HC Deb 01 July 1960 vol 625 cc1759-74

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Peel.]

2.25 p.m.

Dr. Barnett Stross (Stoke-on-Trent, Central)

The problem which I wish to raise concerns dermatitis in industry. Although it is a fairly narrow issue, it is not an easy problem to state as clearly as I should like.

On 30th May I asked the Minister of Pensions and National Insurance the following Question: … how many claims were made in the past accountable year by men and women, respectively, for dermatitis following irritation by irritating dusts or liquids; how many were successful in their claims; and how many, after receiving industrial injury payment or pension, were later judged to be suffering from dermatitis due to constitutional causes. The right hon. Gentleman did not tell me the total number of claims which were made, but he was able to give me this information: In the year ended 30th June, 1958 … there were 16,200 spells of incapacity due to dermatitis for which injury benefit was paid … Of these, 13,100 related to men and 3,100 to women."—[OFFICIAL REPORT, 30th May, 1960; Vol. 624, c. 987.] This shows that four men as against one woman were affected. In industry as a whole, there are only twice as many men at work as women. I make no point about it, since it is obvious that, by and large, men work in industries where there is a greater likelihood of their suffering industrial dematitis.

With regard to the 16,200 spells to which the Minister referred, he gave me some further information. He said that 2,500 of them were recrudescences of earlier attacks. Then, to my surprise, he said that of these 2,500, 2,300 were men and only 200 women. This makes the proportion of men to women, not 4 to 1, but 11½ to 1. The right hon. Gentleman was unable to give me any information in answer to the last part of my Question. He could not tell me what number of beneficiaries, having first been diagnosed as suffering from industrial dermatitis, was subsequently found as suffering not from industrial dermatitis but from a form which was due to constitutional qualities.

I have made it clear that the grievance which I wish to put before the House is a narrow one, but it is a perplexing and difficult issue. There is widespread anxiety among workers and among the trades union advisers who represent them, because they feel that, in many cases, a diagnosis first made of industrial dermatitis is relinquished by the medical boards some time after injury payments have been made.

The diagnosis is then changed to dermatitis due to constitutional causes. Such a change when made, I am sure the Parliamentary Secretary will agree, means that the injury payment ceases. But, of course, the incapacity to perform work which was formerly within the ability of the worker is still present. With that incapacity there is often a lowering of the standard of life and ensuing anxiety. This alone is particularly bad for the people involved and tends to militate against recovery.

With reference to the recrudescences—the total number being 2,500 as mentioned by the Minister—I am advised, though I have no figures for it and I do not know anyone who has, that an appreciable percentage of recrudescences are diagnosed as being constitutional in origin. That means that payment is made in the first instance, that there is a recovery to allow a return to work, either partial recovery or complete recovery, or apparently complete recovery, and then when a recrudescence occurs the patient finds himself very confused when told that the recrudescence is of constitutional origin. This I find very difficult indeed to understand.

I know that the Parliamentary Secretary will appreciate what this means to the men and women affected. To be rejected in the first place when an initial claim is made is often distressing enough to the people concerned. No one, of course, must or should claim that every breakdown that occurs on the skin of a worker is inevitably due to an industrial factor. That would be absurd and wrong. But it is when the claim is admitted and when payments have once been made that a subsequent change in diagnosis which deprives the worker of his compensation and of his future rights that he enjoyed under the Workmen's Compensation Act, 1925, namely, that he would at least get a declaration of liability, is beyond the comprehension of either the worker or his representative.

The Parliamentary Secretary may say, "What do you expect from me or from my right hon. Friend? We are surely in the hands of the doctors, and rightly so, and we must abide by their judgment." To that I must reply that medical knowledge on this issue is not an exact science. No one would claim that it is. There are real divergencies of opinion both as to diagnosis and prognosis. What is fashionable today may not be held to be so in ten years' time or may not have been held to be so ten years ago. Because variations militate against the workers and create confusion, I feel that I have the right to raise the matter in the House today and to ask the Parliamentary Secretary to give me his views.

I will give an example and I will divide the schools of thought into the optimistic school, on the one hand—which today is the majority view or is certainly becoming so—and, on the other, the school comprising those who do not agree with that view. In the Watson Smith lecture to the Royal College of Physicians delivered by Thomson in 1958 these rather optimistic views were expressed and four points were made, which I will put very briefly to the Parliamentary Secretary.

The first was that the belief that a worker must always suffer from this malady once it was contracted was incorrect. I entirely agree with that and I am sure that everyone would. Indeed, I think it is well known and recognised that many thousands of workers when they first start work and come into contact with irritating substances of any kind achieve what is called a "hardening off process" for their skin. They get an initial slight dermatitis, recover from it while at work and the condition never comes before any medical man. After that, they seem to have an immunity from the disease, probably due to the skin becoming tougher.

The second point, however, is rather more serious. The view expressed in the lecture was that anything at all by way of deterioration of general health would lower the resistance of the skin so that it would react to an external agent for the first time. This seems to me, again, to be obviously true, but I hope that the Parliamentary Secretary will agree that that view should never be allowed to deprive a worker of his rights. The fact that one has had influenza, and that therefore the skin is not in a good condition and is a reason for the irritant breaking down the skin which it would not have done if one had not had influenza, should not enter the mind of anyone asked to certify whether dermatitis is industrial or not.

The third point is that in aged patients the atrophy and the dryness of the skin are more responsible for the break-down of resistance than is long and continued exposure to possible irritants. This too, I think, we would all accept—it is common sense—but it would be very wrong if it ever happened that those who have to certify whether dermatitis is industrial or not were to say, "Ah well, this is an old man or an old woman. The skin ages with them as the years advance. If it were not for their ageing the skin would not have broken down. Therefore, we will not give a certificate showing the condition as being industrial in origin." I would suggest to the Parliamentary Secretary as strongly as I can that that sort of approach was not the spirit in which the Measure was originally drawn up.

The fourth and last point of this optimistic school to which I am referring is that women, in particular, are liable to be affected by sensitising agents used in the home and that the ensuing dermatitis often has nothing to do with their industrial occupation. The Parliamentary Secretary will remember that I showed on the figures given to me by the Minister that where recurrences are concerned they are as 11½ to 1 as between men and women. According to the last figures given to me by the Minister, only 200 women were affected by recrudescence, or received certificates for recrudescence, out of a total of 3,100 cases.

I am disturbed, therefore, lest dermatologists might take the view that, because women wash up dishes and wash clothes at home, and are thus in contact with soap and detergents, the breakdown of the skin of the hands or forearms or, indeed, of any other part of the body, is more likely to be something due to what they do at home. The figures suggest that that is happening.

It is also held by most of the optimistic school—I apologise for using the word "optimistic", which is not perhaps a good word—that where the irritant is of the primary or non-sensitising type, the usual nondescript type of irritant whether dust or liquid, the man should be able to return to his former work—it gives three reasons for this—if he is provided with adequate preventive measures; if, secondly, he is educated in their proper use and if, thirdly, he is intelligent and is allowed to use them.

Again I agree completely. I am delighted to see that the Parliamentary Secretary to the Ministry of Labour is present on the Government Front Bench. I am sure that this is what the Ministry of Labour is trying to get done, through the Factory Inspectorate, everywhere, and in every factory—to teach the people how to care for themselves and to make the facilities available to them at work so that there shall be prevention, and treatment and cure without losing work. We all agree that these three "ifs" do not exist throughout industry.

As against this sort of tendency, or modern or optimistic view, may I quote the work which, for the want of a better term, I will call that of the Leeds school and of Dr. Hellier, the consultant there. Between 1952 and 1954 he made a review of a number of cases. The total, 124, was not tremendously large, but still that is a pretty large number of cases if they are carefully analysed. He found that in 59 cases where the irritant was primary in nature, only eight cases escaped further breakdown at some later stage. That means only 14 per cent. escaped breakdown. About specific sensitisers he was not unhappy. Where the sensitisers caused the irritation, out of 65 cases 21 remained clear for a long time.

I can understand this very easily—I hope that what I am saying is not too obscure. Where an irritant is specific like turpentine, and one knows that it is the sensitising agent for the skin, one recognises the danger and knows what is causing it and one takes care to avoid it by technique or by variation in occupation. But I must stress again that Hellier's view is that, where we are dealing with primary irritants, a great percentage of them—about 77 per cent.—ultimately break down after the first attack. This is important, because, all authorities are agreed that, if we take the total number of cases, about 80 per cent. of them are cases of primary irritants, namely, irritating dust and liquids. Whereas Thomson declares that a real disability is caused in only 1 per cent. of such cases, although he says they are intractable and severe when they occur, Hellier says that we get 77 per cent.

I have taken some time to press this point. I wish to make very clear that there is great divergence of opinion among the most eminent of our dermatologists. Between 77 per cent. and 1 per cent., there is great divergence. Hellier went further and said that 59 per cent. of the cases which have to cease work at all have their earning capacity permanently diminished. This merely highlights the importance of the problem which I am putting to the Parliamentary Secretary.

By and large, the views of dermatologists may be summed up in a quotation which I should like to read in order to get it absolutely right. I have taken it from the Medical Annual of 1959. It is referring to a lecture or an article in the proceedings of the Royal Society of Medicine, volume 48, page 471. It appears under the heading, "Conclusion". A number of dermatologists in England have reached the conclusion which has been summarised by Bettley (1955): 'Any man with a chronic eczema which interferes with his work is in an unhappy position: but his lot is not improved by unnecessary idleness, and he should be encouraged to continue suitable work, I mean actual, work, not as a night watchman. If on the other hand, he is given the benefit of the doubt and certified industrial, he will probably stop work altogether and may deteriorate … There is no 'benefit' of this doubt.' The article goes on to say that, of course, this is worse for elderly men than for young men. Elderly men in particular should still stay at their own work because they cannot change their occupation and their skill cannot be altered so as to tackle something new in the way that that of young men can. Therefore, it is argued, the middle-aged and elderly groups are worse served in the long run through loss of income if they are allowed to stop work.

The whole argument is based on that. We do them no good by telling the truth, which is that it is industrial dermatitis—do not give them a certificate and they will probably stick at work. If they are treated at work they have a better chance to rehabilitate themselves than if they are allowed to stop.

I have raised this subject on the Adjournment because I see serious dangers that perhaps the doctors have not realised in this attitude. It may be this which explains some of the things in the figures. For example, we had only 16,207 spells of incapacity certified in 1957–58, whereas the year before the figure was 21,440. Out of the last figure the number of women affected was 3,100; the year before it was 4,460. I have looked at quite a number of the figures aid extracted details for quite a long time. In pre-war days we had the certificate of incapacity given by the certifying surgeon. In order to be brief, I will only say this. Whereas we had some 5,000 in 1939, the number was doubled by 1942, which is easily understandable—we know why. It went up further to 13,000 and some hundreds by 1945, and when we come to the modern method started in 1949–50, and taking each year right through until the figure given to me by the Minister, we find that last year's figure is appreciably lower than any before. Even for 1949–50, the figure is 18,900 and in every year except this last year, when it was 16,200, it was 21,000 or over and for the worst year, 1953–54, the figure was 25,700.

Again, the figure for women shows what I suspect also, that there is a tendency to try not to certify industrial dermatitis, not to give the benefit of the doubt to the worker because the dermatologist or doctor, rightly, in his opinion, sincerely feels that he is not doing the person any good by so doing. He says, "She will be better off if I do not". They may, in their view, be correct in so doing, but I come now to this point.

The Minister of Labour, of course, will be interested in this. The doctors when taking this view have in mind a factory or installation of work where there will be certain facilities; where there will be not only sympathetic understanding of the problem by the employer, who will see that facilities are made available and insist that they are available, but sympathy on behalf of the workers who will get rid of their ignorance in believing that this is an infectious disease. We have not yet been able to stop people from believing that it is infectious and they do not like working with others suffering from it. That is foolish, and we should try to get them to understand that there is no danger.

Secondly, the doctors have in mind that there should be nurses available to dress these lesions when the men come to work in the morning and again when they leave after the day's work. Thirdly, there should always be available barrier creams and suitable cleansing materials, with the provision of cloths, good washing facilities and so on. How often are all these three main factors available? Not very often, and certainly not universally. As long as they are not universally available, I think it is a great mistake to refuse to give what is called the benefit of the doubt, when there is any doubt, and I think that the doctors are making a mistake against their own better judgment.

In effect, if I am right in my suspicions—and I think I have made a case which certainly merits an answer—it would appear that the medical men are the masters of the Minister in this instance, and that, so far as the workers are concerned they are creating this image of an uncontrolled and uncontrollable tyranny. The workers do not blame the doctors, who are really at fault, if I am right. They blame the Minister and they blame the Government.

The Joint Parliamentary Secretary to the Ministry of Pensions and National Insurance (Mr. W. M. F. Vane)

They always blame the Government.

Dr. Stross

It is not for me to stand here and defend the Government, but to try to find out the truth, ask for an explanation and try to find the remedy.

I do not wish to exaggerate the total scope of this grievance. The number of days lost is about 1 million a year, and the total number of days lost from all accidents and sickness is about 300 million a year or more, so we are dealing here with about one-third of one per cent. of all incapacity. None the less, these are grievous cases individually, and I suppose that in my own experience as medical adviser to the pottery workers and miners in North Staffordshire I must have seen between 1,000 and 2,000 cases and reported on them in the twenty-five years during which I worked there. I know that this is a serious problem, full of anxiety. I appreciate that the Minister of Pensions and National Insurance is not responsible either for prevention or treatment. It is the Minister of Labour who makes himself responsible for prevention and tries to see that there should be adequate sources of treatment available.

The Minister can do something, and I am going to suggest that there are three things he can do. I suggest them with great respect, because I may be wrong in my view. We ought to know more about the problem than we do, but I do not think we ever will until we have industrial dermatitis scheduled as a notifiable disease. If we can get it notified, our statistics will be more valuable, and once we can look at the position carefully we shall know what to do better than we do now.

Secondly, I wish to make reference to the Digest of Statistics. It is probably the most valuable document available anywhere in the world. No other country has anything like it, but I would ask for a further slight improvement. There is some limitation in the figures that I have been trying to get out, because we are not given the numbers of people involved in each of the trades and processes listed in these statistical tables. If these could be shown, and I do not know how difficult it would be, certainly all medical statisticians would be most grateful.

The third thing for which I ask, and this is the last, is more difficult. I ask the Parliamentary Secretary and his right hon. Friend whether they can use any method to point out to the medical profession which is involved in these cases that it really is no part of their duty to refuse the benefit of the doubt to the worker because they fear that he may not recover so quickly if he is certified. So many dermatologists, quite rightly, use the phrase that a man's salvation lies in his work, and this is very true, but if it lies in his work, and if he has to continue working with an irritating and itching condition, there must be made available at his work opportunities for treatment so that his case does not become so intractable that ultimately he can never work again. Same employers do provide the facilities I ask for. This certification should, first, be absolutely exact, and the benefit of any doubt should be given to the worker.

The Parliamentary Secretary to the Ministry of Labour will agree, at least, from the figures shown in the Halifax survey that the situation is not satisfactory in all the establishments. Out of 760 factories there examined by the officers of the Ministry, some 200 were found to be totally unsatisfactory. First-aid arrangements were poor, the elementary principles of cleanliness and the use of dressings were neglected, and in the whole of that town there was no organised medical service in any form whatever.

Until the Government carry out the promise made long ago to establish the Industrial Health Service, my purpose in raising this matter this afternoon is to ask the Minister to see to it that the letter and the spirit of the Act are carried out, and that where doubt exists the benefit should be given to the worker.

2.57 p.m.

The Joint Parliamentary Secretary to the Ministry of Pensions and National Insurance (Mr. W. M. F. Vane)

The hon. Member for Stoke-on-Trent, Central (Dr. Stross), with his usual courtesy, told me the other day same of the points he intended to raise during this Adjournment debate, and I am grateful to him. In consequence, I hope I shall be able to reply a little more fully on some technical points than otherwise would have been the case.

I think we would all agree that the hon. Gentleman was very clear. I am not sure that we would also agree that his approach was very narrow, because the points he covered ranged over a very wide field, covering the responsibilities of several Departments, much of it that of my hon. Friend the Parliamentary Secretary to the Ministry of Labour, whom I am glad to see with me this afternoon, or of no Departments at all but rather that of his own profession. Even on a Friday, when the House is not so full, I am not going to be drawn into the temptation of questioning or criticising different medical views and opinions. I am not competent to do so, and, if by chance I were competent, I still think that it would be most improper from this Box.

In particular, I should like to answer the hon. Gentleman's last question straight away. It amounts to pointing out to the independent adjudicating authorities what we consider their duty is, and I think it would be very wrong of me here to follow up that point, or for any Minister at any other time to do something which would amount to an improper interference with the statutory duty of others.

I do not want to sound unsympathetic in any way, but I should like to make my position clear at the beginning. Under the National Insurance (Industrial Injuries) Act, Parliament laid the responsibility for diagnosis and assessment in these cases on the independent adjudicating authorities. That did not happen by mistake; it was done purposely by this House. The Minister of Pensions and National Insurance implements those decisions, but he does not influence those decisions. I should like to remind the House that the medical members of our medical appeal tribunals, which are our courts of appeal, are consultants of high standing in their profession, who are nominated by the senates of the universities. Therefore, it is reasonable to suppose that their views in general do reflect orthodox medical views of great distinction at the time. There is no such thing as a departmental line with regard to dermatitis, as I thought the hon. Member almost hinted at one time. I can assure him there is no such thing. We have never expressed such, nor have we any hope that a particular line should be reflected in the decisions to which I have been referring. There could not be any such thing.

Dr. Stross

I should not like it to go out that I made such an accusation. I would not dream of doing so, and I am sorry if I gave the impression that I wanted to do so. I hope I have shown that there has been a variation of medical view on the matter and that, even today, there are variations of view between one consultant or one school and another and the poor worker rather gets the worst end of the stick.

Mr. Vane

I am sorry if I misquoted the hon. Member in any way and, perhaps, used rather too strong an expression. I did, not mean that at all, but as I understood the speech of the hon. Member, there was a suggestion that we leaned rather in the direction of the optimistic school and that that might be underlying some of the results. I assure him that no such thing is allowed and, under the circumstances, it would not be possible.

The hon. Member has said, so perhaps I can also be allowed to say, that all the learned men in his profession do not see the causes, the course or cure of the disease in the same way. Bearing in mind the variations and complications, it would be surprising if they did, but we must remember that. I do not want to be unhelpful, but if the hon. Member wants to pursue that point further, I think he will have to make representations to his own profession rather than to me. I may be very innocent in these matters, but I believe that raising the subject in an Adjournment debate is one way of making those representations because it would be likely for an inch, if not more, publicity to be given in most medical journals.

The hon. Member raised one question which has puzzled a lot of people, not only those who have suffered from dermatitis but their friends, their relatives and workmates. That is the question of an apparent change of diagnosis. To the layman the line of demarcation between constitutional and industrial dermatitis is imprecise and very blurred in many cases. A sufferer's disability may have entitled him on one occasion to injury benefit and perhaps on a later occasion it has not so entitled him, or it has entitled him to disablement benefit at a very low assessment. That is puzzling and distressing, but we ought to remember that where a man or woman is certified as being incapable of work and is suffering from industrial dermatitis, the insurance officer is likely to rule that he or she is entitled to injury benefit which is payable at one rate only.

When the total incapacity for work ceases or the injury benefit period ceases, whichever is the earlier, the question comes of assessing entitlement to disablement benefit, which is paid according to the degree of assessment of the incapacity which is due to the industrial element in the disease. Therefore, apparent changes in the pension which may be received by a person do not necessarily constitute a change of diagnosis, as the hon. Member put it, although of course in long-continuing cases it is possible that the learned members of his profession may come to a different conclusion in some cases from that to which they came in the first place.

None the less, these decisions are not taken hastily, as the hon. Member knows. There is proper machinery and a well known line of appeal to the Medical Appeal Tribunal whore, in dermatitis cases, I think I can say one of the members will always be a dermatologist. The hon. Member also mentioned that the number of cases or spells of incapacity through dermatitis from industrial causes is tending to fall and he wondered why. I can add to the figures he gave by saying that those for 1958–59 are likely to show a further small fall, but the record of spells of incapacity entitling sufferers to sickness benefit, which is the parallel stream, is showing the same trend. So the industrial injury payment figures are not out of step with those for sickness benefit. It would be disturbing if that were not so.

I admit that the instance he quoted for last year showed a substantial drop compared with the year before, but it would be surprising if the trend were not downwards. Bearing in mind the great efforts towards prevention which have been made over many fields of industry for many years—a great deal more in some than in others; in some, unhappily, perhaps not yet as many as we should like to see—it is understandable that there has been a wider recognition among individual workers of the value of barrier creams and other measures of that sort.

The hon. Member spoke of recrudescence and asked why the figures showed a much smaller proportion for women than for men. There is no Departmental "tough line" nor, I am sure, is there anything parallel with that among medical boards and medical appeal tribunals. I cannot give him an exact explanation, but since he told me about this point, which was worrying him, a little time ago, I have thought about it a good deal and have discussed it with several people. I will give him what is entirely my personal view.

I would expect the figures of recrudescence for women to be a good deal smaller than those for men even though, perhaps, not as much smaller as the figures which he quoted, because women in industry are often in a different position from men. A man who is the bread winner of a family and who works in a heavy industry, perhaps of a dirty nature, would find it difficult to make up his mind in middle age to change his employment and to accept substantially lower wages. There are fewer women than men who spend their working life in the same job in industry. Many women change their jobs more readily than do men, particularly if they have suffered some disablement in the job in which they have been working. Women are readier than many men to take advantage of such protection as barrier creams, and there are more jobs done by women than by men which can be conveniently done in gloves. Barrier creams and gloves are looked upon by many men as rather unnecessary paraphernalia, and probably a larger proportion of women than of men see an advantage in using them.

The hon. Member spoke about our Digest. I appreciated the compliment which he paid us. Big though it is, he asked whether we could give him a few more figures to show the totals of the men and women employed in different industries and occupations. If he turns to the end of that big book, in Table 52 he will find many figures of the kind which he seeks. I see the point which he makes; what he wants is the isolation of places and processes with excessive risk. Some figures in an analysis such as he suggested could easily be misleading, however, because office workers and workers in dirty jobs might be lumped together in such an analysis. That happens particularly when an analysis is built up on the basis of different trades and industries. That would be misleading rather than helpful. A research worker would want something much more precise, and an analysis by occupation would be more helpful. The last reliable figures in this country are too old to be very valuable for the hon. Member's purpose, but we are not far from the next census and no doubt after the census there will be a flood of fresh figures, some of which may supply the need to which he refers.

We in our Department do not publish everything which we work out; obviously we could not. But if we have anything which would help him in his researches, and if he cares to get in touch with us, I am sure that we may be able to help him with figures which at least illustrate part of the problem which he has in mind.

There are no particular figures, either for industries or for occupations, which would answer his question entirely and give my hon. Friend the Parliamentary Secretary to the Minister of Labour the information which the hon. Member would like him to have, but the fact remains that we do our best in that we pass to the Ministry of Labour particulars of every case of dermatitis in which we pay benefit. Perhaps the hon. Member did not know that. This helps the Ministry to plan their preventive measures, because to research workers it can easily be more useful to have these figures of accurately diagnosed cases passed to them promptly without any trouble to industry at all—and this is done without trouble to industry.

The hon. Member suggested that we might think in terms of having compulsory notification of dermatitis. This can be argued from both sides, and it must not be forgotten that not only would that put a great deal of work on industry but it would mean, from the very nature of the disease, that a great deal of rather inaccurate information would get into my hon. Friend's Department.

Dr. Stross

I recognise these difficulties and I know that some of the information, if we collected and collated it, would appear to be inaccurate—we could not be quite sure—but I am advised by statisticians that they understand human frailty and can make such allowances.

Mr. Vane

Statisticians are wonderful people. If I may return to my point. Even though we have not compulsory notification, the fact is that accurate information about every diagnosed case of industrial dermatitis in which we pay benefit is passed to my hon. Friend's Department, and I believe that he finds that information very valuable.

I think I have answered the greater part of the hon. Gentleman's questions, other than those which I am not competent to pursue. We take very great care to ensure proper diagnosis when any applicant comes to us claiming industrial injury benefit. In difficult cases, a man or woman may be seen by as many as five independent doctors, of whom two are consultant dermatologists. There is no rough and ready examination after which we say that the man has just to take his luck. On the contrary, we take great pains to ensure that an accurate diagnosis is made. We co-operate with other Departments, and. as I have said, in the absence of a provision for compulsory notification we give the Ministry of Labour all the figures which we think it requires and which it finds helpful.

Last but not least, I think that the House should bear in mind that the general interest in prevention, which is so important in this case, is growing, and, I think, respect for these simple preventive measures can be very effective. It is heartening to think that these figures are falling as a result of the lesser incidence of the disease. We all want to use our influence to encourage this work of prevention, whenever it is within our powers to do so, in order that we may ensure that this downward trend continues.

Question put and agreed to.

Adjourned accordingly at twelve minutes past Three o'clock.

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