Dáil Éireann díospóireacht -
Tuesday, 25 Feb 1964

Vol. 207 No. 11

Committee on Finance. - Vote 52—Health (Resumed).

Debate resumed on the following motion:

That the Vote be referred back for reconsideration. — (Deputy Dillon.)

Mr. Sherwin

Before we adjourned I spoke briefly and I placed emphasis on physical disablement. In the debate so far, and usually in these debates, we hear little of physical disablement. The Minister told us that there were 11,000 deaths from heart disease in 1962. I suppose that is a natural disease to some extent as we must die sometime and die of something. I assume heart disease is one of the diseases we suffer from when in decay but I think it is unnatural to suffer from heart disease in middle age.

We are told also there were 4,897 deaths from cancer and 697 from lung cancer in 1962. We are told this disease is something that cannot easily be cured because we do not know what it is. We are told that it is not a germ and cannot be killed. We had 426 deaths from tuberculosis which shows that the problem is almost solved. There were 27 maternal deaths. Then we come to bronchitis and from what I know of it—I have a touch of it myself —smoking aggravates it. Before I gave up smoking 16 years ago, when I did smoke I coughed violently and I had colds regularly and had to go to the doctor regularly. When I gave up smoking, I scarcely coughed any more and, to a large extent, my bronchitis ceased. From my experience, I say smoking aggravates bronchitis.

I have a special interest in this problem of physical disability. Perhaps the reason is that I had quite a bit of trouble myself. I have been in and out of hospitals. I have been with all the experts, or alleged experts, and with all the quacks and I have some idea of the subject. Perhaps the reason it is not spoken of here is, as I have learned, that the medical profession do not study specifically muscular disease in their curriculum. They get a brief outline of the subject but, other than that, they are not trained to diagnose muscular disease or diseases of the nervous system as it affects the muscles, or allied complaints.

In the past, I have gone to numerous doctors and they were not able to express an opinion. I did not know until later that, in fact, they were ignorant of this subject. They did not tell me they were ignorant of it but they were. It is since then that I have learned that physical medicine is a specific subject. It is not part of the curriculum for the M.B. degree but I understand that having got that degree, many doctors make a special study of physical medicine. In other words, it is a separate subject. Unless a doctor decides to go in for this special subject, he remains ignorant of this problem of physical disability. I have learned that there is not a handful of doctors in this country who have specialised in physical medicine. I am told that.

I know some of these people. I spoke to a medical doctor today, a friend of mine. He admitted that they just got a brief outline of physical complaints of a muscular nature, that they do not study it and, in fact, are not able to diagnose the complaints. He said that certain doctors take up physical medicine after they get their degree but that there is not a handful of them in this country. I am asking the Minister to take an interest in this subject. I am asking him to inquire as to whether it is true that there are not many doctors of physical medicine; whether it is true that this is something outside the curriculum and whether he will aid those people who wish to study physical medicine.

There are various forms of physical disability. A person might perhaps have spinal curvature. Anyone with any sense knows that if anyone has spinal curvature, it can impinge on certain nerves. Every limb of the body is controlled from the spine by nerves. If our nerves are impinged upon, it means that the specific muscle associated with a nerve wastes and that particular muscle or that particular limb can become useless and the person become crippled. Not only that, it is quite self-evident to anyone with any sense that if some limb becomes wasted because of some defect of the nerve, then its opposite number will also become affected. I tried to explain here when I spoke last that the muscles in the human body are like the braces on pants. One side balances the other. If you tighten one brace against the other, you know how awkwardly your pants will sit on you, do you not? Commonsense will tell you that there would be a terrific strain on the part that was short and in no time the buttons on part of your pants would pull out.

I want to point out that the muscular system is like that. If part of the muscular system becomes wasted, its opposite number also becomes affected.

In a nutshell, there are various forms of muscular disablement. It can be due to spinal curvature. It can, maybe, be an occupational disease. Some people use one part of the body exceptionally more than the other. That, eventually, would cause what one could describe as occupational disease of the muscles. One part is overworked and its opposite is overstrained. If you overstrain a muscle, it sets in muscle nerve spasms and a person will eventually become crippled.

Altogether apart from that, there is such a thing as arthritis. We all know about and read about arthritis. To a large extent, this also is due to some form of unbalanced condition of the body. Arthritis affects from 15,000 to 20,000 persons in this country. I am satisfied from my inquiries that there must be from 30,000 to 40,000 people in this country suffering from a physical disability of one kind or another— let it be an unbalanced condition, spinal curvature, muscular atrophy, arthritis, call it what you like, they are all allied diseases. My point is that the medical profession are ignorant on this subject to a large extent and cannot diagnose these ailments and therefore cannot help. I have that from doctors. They admit it. I appeal to the Minister to take an interest in this. In the past, when you had people such as those osteopathy people who manipulated the spine, the medical profession refused to recognise them. They are recognised in America and a number of medical doctors have taken up the subject of osteopathy and are accepted because they are MB's. They are recognised doctors who have taken up the subject.

Apart from osteopathy, there is such a thing as muscle disease as apart from any spinal defects. It is pitiful to see the thousands of people suffering, not able to walk, not able to get out of bed, and for whom there is no help. In fact, a doctor told me today that he knows hundreds who are practically bedridden with arthritis or muscular disease of one sort or another and that nothing can be done for them. They will not be accepted into a municipal hospital because they have no blue card and, anyway, hospitals look on those cases as semi-permanent cases and do not want them. They want someone on whom they can do a job and who can then leave the hospital. They do not want cases who could be there for months or years.

I am told that because the families of some of these people, or the people themselves, are alleged to have means they will not be treated in a voluntary hospital or it becomes uneconomic for them to get treatment because this is a form of disease that takes endless treatment. It is not like any other disease where a job can be done on it in two months. You can be affected by arthritis or an allied disease and it could involve years of treatment once or twice a week and nobody could afford that.

Again, because there are not many doctors of physical medicine and because there are not many clinics, those people are overworked. I was told lately by a doctor of physical medicine that he was overworked. He said he could give treatment only once a week to patients who should be getting it two or three times a week. He says he cannot touch cases in the home.

This is a very serious matter. I appeal to the Minister to take an interest in it. Unless somebody such as the Minister takes an interest in it, people will be allowed to suffer. We know all about mental diseases, tuberculosis, and so on. Those people are unfortunate but they get every help. I am asking the Minister to remember that there are from 20,000 to 30,000 people in this country suffering from serious physical disablement of one sort or another. I do not believe five per cent are getting proper treatment because the doctors, the clinics or the facilities generally are not there. I could speak on other subjects but I will not. I want what I said to sink into the Minister's mind. I know he will consider it. I know what I am talking about. I have had experience of this for 40 years and I am appealing to the Minister to do something about it.

Mr. Clinton

In many ways I am kept almost constantly in touch with the problems of ill health. I work in a hospital and I am a member of a number of hospital boards, including the board of the Federated Dublin Voluntary Hospitals and I am also a member of the Dublin Health Authority. It is only fair to say that Deputies on all sides are equally concerned that health services as good and as adequate as the country's resources can afford should be provided for our people. I am aware that there are differences of opinion as to how these services should be financed, and I know that that is a matter which is being considered by the Select Committee on Health Services and that we cannot very well go into these matters. One thing which I should like to say to the Minister is that it would be quite wrong and quite unjust if the existence of this Select Committee or of certain commissions were to delay interim adjustments which are obviously required in certain spheres. That is a matter into which I cannot go into in detail but I might just mention one, that is, the upper income limit for eligibility for certain of the health services—the £100 limit and the valuation limit.

The Minister opened his statement with a general review of vital statistics and there is no doubt that it is quite frightening to be reminded of the number of people who die of heart disease. It is even more alarming when one considers how little progress appears to have been made over the years in finding a solution to this problem of heart disease. If it has even been established that certain living habits lead inevitably to heart disease and certain other habits are conducive to avoiding this trouble, this sort of information should be given the widest publicity possible. Education of this sort is extremely important and perhaps it does not receive sufficient attention. The importance of physical fitness as it applies not only to people who are young enough to play games but also to people who are advancing into the more dangerous age, middle-age or approaching middle-age when naturally they slow down, should be stressed. The question of diet, exercise, sufficient sleep and so on, are all important matters which should receive attention. If the "do's" and "don'ts" have been fairly well established, they should be given the maximum amount of publicity.

There is a campaign at the moment against excessive smoking of cigarettes. Everybody should lend his support to that campaign in order to reduce the incidence of such smoking. This is to be encouraged particularly among younger people who have not yet begun to smoke. It appears to be extremely difficult to stop smoking once the habit has been formed. I know of a number of people who had to have one lung removed and the cause was traceable to excessive smoking. In certain cases some of these people could not be persuaded to give up smoking cigarettes. It is really unbelievable but that is a fact. Everybody should assist in the effort to persuade children not to smoke and to warn them of the dangers that arise from excessive smoking.

The disease that came next to heart trouble in claiming the maximum number of deaths was cancer. It is a well known fact that lung cancer is caused to a considerable extent by excessive cigarette smoking. Of course not only cancer but many other diseases such as bronchitis and other chest complaints as well as heart disease are also caused by excessive smoking. That is another good reason why this sort of publicity should be undertaken as far as possible. My attention was drawn some time ago to a form of cancer which is avoidable. I read about this in an article in the Irish Medical Journal. It is in relation to a certain form of womb cancer which, if detected in time, can be prevented from developing. I have not got the article with me but I was amazed to read about the number of women affected by this type of cancer and by the fact that it was preventable. It was stated that the setting up of a small research and educational unit could prevent large numbers from developing this cancer. It is something the Minister could have investigated to see if it is worth while following it up.

Before I proceed further, I want to acknowledge the Minister's generous expression of appreciation and thanks to the members of the board of Peamount Hospital for making the accommodation which was surplus to the requirements of the hospital for the treatment of chest diseases, available to his Department for accommodating mental defectives. As he said, these were mental defectives who had already received some treatment in other institutions which were better equipped for the purpose but who will always be unable to go out and fend for themselves in the world. The Minister said that the number of beds involved was 40 but to bring him up to date, I can tell him that the number has been increased to 50 and can in fact be increased further. The board of Peamount Hospital are particularly anxious that the maximum use should be made of the accommodation and facilities.

One thing I should like to say in that regard is that it might be dangerous if any institution should become just a rest home, an institution for giving shelter and physical care to people of this kind. It would be very difficult to keep standards up if that were the only part that the institution played in relation to this form of illness. There is something too passive about that. Something active should be going on there as well. What I mean is they should not be interested only in the care; they should have a certain number of mentally retarded children who would be capable of being educated up to the point at which they might, perhaps, be able to return to their own people or even go out into the world and fend for themselves in a reasonable way.

In the same breath practically as the Minister expressed his appreciation for the co-operation, he also expressed his dissatisfaction because, in certain other quarters, the co-operation one would expect was not forthcoming from the various bodies. Being associated with a number of these boards and bodies, I should like to inform the Minister now that they are very often looking for a lead from him and his Department in relation to the overall picture for the country as a whole. Suppose accommodation is becoming available because of the fortunate decrease in the incidence of a certain disease, then these people want to know more or less what the Department is thinking in regard to future requirements or as to the possible use to which that surplus accommodation and those facilities could be put. On the whole, the people I have met on voluntary hospital boards are dedicated people. They give excellent service to the country and to the community. One may occasionally meet on these boards kind, well-intentioned people, who are not practical but, by and large, these are out-numbered by the hardheaded business people who want to do a good job, and want to do it efficiently and economically.

I should like to mention here that recently a large number of circulars seem to be issuing from the Hospitals Commission. Most of the boards getting these circulars are becoming very annoyed. They are upset. I suggest to the Minister that if this type of interference in the small daily domestic affairs of the hospital is not stopped soon he will kill the interest, initiative and dedication of these people in the running of these hospitals. I know how they feel. I know how ready they are to revolt. The Minister's anxiety is due to the fact that the deficits in these hospitals have gone up so much. I believe there is more concern that the Minister perhaps appreciates on the part of these hospitals to keep deficits down to the lowest possible figure and that is supported by the fact that the accounts of these hospitals are open to scrutiny. When a point is reached at which a hospital is told the type of clerk-typist that must be employed and where she must be got, and so on, that is going too far altogether in dealing with the day-to-day domestic affairs of a hospital.

The Minister referred to the setting-up of a central sterile supply service. This is an important matter and one which should be pursued, but I do not know whether or not it is generally appreciated that this will be a very expensive centre to set up. If there is doubt in the minds of surgeons, and those who deal with these matters, as to whether sterilising is being done properly at the moment then there is more justification on that angle for the setting up of such a centre than there is on any other angle. My knowledge is that, where these centres have been set up, it has been found that there is need for as many as six times the number of instruments. These are very expensive instruments for theatres, wards, and so on, and the expense can be considerable. For Dublin city alone, the extra cost could be anything up to £45,000. The establishment of the unit would probably cost £100,000. There is no doubt but that there probably would be a saving in certain instances, but a unit like this is not an easy thing to set up and the adjustment is not an easy one to make. It is probably something that has been found to work somewhere else and there seems to be no reason it should not work here as well.

Deputy Dr. Browne referred to accident services. I have heard frequent adverse comment on this in recent years. There is no proper accident hospital. Accidents are increasing. When an accident occurs there is not a sufficient number of qualified personnel in the hospitals to deal with these cases and many lives are lost as a result. There is, of course, an efficient ambulance service properly equipped now. This is a matter I pursued vigorously as a member of the Dublin Health Authority for quite a time. I am satisfied that there was a very poor ambulance service and I am equally satisfied that there is now a very good ambulance service. The trouble, I believe, now lies in the fact that the hospitals are not properly equipped for these accident cases; personnel are not on the spot at all times, particularly personnel experienced in dealing with accident cases.

In certain European countries insurance companies take a very deep interest in this matter. Not only do they supply a top-class ambulance service but they also provide and run accident hospitals. It pays them to do so. Whatever way the law works in this country, apparently it is not a proposition for insurance companies here to take a similar interest. It is unfortunate that that should be the position; seemingly it would not pay them as it does in other European countries. Insurance companies save by getting people back to work as soon as possible. Here, if a person dies, that costs the insurance company much less in some cases. That has some bearing on the matter.

With regard to overcrowding in mental hospitals, the Minister is right when he says this problem is the result of many years of neglect. When I first became a member of the Dublin Health Authority and had responsibility for visiting the mental hospitals, I was unutterably appalled by what I found. This section of our people has been deplorably neglected. The overcrowding is deplorable. It is all wrong to have 1,850 people in one institution and 1,650 in another. The institutions are so badly overcrowded and so completely understaffed, especially with doctors, that it is impossible to classify these people properly and give them any sort of proper treatment, with the result that the through-put has been almost negligible. There was no effort to treat these people as curable human beings.

I often feel that if the Irish people could do as I had to do, visit these hospitals frequently, they certainly would not complain about having to pay for better conditions for these patients. It is something of which we should all be ashamed. It is something that has improved and is improving but it is not improving fast enough. There is not sufficient utilisation, even if it is only for temporary relief in this connection, of the spare accommodation that becomes available, wherever it happens to be. Local authorities generally throughout the country have not played their part in providing accommodation for mental patients and mental defectives. They have not taken sufficient interest in it and it is too bad that is so.

The Minister, in speaking about mental defectives, referred to the fact that he was having an occupational therapist trained. That is a very good thing because again there is a great shortage of occupational therapists. The Minister spoke of the pride this type of patient takes in his occupational achievements. It is a tonic to watch a group of mental defectives endeavouring to do something, let it be the simplest task. I wish to take this opportunity of thanking publicly the industrial firms, the ESB and the Department of Posts and Telegraphs for the amount of material they make available for this very important work. It is not easy to get a supply of material for occupational therapy and when it is available, it is a wonderful help and consolation to these people.

The Minister mentioned building costs. I want to refer to the delays that occur once a plan is sanctioned. Perhaps consultants are responsible. I am very impatient with consultants from time to time because of the time they take to produce something worth while. There is something wrong with the consultant service. The Minister talks about the cost and efficiency of building operations and all that sort of thing. Everything in the system leads to making building expensive. The consultants are paid on a percentage of the cost and, being human, they will not be overanxious to reduce the cost of building if it means their fees will be similarly reduced. I do not know how that problem can be overcome but it is a problem.

There is a great deal of hospitalisation that could be carried out in comparatively simple buildings, functional buildings which would provide comfort and brightness without any of these palatial decorations. There are so many remedies being found for diseases of one sort or another that these very expensive buildings could become surplus to requirements in a very short time.

Deputy Sherwin has dealt completely with physiotherapy and other such matters. However, one thing I should like to say in that regard is that in large dispensary centres like Ballyfermot and Finglas, a physiotherapist and a psychiatrist should always be in attendance. That would be of enormous benefit and assistance to the people there.

I am not satisfied either with the nursing service. The nursing service could be vastly improved. There is no worthwhile progress made in the provision of a domiciliary nursing service. If there were such a service, many people would not need to go to hospital. I am aware that in certain built-up areas many children and aged people have to be sent to hospital who should never see a hospital. It would be much less expensive if a domiciliary nursing service were available. Perhaps the Minister would have that matter investigated.

May I come back to the Minister's statement about lack of co-operation? I believe the people want to co-operate with him and with his Department. I believe there is an enormous amount of goodwill and all people want is an indication of what the future holds and what is likely to be required of the institutions and the facilities that are available in the country.

Minister for Health (Mr. MacEntee)

I do not know whether I shall be able to go over all the ground which has been covered in the course of this debate. However, I am very grateful to the House for the manner in which they have discussed this very important question of the services which the State provides in order to enable its citizens to maintain health throughout their lives.

When listening to statements about so many people dying of lung cancer, so many people dying of bronchitis and of heart disease, the first thing that occurred to me and which we should all recollect is that one day or another we shall all die, that no man is born to be immortal. Therefore if the number of deaths from what we describe as killer diseases like heart disease, cancer and bronchitis is greater than it was, say, 30 years ago, the principal reason for that statistical situation is the plain and simple one that very many people who die today from those diseases do so because they have lived very much longer than their parents or their grandparents did, who died of other diseases and died very much younger. It is regrettable that a man should die prematurely and leave his family but there is a limit to every man's life. While we may grapple with these diseases which seem more heavily to strike us down in this day and age, something else is bound to emerge to replace them and we have to reconcile ourselves to our inevitable fate.

At the same time, that does not relieve whomsoever may happen to be the Minister for Health for the time being of using whatever provision is accorded to him by the community to prolong where possible the life of every citizen within the community. As the American Declaration says: Man is born with the right to life, liberty and the pursuit of happiness, and it is part of our duty as a Government to try to ensure that those who are born inside our community will enjoy life to the fullest and to the longest extent that Providence will accord to them.

One of the first questions in this debate was raised by the Leader of the main Opposition, Deputy Dillon, and supported by Deputy Esmonde. It was: is air pollution a more effective cause of lung cancer than cigarette smoking? In respect of this very tangled problem, the first thing I want to lay down is that when we talk about deaths from lung cancer, and try to ascribe them to any one cause, whether cigarette smoking or air pollution, we are merely drawing a deduction from a statistical picture. An important fact is that the origin of this malignant disease has not, so far, been established. All we are in a position to do is to say that so many people died from lung cancer in the year, so many more of those people were cigarette smokers than those who were not and, therefore, there must be an association between cigarette smoking and deaths from lung cancer.

We cannot go further than that and, therefore, we have to be, shall I say, a little hesitant in pressing this deduction of ours to what might be its logical conclusion, which would be—if the State could take sole responsibility for a man's conduct of his own life—to prohibit cigarette smoking entirely. I do not think any sensible person would propose to do that because while we are members one of another, nevertheless we still have our right to live our own lives in our own way, if we can do so without harm to others, and to smoke if that is our predisposition.

We cannot set out to prohibit or ration cigarette smoking any more than the Americans or the Scandinavians have been able to prohibit or even ration liquor. We have to consider this problem on that basis. Those who have studied the problem —the Royal College of Physicians in Great Britain and the committee which was set up by the Surgeon General of the United States Department of Health to report to him— have come to the conclusion that it would appear from the statistics, and from certain considerations which are set forth in their reports, that while air pollution is a possible cause of cancer —it may be an aggravative factor rather than originative—cigarette smoking would seem to be a much more influential factor in the development of lung cancer than air pollution. It is not to be thought that these things are exclusive of each other. They appear indeed to operate with each other. In a polluted atmosphere, a heavy smoker is more likely to die of lung cancer than a person who does not smoke, but both are factors—not causes, because we have not yet established the cause of cancer—contributing to the aggravation of this cancerous condition, if not positively associated with causing it.

I do not think that on the figures we would be justified in saying that the heavy increase in deaths from lung cancer can be more credibly ascribed to air pollution than cigarette smoking. On the contrary, so far as the statistics go—and we are only studying the statistics and have not yet been able to find the real origin of the condition —they indicate that undoubtedly cigarette smoking, and perhaps though in a milder degree, pipe-smoking, but certainly in a very high degree, is responsible. I want to be very careful. Let me put it this way. The number of deaths from lung cancer which occur amongst heavy cigarette smokers is much greater than the number of deaths from lung cancer which occur amongst those who do not smoke at all. We cannot press the matter beyond that.

How are we to deal with a problem of that sort? It is not an easy one. I said some two or three years ago that the first thing we have to remember is that no moral turpitude is involved in smoking cigarettes. We can see that as there is a degree of moral infringement in doing anything to excess—even exercising to excess in the sense that it might affect one's physical well-being —it is only in so far as people may be intemperate in indulging in tobacco that there is any element of moral turpitude. We have to proceed from that fundamental basis. The next point is a more practical one. How are we to prevent people from smoking, even to excess, if they have that particular appetite? As the Americans discovered during the prohibition era, that presents quite an insoluble problem.

Mr. Tully

There is a third one. How would the State make up the income it would lose?

Mr. MacEntee

That does not arise at all. We are considering the hazard to health which excessive cigarette smoking constitutes. Therefore, how are we to prevent people from indulging in excessive cigarette smoking? As I said, we certainly cannot ration tobacco. That was tried in respect of alcoholic liquor in some countries, and failed. After a prolonged trial in one Scandinavian country, they have abolished rationing altogether. The same would follow in respect of cigarettes. Everyone would be entitled to have his ration; and everyone would be entitled to draw his ration; and the man who did not smoke could very readily profiteer at the expense of the man who could not do without smoking. Therefore, as I say, it is easy to say we ought to stop cigarette smoking, even to ration cigarettes, but I cannot see how we effectively can. Can we discourage it? Yes. To a minor degree, we can discourage it by advertising, by carrying out a campaign of trying to prevent young people from embarking upon the habit. As Deputy Dr. Browne said in his speech, the young people keep in step with their elders.

Therefore, it is very hard to ask young people to practice what we preach if we do not practice it ourselves. Of course, people do not like being preached at and certainly adults are more rebellious or resentful in that regard even than adolescents are. Therefore, if we are to have any sort of campaign against the cigarette habit the only one we can have is one which will keep before the public mind the stark facts of the situation. I think the mere fact that now and then newspapers publish the synopsis of a report like that which appeared recently in the United States and earlier that which appeared in Britain and people read it in cold print, not with any sort of display occupying a half page—if they read in a newspaper item that an expert committee has considered this problem of cigarette smoking and has drawn a correlation between it and lung cancer and other diseases, it will have a greater effect.

When we talk about lung cancer, let us not forget that the American report goes much further than merely dealing with the effects of cigarette-smoking in relation to lung cancer. It deals also with a number of other diseases which appear to be associated with excessive cigarette smoking. If people see these things in the newspapers as a news item, it sinks in much more than if we were to spend tens of thousands of pounds on display hoardings, advertising in the newspapers and cinemas.

There are, of course, certain things which perhaps we could do but I wonder how some of these things would be received by those who now condemn us because we are not taking what they would regard as effective steps to discourage cigarette smoking. We could of course fiscally penalise cigarette smoking. I remember well an unfortunate experience of mine, when I introduced a Budget in 1952 and increased the price of a packet of 20 cigarettes by, I think, 2d. I remember—indeed, I shall never forget it—the then deputy leader of the Labour Party, Deputy Corish, got up and bemoaned the fact that I, as Minister for Finance who had the very hard task of trying to make the Budget balance, had increased the tax on cigarettes by 2d per packet of 20. We did not hear anything then about lung cancer.

Mr. Tully

He said a few other things as well.

Mr. MacEntee

He did not say we should discourage cigarette smoking.

Mr. T.F. O'Higgins

Did the Minister offer it as a reason for the tax?

Mr. MacEntee

I did discourage cigarette smoking because I increased the tax on pipe tobacco by only about one-half the tax on cigarettes. I am speaking from recollection and I hope nobody will pin me down to the exact figure. I put 2d on the cigarettes and about 50 per cent less on pipe tobacco but nobody threw any bouquets at me for doing that.

Mr. T.F. O'Higgins

The Minister is generally good at throwing bouquets himself.

Mr. MacEntee

I was held up to odium as the man who was trying to prevent the nice girl or fellow from smoking cigarettes in the cinema where they would not be allowed to smoke a pipe. Do not let us assume, therefore, we are going to deal with the problem merely by increasing the price of cigarettes—unless we increase the tax exorbitantly and make it prohibitive to smoke. If you put it up by 1d, 2d, 3d, or 4d, most people will spring the extra 1d, 2d, or 3d if they are sufficiently addicted to cigarettes to want them. Therefore, it is not an easy problem to deal with and the only thing I can suggest is that those who are in a position to set an example should do so. I am not, because I do not smoke. I gave up smoking in Dartmoor in 1916. That is one thing I have to thank his Britannic Majesty for. I did not resume smoking and therefore I am not in a position to give good example.

But there are a great many Deputies and a great many members of public bodies and if they say, when they are offered a cigarette: "I will not smoke a cigarette", and if other people follow their example, that is the way to get the young people to stop smoking, as Deputy Dr. Browne said. We can do very much more by exhortation in this matter and I hope all those who have been talking about this very serious problem of lung cancer and other cancerous conditions will at least carry that into effect.

Sir Anthony Esmonde

Does the Minister associate tobacco smoking with coronary thrombosis?

Mr. MacEntee

I am a layman and I merely take the advice of those who are in a position to give it. The medical profession certainly associates cigarette smoking with coronary diseases. I do not know whether they have established it as a fact or not but they do associate it with coronary diseases.

Deputy Dillon raised the question of what provision we were making for the treatment of autistic children. The position is that in February, 1963 a special 30-bed unit for the treatment of psychotic children and other mentally deranged children was opened at St. Loman's Hospital, Ballyowen, County Dublin. This unit was established with children such as these in mind.

We must remember in regard to this whole question that inside that very broad category of mental handicap there are many conditions which have to be isolated and which require special treatment. We are only getting down to this. This problem was never examined in this country until we had the preliminary investigation in the Department of Health some years ago. We are now following this up by the much closer and searching investigation which is being conducted by the Commission on Mental Illness.

We are no different in that regard, or very little different at any rate, from other countries. This problem of mental condition has really only begun to be considered as something which is not innate—something which is perhaps engendered by deficiencies of one sort or another, something which is treatable—since the 1914-18 war and subsequently as a consequence of what happened during the 1939-45 war. We are not lagging very far behind other European countries in this regard. Indeed, if we had had the established services here which have been built up over generations elsewhere, if this matter had not been neglected by our former governors, we should now be very much abreast of the times.

As I have said, we are giving full consideration to this and making quite good progress. The difficulty is not merely one of buildings or of money. It is that the recruitment of personnel is a matter very much like the growing of a tree. It develops from a small root and expands, but it has to be organic and it has to be for ever increasing. It is a mistake to say that mentally handicapped children require only custodial care—suitable clothing, food, et cetera. They must also be treated by people who have a certain amount of psychological training which will enable them to understand the difficulties of these young people.

We cannot provide that overnight. It is not something that can be learned like a trade. We have to build upon a foundation of experience and tradition and training, and we must absorb our new trainees into that work, making it a homogeneous whole. We are handicapped by the fact that we have not got all the money we require, all the buildings we need, but more than anything else by the fact that in order to staff our institutions, we require personnel who are trained, skilled and who have tradition behind them.

While the service is in itself very rewarding to those who have the vocation, it can be very repellent for those who have not got the vocation for it. When you see children who are so pitiable that they really become revolting to ordinary people, you will understand more clearly the necessity for this vocation. A person caring for such children must be able to say: "The children are so pitiable it gives me the utmost pleasure to be able to look after them and help them." Unless you can get that type of personnel, it is extremely difficult to do anything for these children. In turn, it is very difficult to recruit staff for this service, to get people of the right disposition. They require a great deal of patience, kindness and understanding.

Those are the difficulties. We have been relying substantially up to this on the religious orders to provide this care but their capacity has been stretched to the utmost. We have been trying to induce people from abroad to come in here. Certain difficulties have been experienced in that respect, the greatest being that in every country on the continent there is a pressing demand for services of this kind. If this position does not improve, we may have to consider doing a great deal of the work now done by religious orders by lay personnel.

I do not think I should, here, say very much about the provision of accommodation for mentally handicapped children. This work has been going on apace during the past 12 years. I am not claiming any credit for it. I continue to provide additional accommodation as places become available, as I get the personnel and as the money becomes available. I am not, as I have said, claiming credit for it. However, I shall defend myself against any suggestion that I have been negligent or amiss in dealing with this problem. Having regard to our capacity to build, we have, by and large, covered a great deal of ground during the past seven years. I hope that during the coming year we may be in a position to come much closer to the half way mark. I hope we shall top the 3,000 bed figure in the coming year. We may not do it but it is our minimum target. If we can do it, we will. In this respect, we are awaiting the report of the experts in this field. The best way of dealing with these children seems to be to institutionalise them. There is a great deal to be said on both sides, but in the circumstances of our people, there will always be a very great demand for institutional accommodation. Most of these children are born into families in poor economic circumstances, many into rural families where the mother finds it impossible to look after them and where they are a source of pain and disturbance to the younger members of the family.

Therefore, we shall always have a demand for institutions. It is true that if we were a more densely populated country, if we had greater facilities for employment in ordinary industrial enterprise, if we had full employment, it would be better that a larger number of these children were left in their homes. We have not those circumstances. They have them in Britain where they are able usefully, sociologically profitably, to absorb a substantial number of mentally deficient people in industry. We have not got that here and therefore since these children will be a burden on the home if they continue to live in the home, and since there would not be any person to look after them, we have to face up to the fact that we shall always require quite a great deal of institutional accommodation here, perhaps, relatively speaking, more than would be required in other countries. I do not want any person to think that I regard that as being the best solution to this problem, but I think it is one that, for want of a better one being available, we must accept.

I do not know whether I can say very much more about mental illness than I said in presenting this Estimate to the House. No one, certainly no Minister for Health, certainly no one of my predecessors any more than myself, is happy about our mental services. However, we must remember we have inherited a problem which was neglected for generations. We ourselves—certainly our public men— have been influenced by the general attitude of the community towards mental illness. It was regarded as a visitation from the Almighty, as being incurable. Those who were afflicted in this way were regarded as a menace to their fellows in society. Therefore, the one thing to be done was to keep them within four walls in order that they might not do harm to themselves or anybody else.

That, quite frankly, was the situation which existed here until 1945, when my then Parliamentary Secretary, Dr. Ward, with my support, brought in the Mental Treatment Act, 1945. We were beginning to make an attack on this problem. We had seen during the war how the populations of our mental hospitals had declined very substantially from 1940 to 1946. During the period when labour was scarce on the land, a great many people were taken out of our mental hospitals and usefully employed on the land and maintained in their own homes. When the demand for labour declined, these people began to drift back into the mental hospitals again.

As a result of discussions about that aspect of the problem, Dr. Ward gave it a great deal of consideration. He came to me with the idea of amending the fundamental law dealing with mental illness in a way which would make it possible for a person to go into hospital easily if he felt the need for psychiatric treatment and as readily to come out again when he felt he was cured without having the stigma of certification. We are hoping to develop from that and to revolutionise our service for the treatment of mental illness. We have not gone anything like as far as appeared to be possible then, but there was not very rapid progress anywhere in the field of mental illness in the decade after 1945. It is only within the past ten years that people elsewhere as well as ourselves began to realise that perhaps we had been too ready to accept the suggestion that a person must be 100 per cent sane—God knows, which of us is?—before he is allowed to leave a mental hospital, to mix with his fellows or to employ himself usefully in society.

The great change has been that that old concept of mental illness as something almost incurable, untouchable and, therefore, to be shunned, has disappeared. We are trying to walk with the times. We have not been geared over the years to deal with this changed approach to mental illness. I am not going to say that this idea of occupational therapy developed within the past ten years, but it was at one time closely associated with the running of a farm attached to a mental hospital, or perhaps making a few sandbags or clothes for the inmates, in a most rudimentary way. The new idea is that you can make occupational therapy not merely therapeutic in its impact, but that you can also make it useful, that you employ it in such a way that you can make it, if not self-supporting, certainly not as utterly dependent on public funds as it was in earlier years.

All this is merely a changing trend in our approach to this very great problem of mental illness. I am talking very discursively. We have been talking about cancer and heart illnesses, but the one thing which is increasing very rapidly in the times in which we live is the stress imposed on the human mind and the human individual, and that stress is leading to an increase in neurosis. These neuroses were extremely rare two generations ago. While the consideration of the problems presented by the killer diseases are, of course very important from the point of view of preserving and prolonging life, to my mind it is much more important to do as Deputy Tully said and to concern ourselves with the disabling diseases, and mental illness is one of the greatest. If we could only manage to relieve our mental hospital accommodation of 50 per cent of the 19,000 patients there and return 9,000 of them to some sort of useful life outside the institution, we would be doing a great deal to further stimulate our economy.

Deputy Dillon spoke—rather regretfully, I think—of the fact that we were carrying out a programme of reconstruction in the county homes which was decided on a long time ago. Again, I must hark back to Dr. Ward. He undertook an examination of this problem in 1946. We tried to do something with St. Kevins at that time, but the matter was taken up very energetically by Deputy Dr. Browne when he was Minister for Health. When we came back, there was a review of the position in the county homes in 1951 or 1952 and the Government then adopted a programme for their modernisation. However, a great many difficulties have arisen; I mentioned some of them in the course of my opening address. The programme has been set back, partially due to financial reasons six or seven years ago, but largely because we have had to modify very severely our ideas as to what was actually necessary in order to provide proper accommodation for the aged people. Therefore, we are only now getting that programme under way in the sense of actually embarking on projects which were conceived ten years ago.

The real issue raised by Deputy Dillon was whether we were wise in embarking upon this programme, whether it was a wise policy to try to provide institutions for the aged people. He spoke very feelingly about the position of the old man who had been living in the community, perhaps in his own house. It was, I think, a somewhat idealistic picture, but nevertheless it was a picture we can all conceive of this elderly person living with his wife in their own little home. They become more and more uniform until, eventually, for their own sake and in order to avoid tragedy, they are received into the county home.

Deputy Dillon spoke about the loneliness of these old people in an institution. I think he rather exaggerated the lonely aspect of it. I have been in some of these institutions and, provided the people were not completely senile, there seemed to be quite an amount of lively conversation and chatter going on. I thought that many of them found a great deal of delight in the idiosyncrasies of some of their fellows and that it was not the sort of dull, drab existence that Deputy Dillon painted to us here. I thought, as I say, they were living in a community. They adjusted themselves to community life. They were very happy with the nuns—in general, they were nuns—or religious who were looking after them and I would not say that they really felt the loss of neighbourly companionship to which Deputy Dillon referred in the same degree as he suggested to us when he was speaking.

But it is undoubtedly a problem. It would be very much better if these people were able to live in what he described as alms houses throughout the country rather than to have them inmates of larger institutions. But, let us look at the facts. Undoubtedly, there have been many charitable foundations established in this country, not as many as there are in Great Britain, but there have been, we know, in Cork, Waterford, Laois and elsewhere, these charitable foundations established where elderly people were supposed to live either with their spouses or alone, if they happened to be widows or widowers, in separate little domiciles. They have all disappeared and they are all disappearing, and they are disappearing for one reason, that the people for whom they were intended really find themselves and think themselves better off if they go to an institution where they will have geriatric care, where they will have a degree of companionship and where they will not have to be so dependent upon themselves for doing the essential chores of life.

While it would be very nice if we were able to adopt as a settled policy this suggestion of Deputy Dillon, that is to say, that we should close these large institutions and should establish colonies here and there throughout the country and in small country towns where people might live, as I said, in their own little homes, shut off in the evening from their neighbours, and so on, and, have that degree of privacy which you can have only in your own home, nevertheless, I do not think that in our day and age it is a practicable proposition. That does not mean to say that we are going to stop any person who thinks there is an alternative to that. In fact, in the city of Dublin at this very moment, thanks to the Minister for Local Government, with my help and support, there is at least one —I think there are more than one, but at least one—project where that sort of provision is being made, to provide elderly people with separate accommodation.

Mr. Tully

Not the one-room flats?

Mr. MacEntee

No, no, but they are going to have a degree of communal service. I think they are two-room flats.

Mr. Tully

Two will be all right.

Mr. MacEntee

This is going to be a little centre, a little community, with certain communal services, including among other things a recreation hall, and what not. That is being done. We are not stopping any person who thinks that he can make, shall I say, a go of it. In fact, we are rather anxious to encourage it but we must not shut our eyes to the fact that there is a general demand and that public representatives, particularly those who are members of local authorities, do not speak without their brief and when they say: "We want county homes here and county homes there," we must realise that they say that because people are telling them how advantageous it would be if they had these institutions throughout the country.

Therefore, as I say, while I should like to think that it would be possible and practicable to accept Deputy Dillon's suggestion as the basis of our policy in relation to the restriction of the county homes, I am sorry to say that I do not see it that way. I think we shall have to go ahead and shall have to spend three or four million pounds of money reconstructing these county homes and we will not be reconstructing or reviving the old workhouse system here. Not at all. These will be geriatric homes for elderly people where we will have good staff, good surroundings and where people will not be regarded as paupers but merely as the parents of the productive generation, who have to be looked after because there is nobody else to look after them. They are the responsibility of the community and they have become the responsibility of the community, not because they are idle or worthless or workless but just because they are old and require some person to look after them.

Deputy Dr. Browne raised the question of the suitability and length of the present curriculum in the medical teaching schools. Of course, that is not quite within my province. That is a matter for the Medical Registration Council and perhaps, also, a matter for, if you like, the Minister for Education. I am, of course, concerned in trying to secure that the end-product of the curriculum, whatever it may be, will be an effective unit in the health services if he joins those services but I have no responsibility for medical education and I would not without a great deal of further consideration like to endorse or to criticise what Deputy Dr. Browne has said.

Deputy Sherwin raised the question of physical medicine. I think he stated it in over-simple terms. Specialists in physical medicine, I think, direct the application of medical procedures, including those in the field of physical therapy and occupational therapy which are designed to remove or to minimise the effects of a patient's physical disability or handicap. I should like to say that where, however, it is recognised that a patient might benefit from an operation, that operation ought to be performed by a surgeon and in this case I presume, most probably, an orthopaedic surgeon. There has been a considerable development, let us not forget, of the orthopaedic services throughout the country in recent years. That has resulted in the appointment of regional orthopaedic surgeons and assistant surgeons and the provision of appropriate accommodation for the treatment of orthopaedic cases. More recently we had the National Medical Rehabilitation Centre established in Dún Laoghaire. We have also other institutions like St. Anthony's Medical Rehabilitation Service and most of the general hospitals have facilities for physiotherapy treatment, so that we are not neglecting that aspect. It is a comparatively recent development in modern medicine, a specialty which has developed very rapidly in the industrial centres where, of course, there is a tremendous incentive to deal with the problems which physical disability brings. We have not had that incentive here but we have not been neglectful of the fact that something must be done in that respect.

May I say in tribute to my predecessor, Deputy O'Higgins, that he set up the Commission that examined this matter and it has fallen to me to give effect to the recommendations and form the National Rehabilitation Centre to which I have referred.

Deputy Dr. Browne asked for some figures of the cost of mass X-ray. I think I should give them as they have been given to me. First, the amount apportioned among participating health authorities in respect of the cost of the mass radiography service during the financial year 1963-64 was £57,110. This figure included capital expenditure. The estimated cost of running the service during the same calendar year was £45,500 and this figure includes provision for depreciation but is exclusive of capital expenditure.

The number of persons examined during the year—I think this is a really important statistic—was 284.842. The total number of abnormalities discovered by the mass radiography service was 5,094. Those likely to be clinically significant as regards respiratory tuberculosis were 2,813, almost one per cent. Those who had other tuberculous manifestations numbered 669: those with conditions of lung other than respiratory tuberculosis, 1,142: those with cardio-vascular conditions, 470.

On the basis of the figures which I have given, the cost of discovering one abnormality likely to be clinically significant in respect of respiratory tuberculosis was £16 3s. 5d. The cost of discovering one abnormality likely to be tuberculosis was £13 1s. 5d. and the percentage of persons considered to be clinically significant as regards respiratory tuberculosis was almost one per cent—in fact, .98. On the whole, that service is fully justifying itself but particularly because it keeps the public mind alert to the fact that tuberculosis is still—I shall not say rampant among us——

Mr. Tully

Could the Minister say if many people were asked to report for X-ray after having attended the mass radiography centre service?

Mr. MacEntee

I should have to ask the Mass-Radiography Association for that figure: I have not got it. First, as a qualification of the figures I have given. I should say these figures do not include Cork which does not normally utilise the National Mass-Radiography Service. If the Deputy puts down a question. I shall be glad to answer it. By and large, expenditure on this service is very well worthwhile. It keeps the public mind alert to the fact that tuberculosis still exists among us, that we have not completely eradicated this problem. The many things we have been saying about closing sanatoria and so on tended to engender a feeling of complacency about the situation in regard to tuberculosis. We cannot become complacent at all about it because while it is true that we have a diminishing incidence of the disease among us, we must remember we have also built up a much more vulnerable population.

Therefore, where there are sources of infection, such as undoubtedly exist in the higher age groups, these sources are likely to be much more dangerous now and much more of a risk than they would have been when many people had had tuberculosis in a primary degree and had, to some extent, been immunised against the disease. We tend to become a very vulnerable population and it is of great importance, therefore, even if we had succeeded in wiping out this disease, that we should try to retain mass radiography actively and try to persuade everybody to come along at least once a year for a check-up. I think that is one of the ways in which we would be able not merely to continue to reduce the incidence of the disease among us but also to become aware of any undesirable reversal of the trend which could quite readily take place if our people did not keep themselves under continuous survey.

Deputy Tully referred to the increased cost of hospital services in the voluntary hospitals and asked if it was due to reduced income from the Sweepstakes or was it because money was being channelled into building hospitals. I have not been able to get the Deputy's point completely and I may be misunderstanding him. Perhaps the best thing for me to do is to recapitulate more or less what I said in my opening address. Over the past few years, the cost of running hospitals of all kinds has been rising steeply but the rate at which health authorities have been paying for services supplied by the voluntary hospitals remained unaltered in the period from 1956 to 1962 in which year it was increased by relatively small amounts dependent on whether the hospitals were teaching or non-teaching institutions.

The increases in the capitalisation rate which were made in the year 1962 were barely sufficient to cover the cost of the eighth round increases in the remuneration of staffs of hospitals and the result of this situation has been that the losses on the running of hospitals which have had to be covered by grants out of the Hospitals Trust Funds have increased enormously. I gave the House a series of figures from 1956 to 1963 in the course of my statement. Perhaps I should just repeat the end figures, that is, in 1956, the total revenue deficit for hospitals receiving grants from the Hospitals Trust Fund amounted to £920,000 while for the year 1963—seven years later—the figure is estimated at £2,200,000. That means that the hospitals deficits increased — making a rough guess—by about 25 per cent in that period. The situation, therefore, is that apart from funds having been channelled into the building of hospitals, which was the original intention, they have also been used in very good measure to make good the losses on the running of the hospitals.

Mr. Tully

There has been an almost 50 per cent increase in the costs over the past couple of years.

Mr. MacEntee

No. There has been a very substantial increase in the contribution which the local health authority makes towards these voluntary general hospitals but it is not nearly sufficient to cover the increase in the cost. This may be the subject of something which will come before the Dáil if I am long enough in office to deal with it. I think we shall have to ask the health authorities, particularly in the larger centres because they are getting away with a great deal, to make a much more realistic contribution towards the cost of maintaining patients in the voluntary hospitals than they are doing at the present moment. Either that or—and this would be unthinkable—we shall have to set a limit to the deficits and say: "If you cannot keep within this limit, you will have to reduce your services to the patients." We cannot of course do that.

Medicine and surgery are becoming more expensive every day. Therefore, as the facilities for the treatment of illness and disease improve and become more costly and more complicated we shall have to ask the health authorities to face up to that fact and to provide the funds and to release a larger proportion of the Hospitals Trust Fund for providing the buildings for which there is such a very heavy demand.

Mr. Tully

It would not have been safe to say that last week but it is safe to say it this week.

Mr. Corry

I suggest you get it out of the Central Fund.

Mr. MacEntee

I suggest we get it from the South Cork Board of Assistance.

Mr. Corry

It did a good job.

Mr. MacEntee

I have a note here about what Deputy T. Lynch said in relation to the cost of the health services. Deputy Dr. Ryan said in 1953 that the Health Act, when fully implemented, would cost the ratepayers an extra 2/- in the £. This is ten years later. Has any cost stood still since? There has been a very marked improvement in the services provided by all our hospitals.

Mr. Tully

Is the Minister asking Deputy Corry to comment on that?

Mr. MacEntee

No. No doubt he could. He will find an excuse, despite all the efforts of the Chair to do it. No cost has stood still over the past ten years and unfortunately hospital costs, like everything else, have moved with the times.

Deputy McQuillan referred to the increase in the cost of drugs and medicines which amounted to £50,000 for 1963-64. That has been a continuing feature of the finances of the health services not only here but elsewhere, the reason being that more and more new drugs are coming into use. New drugs are being developed and they have to be paid for. I am not prepared to say they may not, in certain circumstances, be paying too much for them, but the source of supply of these drugs is perhaps limited and therefore since we want them, we have to pay the price which will secure them for us.

Deputy Dr. Browne suggested, I think, that a reduction in the number of immunisation injections in any one individual's case would be of benefit. I think they are trying to develop combined antigens for a number of these conditions. In some cases, this combination has been associated with an anti-tetanus component as well. We should like to reduce the number of injections. I do not think it is any great pleasure to any person to subject a child to a series of ordeals like this but on the other hand, we really have to choose between being tender-hearted and ultimately providing for the child's welfare.

It is much better, I think, even if we do have to give more than one injection, to give the child a degree of immunity against some of these diseases than simply to say: "Well, it would be better if we cut down the number of injections." On the other hand, every effort I think is being made by those engaged in that sort of research to provide a combined antigen which will give immunity against a number of infections.

Deputy Tully and Deputy Dr. Browne also asked whether we issued any directive to the local authorities to proceed with the polio vaccination scheme. Standing arrangements for the administration of the Salk scheme have been in operation for a number of years. It will be necessary to communicate with the local authorities in connection with the detailed arrangements which will be necessary for the introduction of a live vaccine. Deputy Dillon asked whether the use of oral vaccine is prohibited in the case of a person already vaccinated with the Salk vaccine. I am satisfied that the use of oral vaccine is quite compatible with an earlier course of Salk vaccine. In the case of a person or a child who has received the Salk vaccine, it is desirable that the protection be maintained, whether by oral vaccine or by Salk.

Deputy Esmonde objected to the introduction of a means test in the disability allowances. I am in the hands of the House. I have to operate under the Act of 1963 which incidentally for the first time, made any provision whatsoever for disability allowances. Subsection (6) of Section 50 of that Act enables local authorities to grant these disability allowances. It is laid down that they are to be granted only to persons who are unable to provide for their own maintenance or whose relatives are unable to provide for their maintenance — the relatives, for this purpose, being defined as the spouse, son, daughter, parent, brother or sister who is normally resident with the disabled person. It is not, then, a matter of rigid application of a means test.

Each application for a disability allowance is considered on its merits by the local authority. With due regard to its responsibilities to the other members of the community, the local authority determines whether or not, in its judgment, the application should be granted and we do not interfere. The Minister for Health does not interfere in any way with the discretion which local authorities may exercise in that regard.

Mr. Tully

Too many people are getting reduced amounts even though the family income is very low.

Mr. MacEntee

Do not forget that these allowances are given at the expense of the person's neighbours. As I say, I only come in for half the bill. I may say that the size of that bill has increased enormously. I happened to be the Minister for Finance when this proposal was put before me and at that time it was estimated that it might cost a couple of hundred thousand pounds but this year it will cost a million pounds.

Mr. Tully

It might equally be argued that both the Minister's salary and my salary come from our neighbours.

Mr. MacEntee

I do not think that is quite fair. They come from the community at large. I hope that you and I are doing something for it.

Mr. Tully

Those people have done a lot, too.

Mr. MacEntee

I am not going to say that a person does not fulfil a useful function even if he is not able to work with his head or with his hands. I do not suggest that for a moment. To suggest that is merely to prejudice the consideration of the whole position. After all, is there any person who does not live at the expense of the community? Remember that if he does, he is supposed to give a very definite economic return for what he costs. These unfortunate people are in quite a different position. They are carried by the producers of the community. I am saying that because wherever else we should allow our hearts to override our heads, it is not in Dáil Éireann.

Sir Anthony Esmonde

If they did go in for institutional treatment it would cost a great deal more.

Mr. MacEntee

They do not have to go in for institutional treatment. These are people who are unable to earn a livelihood in an occupation for which they would be suitable because of some disability. That is a paraphrase on the words in the Act. That is what it means. They live at home and are maintained there and their handicap in relation to their earning capacity is considered in relation to these allowances. Look at it from another point of view. I have said that these are going to cost £1 million this year. Will the Deputy suggest how he would raise that £1 million? We have the responsibility of raising it.

Mr. Tully

I am not blaming the Minister. He need not get angry with me.

Mr. MacEntee

How are the ratepayers going to raise their share? We hear a great deal from Deputy Esmonde and other people who interest themselves in the position of the farmers and we hear a great deal about the size of the rates and the heavy burden the rates constitute on them, but at Budget time we will hear a great deal from the Opposition about the heavy imposts being put on the population by the Minister for Finance. I am just putting a simple question regarding disabled persons' allowances and I am asking Deputy Tully and Deputy Esmonde how they would propose to raise this money.

Mr. Tully

The Minister for Finance will tell us how he proposes to do it and then we will give him the information.

Mr. MacEntee

I am prepared to bet—and I did not make much out of the by-elections—and I would give 100 to 1, that no member of the Opposition will get up and cheer the Minister for Finance—not in regard to the way in which he proposes to spend the £1 million but for the manner by which he proposes to raise it.

Mr. Tully

The Minister was not in the habit of cheering the Minister for Finance when he was in opposition.

An Leas-Cheann Comhairle

I think the Minister should be allowed to continue. There have been many interruptions.

Sir Anthony Esmonde

I only wanted to ask him——

An Leas-Cheann Comhairle

The Deputy may put a question when the Minister has concluded. There have been a good deal of questions already.

Mr. Corry

All the questions were answered last week.

Mr. Tully

The Deputy's were not because he was at variance with the Minister a few moments ago.

Mr. Corry

I have my own way of dealing with that.

An Leas-Cheann Comhairle

The Minister, to continue.

Sir Anthony Esmonde

Is the Minister going to conclude?

Mr. MacEntee

Of course. Can the Deputy not face it? I was going to deal with a question raised by Deputy Esmonde, but as he appears to be so impatient, I was going to sit down. On the other hand, as it was a serious question, I will deal with it seriously. He adverted to the research carried out in particular in the United States of America and in the Federal Republic of Germany on the relationship of fat in diet to heart disease. He asked that I should give the House information on this matter. If the Deputy will bear with me, I will read out the information for the record. Very considerable research has of course been carried out in various parts of the world in relation to the etiology of cardiovascular and other heart diseases. It has been widely held, and occasionally denied, that a diet high in saturated fat predisposes to the development of coronary heart disease. A correlation between the national incidence of coronary disease and the percentage of food calories available as saturated fat has also been reported among those countries for which adequate data exist. On the other hand, it has been suggested that general over-nutrition, rather than excess saturated fat, predisposes to coronary disease. These facts are referred to in the United States "Smoking Report" which also of course adverts to the established association between certain heart ailment and smoking.

Of particular interest to us is the Boston-Ireland Heart Study which is being carried out for some years now. This study covers an investigation into the diet, working conditions, etc. of (1) a representative section of Irish-born males residing in Boston and (2) their brothers in Ireland, with a view to ascertaining the factors influencing susceptibility to heart disease. The survey also covers male workers in certain large undertakings, for example, CIE, Guinness's and the Post Office. A number of interim reports have been published in Boston and these I may say are generally to the effect that Irish-born Bostonians are more liable to coronary heart disease than their brothers residing in Ireland. The Boston residents, while they eat less, take much less exercise. I understand that a similar study is being carried out in America in relation to the Poles.

Deputy Dillon put a question which I am not in a position to answer fully today. He asked what is the reason for the discrepancy between maternal and infant mortality rates in Ireland and in England, Scotland and Wales.

Deputy Tully asked me to clarify a statement which appeared on page 5 of my speech that congenital malformation may be associated with a somewhat higher infant rate in Dublin. The position there is that in 1962 the rate was 33.9 per 1,000 live births for Dublin and 29.1 for the whole country. It is not possible to say with certainty whether the prevalence of congenital abnormalities is associated with the higher rate in Dublin, and it was in order to investigate the incidence of such abnormalities in Dublin city infants that the Medical Research Council were asked to survey the position.

Mr. Tully

Would the fact that difficult cases are being brought in from the country have an effect?

Mr. MacEntee

It may. It is not a question which is susceptible of ready answer and that is why we brought the Medical Research Council into it.

With regard to thalidomide, Deputy Tully said he was rather surprised to find there were quite a number of thalidomide babies in the country. May I say that, well before the results of the survey carried out by the Medical Research Council had been worked out, the National Organisation for Rehabilitation were actively preparing to ensure that all the facilities, including the provision of, and training in the use of, specialised artificial limbs and devices which would enable affected children to develop and lead a full life, would be available to them.

Some of these children have already been treated at the National Medical Rehabilitation Centre at Dún Laoghaire, and others have been seen by the consultant orthopaedic surgeon to the centre at regional orthopaedic and other hospitals. The services of the team at the centre, consisting of the medical director, who is a specialist in physical medicine, the orthopaedic consultant, doctors specially trained in limb-fitting, physiotherapists, occupational therapists and trained limb-fitters are available to deal, on an integrated basis, with these cases.

Many members of this team have during the past year, been sent to visit leading centres in Great Britain and Germany and to study, under experts there, all the latest developments in limb-fitting techniques, including the development of special prostheses for children with congenital deformities. Limb-fitting workshops have been opened at the National Centre and specially trained technicians have been appointed.

I have, I think, fairly covered all the points raised. I have already dealt with the points raised by Deputy Sherwin today. Deputy Clinton expressed the hope that the fact that the Select Committee was sitting, and other commissions had been set up, would not prevent us from proceeding with such measures as we could possibly implement in order to improve the services or to make good deficiencies. I may say, and my earlier statement is proof of it, that we are not allowing the fact that the Select Committee, or other commissions, are at work to impede our conduct with regard to the problems, principally of accommodation and personnel, with which we are confronted. As I say, our ability to deal with these problems is largely conditioned by the financial resources which are made available to me. I did not hear anybody say we are spending too much on the health services and I think some people would tell me they would readily support the taxation necessary to enable the services to be expanded more rapidly and, from that point of view, I would, perhaps, fare rather better with the Minister for Finance.

With regard to the central sterilising unit, may I remind the House of what I said? While this proposal was under cogitation in the Department, it really originated in its present form with the surgeons of the leading hospitals in Dublin. Their justification for it is that, first of all, it will not be more expensive in the long run and, secondly, it will be much more secure. Sterilisation will be carried out under conditions which may not always be fulfilled in the ordinary institution. This will be a specialist service catering for a wide market, certainly for a greatly increased personnel, and, from that point of view, it justifies a greater degree of expenditure upon it than might otherwise be necessary in isolated units. There is no difficulty about the provision of adequate protection for the sterilisation of instruments and conveying them in sterile form to the institutions requiring them.

I was glad to hear Deputy Clinton pay tribute to the Dublin Health Authority and its officials when he commended the greatly improved ambulance service. The question of having a hospital specialising solely in accident cases is a rather vexed one. The matter has been under consideration, though not in that precise form, in the Department of Health. There are many conflicting interests to be reconciled.

The suggestion that there should be a psychiatrist in attendance in the larger dispensary centres is a very useful one and I hope the Deputy will press the matter with his own health authority. There have, of course, been difficulties in the development of the domiciliary service, but I do not think the Minister for Health can be held responsible for these difficulties.

Motion, by leave, withdrawn.

Vote put and agreed to.