11 February 2004
Dr. Henry: As the Minister of State knows, I objected to this part of the Bill from the start. This is not because I want him or the Minister for Justice, Equality and Law Reform to fail in their duty to the State. There is a public health issue involved. All countries must be in a position to close their borders to certain people whom they think may be carrying a communicable disease which could result in a serious public health problem. However, we should try to bring these regulations in line with what is currently considered best practice in medicine. While it is commendable that we have got rid of the language in the Aliens Order, it would be a good idea to try to ensure we are right up to date with medical teaching on these issues.
In general, if there is a communicable disease in some part of the world which is causing great worry about its spread to this country - which can be rapid, thanks to international air transport - best practice is usually to decide that nobody from that country can come here until the outbreak is under control. If there is an outbreak of smallpox in Outer Mongolia, nobody from Outer Mongolia will be allowed into Ireland until the outbreak is under control and Irish people are advised that if they go to Outer Mongolia they will have a great deal of difficulty in returning. None of the changes that have been made to the First Schedule of the Bill address the issue this way. For example, the First Schedule refers to "diseases subject to International Health Regulations for the time being adopted by the World Health Assembly of the World Health Organisation". These diseases are plague, cholera and yellow fever. Whatever about plague and cholera, yellow fever is most unlikely to become a problem in Ireland because there is no suitable vector to spread the disease. The international health regulations are currently being assessed by the WHO in terms of being updated and will be reported on in 2005. We are introducing legislation that is of little practical use to us.
The next disease referred to is "tuberculosis of the respiratory system in an active state or showing a tendency to develop". I do not know how, without an X-ray, somebody can diagnose this at ports or airports. The Minister of State will say that it happens rarely. However, why put such a provision into the legislation when it is internationally recognised as being of little value? In this week's British Medical Journal, there is an article from a professor at the London School of Hygiene and Tropical Medicine on this topic. The article states that one cannot rely on the fact that one will exclude people if one specifically pinpoints countries with a high incidence of tuberculosis. This is a complex problem. I understand from the Minister's speech in the Dáil that he is relying on a person to give medical details - which should be confidential - over the telephone to him that an individual travelling to Ireland has tuberculosis. The person should be stopped at the port of origin. The chance of spreading the disease on the aeroplane is much more likely than when the person gets to this country. It is a dereliction of duty to the Irish people if one waits till the person has landed.
The next disease is syphilis. The Minister for Justice, Equality and Law Reform made a chivalrous and gracious speech in the Dáil about how he wanted to protect Irish women from being infected by promiscuous carriers. He said:
The carrier of such a condition could be somebody one would not want to come to Ireland because of his irresponsible attitude and the fact that he had infected five, ten or 15 women in a particular place.
However, the latest information on syphilis in this country was published on 14 January 2004 in Medicine Weekly. It was a synopsis of the National Disease Surveillance Centre's report on syphilis in this country. The article pointed out that between January 2000 and December 2001, 595 new cases of syphilis in this country were notified to the centre. More than three quarters were male and 60% were men who had sex with men. One fifth of those had contracted the disease abroad. These were Irish nationals bringing the disease in from London, Manchester and Amsterdam where there were epidemics of the disease. I wonder how helpful it will be to the nation to be screening non-nationals for this disease at the point of entry. It seems that this is being written into the legislation for the sake of it. The association between syphilis and HIV infection is well-known, but it is left out. It seems to be on the same level as the infectious and contagious parasitic diseases, in respect of which special provisions are in operation to prevent their spread from abroad. What are the special provisions? The most likely disease is giardia and I do not know if there are any special provisions relating to it. I cannot help but wonder if the Minister took any advice from the Department of Health and Children or the National Disease Surveillance Centre.
In the Dáil, the Minister spoke about SARS, which caused a great deal of trouble last year when we nearly had to bar people coming to the Special Olympics. Personally, I was glad they were all able to attend. He said:
Likewise in cases of communicable diseases, such as SARS and other types of conditions, if the situation arises that we have to deal with these types of infections, somebody will have to make decisions and the Bill provides for medical inspectors to be appointed in addition to back up the immigration officers in certain cases. I am very clear in my mind that it is responsible to provide protection of this kind and it would be irresponsible to tear it down in a hallucinatory moment [which comes into the last bit of the Schedule] in Parliament in the belief that by doing so we were being somehow compassionate. There is nothing compassionate about exposing people to SARS if one can avoid it.
What the Minister is doing is in contradiction of what the National Disease Surveillance Centre has suggested if there is a problem with SARS entering the country. Although the Bill does not specify, I presume the medical officer will be a public health medical practitioner. Currently, there is an outcry over the lack of 24 hour cover by public health specialists. These are the very people who would be expected to assist the immigration officer. The Minister for Health and Children is attempting to establish an all-European body to look at these issues in a much more comprehensive way. The public health doctors have said that they welcome the EU Commissioner for Health and Consumer Protection, Mr. David Byrne's advocacy that each member state should have a 24 hour, seven day a week cover for threats from infectious diseases. It is extraordinary that this legislation requires such cover, yet we do not have it. It strikes me as being half mad.
The Minister for Justice, Equality and Law Reform proposes that an immigration officer will have the back-up of a public health medical officer, if he can get one. However, the following are the guidelines outlined in the interim guidance for aircraft cabin staff on management of suspected severe acute respiratory syndrome:
In-flight care of suspected case of SARS: If a passenger on a flight from an affected area becomes noticeably ill with a fever and respiratory symptoms, the following action is recommended for cabin crew:
1. The passenger should be, as far as possible, isolated from other passengers and crew.
2. The passenger should be asked to wear a protective (surgical) mask and those caring for the ill passenger should follow the infection control measures recommended for cases of SARS.
3. A toilet should be identified and made available for the exclusive use of the ill passenger.
4. The captain should radio ahead to the airport of destination so that the local director of public health can be alerted to the arrival of a suspected case of SARS.
5. On arrival, the ill passenger should be placed in isolation and medically assessed.
The guidelines continue on the management of contact with the ill passenger:
If the immediate medical assessment of the ill passenger excludes SARS as a possible cause of his or her illness, the passenger should be referred to local health care facilities for any necessary follow up. If however, the initial medical assessment conducted in the airport concludes that the passenger is a suspect or probable case of SARS the following action should be taken:
1. All contacts of the ill passenger should have already been identified during the flight. For the purposes of air travel a contact is defined as:
Passengers sitting in the same seat row or within at least 2 rows in front or behind the ill passenger.
All flight attendants on board.
Anyone having intimate contact, providing care or otherwise having contact with respiratory secretions of the ill passenger.
Anyone on the flight living in the same household as the ill passenger.
If it is a flight attendant who is considered to be a suspect or probable SARS case all the passengers are considered to be contacts.
The guidelines continue to give more information as to what cabin staff should do about other passengers. However, the Minister for Justice, Equality and Law Reform proposes to refuse them entry and put infected persons back on a return flight. There is nothing in the legislation that says otherwise that they are to be refused entry. An immigration officer will be there at the point of entry and that is what he will have to look at.
Drug addiction is another criteria. We have as much in the way of drug addiction as any other country, so why we are deciding to refuse people entry on these grounds is beyond me.
Those working in psychiatric medicine to whom I have spoken have objected strongly to the last part of the Schedule. The Department did not contact anyone in that field to whom I spoke, including the Royal College of Psychiatrists, about including this section in the Bill. Schizophrenia Ireland is dismayed because this is virtually a description of someone in a florid attack of schizophrenia. The positive symptoms of schizophrenia are likely to be delusions, hallucinations, disorganised thinking and disorganised behaviour. This is exactly the type of person who is to be excluded from entry here rather than being taken into care and given proper treatment. This is such a retrograde way of looking at disease, mental and physical, that I cannot support its inclusion in the Bill.
Dr. Henry: I share Senator Terry's concerns about the manner in which the Bill has been rushed through the Houses of the Oireachtas. Regardless of the fact that the legislation is described as temporary, we have a duty to try to make it seem that we have considered it carefully, but that has been virtually impossible to do with this Bill. I also cannot support this Bill because I do not believe the Department of Justice, Equality and Law Reform sought advice on the medical aspects of the legislation, particularly the section I addressed which is now the First Schedule. I do not believe the Department of Health and Children was adequately consulted - I do not know if it was consulted at all - and I do not think the National Disease Surveillance Centre was consulted.
I have not met anyone in public health who was consulted about it and I certainly have not found anyone who could have given advice from a psychiatric point of view. The Minister of State described how broad the UK legislation is but said our Bill is better. I think the Bill is probably worse because totally impractical areas are being singled out when I have given medical evidence that can be verified which shows that these areas are considered impractical. I remember getting a work permit in the 1960s to go to the United States. As non-nationals, one had to X-rayed, have blood taken and so forth. If we want to look for tuberculosis and syphilis by taking blood samples, that is fair enough, but there is no point singling out specific conditions in important legislation, which will be very rarely implemented. What value is it to have such conditions specified? I certainly will not be able to support the Bill.
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