a year. If that is the case, it really amounts to the execution of the people in that house. It would appear that people generally in this country do not realise the importance of having dry bedclothes, dry underwear, and dry outer clothing, and I think it is very important that our young housewives should be taught, as they are in other countries, that these things are very important. I think we should have more of that kind of education here, because I believe that it would have an important effect on the prevention of the disease.

Mr. S. O'Donovan

Like many other speakers, I had not intended to speak on this stage of the Bill but, as on many other occasions, Senator Baxter's remarks have brought me to my feet. Apart from that, however, I should like to express the opinion that we have had a very interesting debate on the subject of tuberculosis, although that is practically outside the scope of the Bill that is now before the House.

When I spoke on this Bill I said I did not think I could add anything very new to what had been said, because we were dealing with the construction of sanatoria. The debate, however, ranged over a much wider field than that, and to good purpose, if we have all learned something, and if the public outside learned something both in the sphere of prevention and of cure of this disease. Necessarily, I have to intervene on account of the remarks of Senator Baxter. I have looked at the official report of the debate, and I found that the Parliamentary Secretary has not in any way referred to the incidence of human tuberculosis of bovine origin. He did refer to what I said, and he used these words: "Now, it is always well in connection with such a matter that we should endeavour not to lose our bearings."

Well I have never lost my bearings in connection with it, and I want as a final word to emphasise that I do not in any way attach the same importance to human tuberculosis contracted from the bovine subject as to that contracted from other human beings. Necessarily it is in a secondary position. I never want anybody to believe that I have lost my bearings or that any of us lose our bearings in that connection, but I do know people who have taken every possible precaution against infection from tuberculosis. We all try to do it as far as lies in our power, but if you question any of these people about what is the source of their supply, you find they have never once thought of it. I agree with Senator Baxter that there is nothing better for us than milk. There is nothing better for the people of the country, and for the citizens of Dublin than to drink more milk, if they are satisfied that in drinking that milk there is no danger of contracting disease. The danger is small, but it is there, and if the milk is infected with tubercular bacilli they are bound to get it. They will know if they are subjected to the tuberculin test. They may not become patients or clinically infected with tuberculosis, but the danger is there. The point I did make is that we have no definite statistics to show what is the percentage of human tuberculosis that is of bovine origin. The Parliamentary Secretary referred to lesions in the glands. Take the Cappagh Hospital for children. It is full of young patients. I can say the majority of them are there from tuberculosis of bone origin but I cannot prove it. I think the Parliamentary Secretary will agree with that.

Dr. Ward

I doubt it.

Mr. S. O'Donovan

Pardon?

Dr. Ward

I doubt it very much. Very often bone and joint cases are secondary to tuberculosis in other parts of the body.

Mr. S. O'Donovan

That is so. We should have statistics and it could easily be done by typing cases to give us statistics. I could quote statistics from Dr. Griffiths in Britain but here we have not these statistics. I want to say again that I have never lost my bearings on the matter. It is secondary to human tuberculosis contracted from a human subject, but I must emphasise at the same time that it would be a pity if, coincident with the campaign against tuberculosis generally, we did not keep this matter in mind. The percentage in the bovine subject is very low. The figure is 8 or 9 per cent. of bullocks or heifers infected with tuberculosis. When we come to milch cows that are housed, the percentage rises. Our cattle are healthier than cattle in England or anywhere else but that is no reason why we should not make them healthier. The percentage in cows is about 35 per cent., which is less than in a human subject. That does not mean that every one of the cows is secreting tuberculosis.

Dr. Ward

On a point of information, and for the benefit of the House, would the Senator tell the House if, in fact, a very small focus in the bovine subject will give a positive reaction to the tuberculin test?

Mr. S. O'Donovan

That is what I was coming to. I say that 35 per cent. of the cows infected does not mean that every one of these is secreting tubercle bacilli. They have a focus of tuberculosis that will give a reaction but the cows are perfectly safe for the time being although they are a potential danger that the disease will spread. I will say from post-mortem examination that the lesions in the bovine subject seem to be progressive. We get very few cases in which the lesion is calcified and healed up. We do get this in the younger animals, but the fact is that it would seem to be more progressive than apparently it is in the human subject.

I have no experience of post-mortem examination of a human subject but I know in this case it is only a potential danger. I would not like anybody to think that when I say 35 per cent. of the cows are infected that these cows are secreting tubercle bacilli. The percentage doing that would be .2 per cent. or two cows in a thousand. We have had cases of cows primarily infected in the udder and there was no lesion elsewhere.

I only want to emphasis that it is to be regarded as secondary and should always take second place, but we must keep it in mind in our campaign against the disease as a whole. I hope I have gone sufficiently into it so that no member of the House would think that the reaction to a tuberculin test in cattle is any more indicative of danger to other animals than our reaction of 70 per cent. means that we are a danger to the other 30 per cent. who do not react. We react from a focus that may never give any clinical evidence that it is there.

One other point that struck me from the various items mentioned in the debate is that I have often found that cow keepers, whether they are dairymen in the city or farmers, have only one thing that they get for nothing and they are inclined to shut it out. The only thing they get for nothing is the thing they try to exclude. I think through the country as a whole people are too much inclined to shut out fresh air and sunshine from buildings which would be far drier and more comfortable if they allowed the sunshine and fresh air into rooms that are otherwise closed to daylight. I was not going to speak but for the remark of Senator Baxter that I seemed to be far more complacent about this question than I was previously. I have not lost my bearings in connection with it. I regard it as a very serious thing for the country and until we can get all the cattle free from tuberculosis I would not consider the situation satisfactory. That can be done by degrees. We have discussed the approach to the matter and, ultimately, I hope that we shall reach that stage.

Mr. Kingsmill Moore

I should like to ask the Parliamentary Secretary, when replying, to give us a little more light as to the nature of the proposed hospitals and their equipment. I have been in a sanatorium for a considerable period. So far as my observation went, the treatment of tuberculosis is not very expensive. An eye has to be kept on patients to see that they are not developing any "side" illnesses but, so far as my observation went, what a tuberculosis patient wants are plenty of food, plenty of rest, plenty of fresh air and graduated exercise. None of these is extraordinarily expensive and they do not involve very much in the way of expenditure on buildings.

I have known a very successful sanatorium which was conducted in hutments. Nor is the question of warmth so very vital, either, because I have often wakened up with snow piled upon my bed. If one is a great deal in the open, it is extraordinary how one becomes inured to cold. I could not tolerate the same conditions now but, at that time, I was inured to cold. The treatment of tuberculosis—I am not talking of surgical cases but of the ordinary incipient case in which there is a certain infection of the apexes— does not require very much money. I am anxious that, under this scheme, we should treat as many people as possible as cheaply as possible. When I say that, I do not mean that anything should be skimped but rather that a certain amount of the money available might be more effectively employed in giving necessary treatment to a large number of people than in providing expensive, over-elaborate equipment and unnecessarily elaborate buildings for a smaller number of people. I should like the Parliamentary Secretary to give us a sketch of the kind of sanatorium he envisages and an indication of the demand which it will make upon the available finances.

Sir John Keane

I wish briefly to refer to a matter I raised on the Second Stage. This is only one aspect of the medical needs of the country. I hope that the Parliamentary Secretary will have the whole of the medical services for the future examined in a comprehensive manner. In that respect, I suggested the appointment of a commission. I am not really wedded to a commission. What I want to see is something in the nature of a White Paper, setting out the long-term policy as regards medical services. I trust that, not only in the medical department but in relation to all our future activities, such White Papers will be circulated and receive ample comment in the Press. This is the system now being employed in Great Britain. To my mind, it is an admirable method of handling such questions. People write to the newspapers regarding the White Paper. The Government then come to Parliament with only a resolution, approving the principles of the scheme contained in the White Paper. There is a discussion in Parliament and, as a result of the public discussion and the discussion in Parliament, legislation is introduced. I hope that not only the Parliamentary Secretary but those in charge of other Departments will consider that method of approach to reform and development in the future. In that way you get public opinion prepared, you get the general criticism in Parliament and, finally, you get a Bill which is much more likely to evoke agreement than would otherwise be the case. I press that suggestion upon the Parliamentary Secretary and I hope he will prove to be a pioneer in that respect.

Dr. Ward

Nearly everybody who has spoken to-day introduced his remarks by explaining that he did not intend to make a speech. I might make the same remark, because I thought I had said everything necessary on this subject in the two very detailed statements I made in the Dáil and in the correspondingly detailed statements I made in this House. If Senators had read those statements or if they had been present when they were made, a great deal of the discussion we have had on the Fifth Stage would not have been necessary. I do not say that in any complaining spirit, but I do not intend to go over the matters which I have already treated in very considerable detail. Some points were raised to-day, however, which call for further elucidation.

Reference was made to the question of a tuberculosis settlement on the lines of the Papworth Settlement in Britain. The House, apparently, concluded from my treatment of a suggestion by Senator Duffy, that I was radically opposed to any such development here. I rather think, from the tone of the discussion here, that I must have created the impression that I was opposed to the idea of occupational therapy. It is well we should get our minds cleared about both these matters. I have no fundamental objection to the Papworth Scheme or to the establishment of a corresponding scheme in this country, except the objection that is rooted in the belief that such a scheme would not succeed here. As I said on one of the many occasions on which I have been speaking on this subject recently, I do not believe that our people will ever take kindly to the settlement idea. I may be wrong in that but it is my firm conviction that the settlement idea would not work successfully except, perhaps, in large centres of population, such as the City of Dublin, and we have not many such centres. We hope to bring to our regional sanatoria patients requiring institutional treatment from very large areas, and I cannot picture the possibility of inducing those people to settle for ever in the sanatorium, or its neighbourhood—and not only to stay there themselves, but to bring up their families and make their homes in an area isolated from the rest of the community and looked upon as a tuberculosis colony. The time may be reached when that system will operate here but I do not believe that we shall see that time. Possibly, it would be a good thing if people could get over that type of prejudice but what we have to deal with in our plans is the probability of the people affected cooperating with us so that those plans may be successful.

Senator Duffy precipitated this discussion by suggesting that in connection with each sanatorium we should acquire land for the purpose of engaging patients in the sanatorium in farm work. I indicated to the House that I did not approve of that, or that I did not believe that medical opinion would approve of it, because during the treatment stage, farm work is much too heavy for the average patient, and it entails exposure to weather, etc. Occupational therapy is a different matter. Patients who would be in a comparatively good state of health prior to their discharge would certainly find some difficulty in occupying their bodies or their minds during that time. I should like to suggest—again, this is a personal idea that will have to be subjected to the criticism of other people who are better equipped than I am to determine what is the best line of treatment in the matter of occupational therapy—that it would be a good idea, particularly in regard to patients whom we take up from the provinces, if we trained the men, say, in such useful accomplishments or arts as the soleing of a pair of shoes, the making of a wheelbarrow, or the mixing of paints, so that if possible we would send them home to their families more useful members of the community than we got them. That is my idea of the type of occupational therapy we should adopt, not the idea of mass production of anything, not the idea of entering into close competition with people who are legitimately engaged in the production of certain classes of goods, but the idea of training these people, in fact, of putting them through a system of vocational education.

Similarly, in the case of the female patients, I think we should be doing very useful work if we taught young girls how to turn the heel of a sock, if they did not know how to do so already, and how to cook, or taught them something about food values, something about domestic economy, personal hygiene and domestic hygiene. If, for example, we also were able to send them home with more than an ordinary knowledge, if not an expert knowledge, of poultry keeping, I think we would be doing really good work. These are my ideas, and these are the ideas I propose to submit to and urge upon the people who will be administering these schemes.

They are not ideas that have been formed on the spur of the moment. They are ideas that have worn themselves into me after a considerable amount of thought on every aspect of the problem. If it can be shown that these ideas are not sound or that there are any dangers in them to the success of the scheme, that is another question. All I can say at the moment is that I believe they are practicable and that it would be a good thing for the people concerned to put them into operation.

I think it was Senator Baxter—I am not quite sure; if I attribute it to Senator Baxter and that he did not emphasise this point but that other Senators did, he will understand—who made the point to-day that we should emphasise, and continue to emphasise through propaganda, that the disease is curable. That is one of the things that I have been harping on for quite a long time. There are three points to be considered, and I think Senator Mrs. Concannon emphasised them too. We cannot repeat them too often and we shall have to keep repeating them until certain classes of our people listen. The first is that nobody is born with the disease, that it is not hereditary. The second is that it is curable, much more curable than a very big number of diseases that, as I have often said before, always have been looked upon as curable, and that in fact 90 per cent. of the people who contract tuberculosis get better without knowing that they have ever had it. That is a staggering but a scientific fact.

Mr. Douglas

I would not advert to that, I think.

Dr. Ward

If you want people to understand that it is curable——

Mr. Douglas

It will have the opposite effect to what you desire.

Dr. Ward

Senator Johnston has just mentioned the importance of taking the disease early. Other Senators have emphasised the same thing. We must concern ourselves, if we are to succeed, more with the prevention of the disease than with the cure of it. I could not work up half the enthusiasm I have for this difficult task—and I am full of enthusiasm —if I did not feel that we were tackling something that we can do. Tuberculosis is preventable. That is the point that Senators should carry away with them, that if the germ of tuberculosis can be removed from infecting our people then tuberculosis is finished with. There is no reason other than the limitations of finance why we should not reach that position. It can be done if we have sufficient money.

Mr. Baxter

We will tell you where to get the money.

Dr. Ward

We get into a difficulty when we look around to see what particular stocking we are going to raid. We were warned about the Hospitals Trust Fund that we cannot go too deeply there. Somebody told us to beware of the rates, not to raise the rates any further, and I am sure the Minister for Finance will tell us not to come to central taxation wherever we go. That is the sort of difficulty I am going to find myself up against, but I think in the long run, by a fair distribution of the financial burden over the various sources we have available, we shall find a solution.

The question of nutrition has again been mentioned. I fully emphasised the importance of it in previous statements, but again this is a matter that cannot be emphasised too often. Let me once more avail myself of this opportunity to appeal to Senators, and to appeal to anybody whom my words can reach, not to over-emphasise this question of malnutrition—not that it is not scientifically sound, but the ordinary man in the street does not look on malnutrition from a scientific point of view. If we talk about malnutrition in the case of tuberculosis, the ordinary man in the street will conclude that it is only people who are not well fed who contract tuberculosis. You know as well as I know the difficulties that confront us because of the prejudices that have been created as to the untouchability of people suffering from tuberculosis in the past. It has been the one great handicap, and we have not succeeded in getting over it as yet. If the impression goes out that tuberculosis is evidence of poverty, of failure to get sufficient food to maintain health, you are going to have a new stigma attached to it, and, as certain as I am addressing the House to-day, the tuberculosis patients of the future will be ashamed and afraid to disclose that they are suffering from tuberculosis, because their neighbours will say: "If they were properly fed they would not get it." I should like your assistance in this matter. We realise the proper setting for malnutrition, but the ordinary man in the street does not.

Before I leave the question of nutrition—I am sure I mentioned this before, but I will mention it again lest some Senators may have missed it— we are looking into this question, and at the present time I am in close touch with the Medical Research Council with a view to establishing, if we can establish, nutritional standards. If we had the nutritional standards agreed upon, I would then proceed to have some investigation made at any rate of our nutritional state, to see in how far we may be suffering from certain mineral, vitamin, or other deficiencies in our diet.

Mr. Baxter

When does the Parliamentary Secretary expect a decision?

Dr. Ward

This matter of establishing standards is a very difficult and intricate problem. As I said previously, you cannot just take up the standards that apply in another country where the conditions are different, where the ordinary diets are different, and automatically apply them in this country. We have to work out standards which are applicable to our own people. When, for example, it comes to estimating the minimum requirements of the whole host of vitamins which are now known to medical science, we realise at once that we are entering into a very complex scientific domain. I cannot then go further than to say that this big and difficult problem is at any rate being examined with a view to tackling it effectively. It certainly will not be for want of goodwill that we will fall down on it.

The importance of the inspection of school children has been mentioned. Well, we cannot have a whole, full-dress debate on general public health policy on this Bill, which is merely intended for the purpose of giving us power to provide sanatoria. Another opportunity will be available to the House I would say within the next six months. A Public Health Bill has already been introduced in the Dáil. I have had to handle this measure, and I have on hands another very comprehensive measure which will occupy my attention—the Mental Treatment Bill. As soon as I get that out of the way, I will be coming along with the Public Health Bill, and Senators will have an opportunity of discussing all aspects of the question when that Bill comes before the House.

Once again I want to join issue with the people who talk about the badge of home help, the stigma of home assistance. This is another of those things about which we ought to have more intelligent thinking. I am not speaking in any personal sense of the Senator who raised this matter, but I think we have not yet developed the proper approach to this question of relief out of taxation. I cannot see any stigma attaching to financial relief or relief in kind financed out of local rates that does not equally attach to corresponding relief which is financed out of central taxation. I wish Senators would assist us in getting a healthier and a better informed public opinion on that matter. If our poor are legally entitled—and they are both legally entitled and morally entitled— to sustenance, and to proper institutional accommodation and treatment when they are ill, what is wrong with calling upon local taxation to help to finance it that is not wrong with calling upon central taxation to help to finance it? There is nothing in the world wrong with it.

Mr. P. O'Reilly

The patients might take a different view.

Dr. Ward

But instead of encouraging the patients to take that different view, we must encourage them to take an intelligent view of it. When we come to that difficult question as to whether those various social schemes should be financed out of central taxation or out of local taxation, we get into a problem which provides material for a very interesting debate. We need not debate it at any length here to-day. In general terms, I myself prefer the local taxation, from a social point of view, to the central taxation. I am sure lots of people may disagree with me on that. But can they tell me the things which ought to be taxed in order to provide the money? Am I to tax tea, am I to tax sugar, am I to tax tobacco, in order to finance any of those schemes? If we have to tax any of the essential commodities, that tax will fall more heavily on the poor man than an imposition which will be graded down in accordance with his valuation and in accordance with the estimated value of his real estate. I will not develop that any further to-day, but will ask Senators to think over how it would work out for the poor man, with five or six or seven of a family, if we put a tax of 1d. or 2d. a lb. on tea or sugar, or if we put a tax on his tobacco. I may be told: "Put it on income-tax." That may be all very well up to a point, but there are members of the House who will advance the view that there is a limit beyond which you cannot increase income-tax either.

Mr. M. Hayes

That there is a law of diminishing return.

Dr. Ward

We would be getting into a vicious circle if we reached the stage where the man who has money to invest will say: "It is not worth taking the risk, because the State will take the profit, anyway." He will not take the risk, and there will be consequential unemployment. It is a very interesting matter to debate, but is not altogether appropriate to this Bill.

Everybody is strongly in favour of maintaining the bread-winner and his dependents. There is nobody more strongly in favour of it than I am. But everybody says: "Spend plenty; treat them generously; but do not increase taxation and do not increase the rates." Now, I want Senators to consider the matter before I come here again, and tell me how I am to treat them generously. How am I to provide for the dependents of a man who has a wife and six or seven children, and who must be taken into a sanatorium in order to save his wife and children and save the community, if I do not put on taxation somewhere?

Mr. Douglas

You will have to save it somewhere else. The only way to do it is by taking something else off. It would be just as difficult, I admit.

Dr. Ward

In all probability, when we come to take something else off, there will be people who will say: "We would like a slice of what you are taking off. Those tuberculosis people, about whom such a row is being kicked up, are not entitled to the whole of it."

Mr. Sweetman

You can save the £12,000 I was talking about yesterday.

Dr. Ward

I am afraid it would not go too far.

Mr. Sweetman

Well, where there is one £12,000, you may be sure there are plenty.

Dr. Ward

Senator Baxter emphasised the value of milk. I do not know if he was in the House at the time, but he drew a fairly long speech from Senator O'Donovan. By the time he had finished, I think we had got at most of the truth. I do not suggest that the Senator gave it in any grudging way, but in any case we got down to the truth that about 2 per cent. of our milch cows are a danger to the community. That is the important thing which we should register here. Do not run away with the idea that not only are human beings reeking with tuberculosis but that the cattle are reeking with tuberculosis, too. I suppose the next conclusion that foreigners might draw about it is that it is the close relationship between the Irishmen and the cattle that accounts for the high percentage of tuberculosis. We have to get away from that offensive conception.

Senator Foran raised the matter of how soon we hope to have any of these institutions in operation. In present circumstances it is a very difficult question to answer. I will not undertake to tie myself down to any time limit. I can only promise the House that as soon as it is humanly possible to provide these institutions, they will be provided. What that means when it is translated into bricks and mortar remains to be seen, but it will not be for want of pushing, at any rate. I will be disappointed, I may say, if I have not this Dublin institution occupied within two years, although Senator Foran was giving me five. However, I may be disappointed, but I will do the best I can to provide them with the least possible delay.

There are a couple of small points left. One of them I might not bother about, because it is a matter over which we have not any control. It was referred to by Senator Baxter and by Senator Mrs. Concannon. That was a note of complaint that more publicity is not given in our daily papers to such an important discussion as the discussion on tuberculosis. I do not see that we can do anything about it, but it does seem extraordinary in this neutral country that whole pages can be given in to-day's paper and tomorrow's papers to tell us about the progress on the Eastern front and on the Western front——

Mr. S. O'Donovan

And the Censor.

Dr. Ward

——and the Censor, and that for all practical purposes this matter, which is of such vital importance to our people, is scarcely featured. It is not that we want publicity—I am not a publicity man, and I do not care tuppence if they never mentioned my name in the Press. In fact, I avoid it, but I do agree with the Senators who mentioned it that it is a matter of vital importance, in view of the fact that there is so much prejudice to be worn down and so many things that we cannot say often enough. If we do not get the assistance of the Press in publicising these facts, we cannot get the message home to the people.

Senator Kingsmill Moore raised the final point with which I wish to deal. He raised the question of the type of the institution and its general lay-out. Again, I can only deal with it very briefly and convey some idea. Let us take a 1,000-bed hospital. It will be laid out in ward blocks, say, 40 such blocks, and there will be a central hospital unit that will serve the entire institution, a proper hospital unit as distinct from the various ward blocks where the patients will rest between the periods when they will require hospital treatment. A number of cases will require pneumo-thorax or surgical treatment. They will be brought into the hospital unit for the treatment, but it will not be necessary to keep them there for more than a week or ten days.

They will then be brought back to the ward block, and in that way the hospital unit will serve the whole institution. The unit will be staffed by the most highly qualified staff we can provide. Similarly, we will have the unit as well equipped as it will be possible to equip it in present circumstances. If we are not able to do everything perfectly at first we can remedy it later on. We shall have to be satisfied with the best provision that can be made, with a view, when times are more favourable, to securing better equipment that may be necessary in order to complete our scheme.

Question: "That the Bill do now pass", put and agreed to.

Ordered: "That the Bill, as amended, be returned to the Dáil".